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Lee CC, Lo A, Lorenz FJ, Martinazzi BJ, Johnson TS. Use of Thromboprophylaxis after Autologous Breast Reconstruction: A Cost-Effective Break-Even Analysis. Plast Reconstr Surg 2024; 154:288-295. [PMID: 37699552 DOI: 10.1097/prs.0000000000011055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND Postoperative venous thromboembolism (VTE) is a major source of morbidity and mortality. The use of thromboprophylaxis among surgeons is not well studied in autologous breast reconstruction. The purpose of this study was to determine the rate of VTE in patients with breast cancer undergoing autologous breast reconstruction and to compare the cost-effectiveness of postoperative chemoprophylactic agents. METHODS The TriNetX National Health Research Network database was used to identify patients with breast cancer who underwent autologous breast reconstruction surgery between 2002 and 2022. The incidence of VTE within the first 30 days of surgery was calculated. A break-even analysis was performed to determine the break-even rate of VTE at which a chemoprophylactic agent would be cost-effective. RESULTS A cohort of 8221 patients was identified in this study. The rate of VTE was significantly higher in those without anticoagulation (4.0%) compared with those who received anticoagulation (2.6%) ( P = 0.0008). The break-even analysis for heparin and enoxaparin cost-effectiveness yielded absolute risk reductions of 0.73% and 1.63% for high-risk patients requiring 30 days of therapy and 0.20% and 0.43% for moderate-risk patients requiring 7 days of therapy, respectively. CONCLUSIONS The use of thromboprophylaxis significantly lowered the risk of VTE within 30 days after autologous breast reconstruction. Heparin appeared to be more cost-effective at preventing VTE compared with enoxaparin for both high- and moderate-risk patients. The presented model holds potential for other institution-specific variables that can be easily applied by plastic surgeons to determine the cost-effectiveness of any therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Charles C Lee
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Penn State Health Milton S. Hershey Medical Center
| | - Alexis Lo
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Penn State Health Milton S. Hershey Medical Center
| | | | | | - T Shane Johnson
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Penn State Health Milton S. Hershey Medical Center
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Wang C, Fan X, Nie L, Wang Q, Li S, Zheng W, Zhang W, Dai W, Chen M. Efficacy and Safety of Rivaroxaban for Extremely Aged Patients with Venous Thromboembolism: A Retrospective, Cross-Sectional Real-World Study. Clin Interv Aging 2024; 19:1103-1116. [PMID: 38915432 PMCID: PMC11194160 DOI: 10.2147/cia.s405075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 05/15/2024] [Indexed: 06/26/2024] Open
Abstract
Background Rivaroxaban, a non-vitamin K antagonist oral anticoagulant, has become widely used for the management of venous thromboembolism (VTE) in adult patients. However, few trials have explored the efficacy and safety of rivaroxaban in VTE patients over 80 years of age. This necessitates further real-world studies of rivaroxaban across elderly populations. Methods We performed a retrospective single center study involving extremely aged VTE sufferers treated with rivaroxaban. The sample comprised 121 patients newly initiated on rivaroxaban diagnosed between January 2018 and January 2020. Patients were followed up for no less than 2 years. The effectiveness outcome was the disappearance of thromboembolism. The safety outcome was the incidence of major bleeding events. Comorbidities and complications were recorded throughout the entire study. Results The efficacy outcome occurred in 114 of 121 patients (94.21%) and the safety outcome occurred in 12 of 121 patients (9.91%). Increased hemorrhages were observed in patients with infection (15.15% vs 7.80%), but no significant difference was observed due to limited sample size (P=0.3053). Patients with an age-adjusted Charlson comorbidity index score higher than 6 points exhibited higher bleeding rates (14.08% vs 4.00%; P=0.0676) and lower thrombus cure rates (88.73% vs 100%; P=0.0203). Key conclusions Patients with infection should be more careful of bleeding events during rivaroxaban therapy. An age-adjusted Charlson comorbidity index score higher than 6, which predicted poor survival, indicated inferior safety and efficacy of rivaroxaban. Aim To investigate the efficacy and safety of Rivaroxaban in an aged venous thromboembolism patient population under real-world conditions.
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Affiliation(s)
- Chun Wang
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Xiaohong Fan
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Li Nie
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Qing Wang
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Shanshan Li
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Wen Zheng
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Wei Zhang
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Wangshu Dai
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
| | - Minmin Chen
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China
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Poljo A, Billeter AT. Comment on: Risk stratified venous thromboembolism prophylaxis in bariatric patients using Caprini assessment: practice patterns and opportunities for improvement. Surg Obes Relat Dis 2024; 20:235-236. [PMID: 38016877 DOI: 10.1016/j.soard.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/29/2023] [Indexed: 11/30/2023]
Affiliation(s)
- Adisa Poljo
- Department of Visceral Surgery, Clarunis-University Digestive Healthcare Center, St. Claraspital and University Hospital Basel, Basel, Switzerland
| | - Adrian T Billeter
- Department of Visceral Surgery, Clarunis-University Digestive Healthcare Center, St. Claraspital and University Hospital Basel, Basel, Switzerland
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Nassour N, Akhbari B, Ranganathan N, Tawakol A, Rosovsky RP, Guss D, DiGiovanni CW, Ashkani-Esfahani S. Correlation Between Statin Use and Symptomatic Venous Thromboembolism Incidence in Patients With Ankle Fracture: A Machine Learning Approach. Foot Ankle Spec 2023:19386400231207692. [PMID: 37905534 DOI: 10.1177/19386400231207692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
BACKGROUND Identifying factors that correlate with the incidence of venous thromboembolism (VTE) has the potential to improve VTE prevention and positively influence decision-making regarding prophylaxis. In this study, we aimed to investigate the correlation between statin consumption and the incidence of VTE in patients who sustained an ankle fracture. METHODS In this retrospective, case-controlled study, cases were those who developed VTE and controls were those who had no VTE, and the ratio was 1:4. Patients' demographics, history of hyperlipidemia, and reported statins use were obtained. A random forest classifier (RFC) model was used to predict whether statin consumers were at risk of VTE after ankle fracture regardless of VTE prophylaxis administration based on statin consumption, body mass index (BMI), age, and biological sex. RESULTS Of the 1175 patients with ankle fractures, 238 had confirmed VTE (case group), and 937 had no symptomatic VTE (control group; ratio 1:4). Fifty (21%) cases and 407 (43%) controls were on a statin. Statin users had a significantly lower incidence of VTE after ankle fracture, odds ratio (OR) = 0.35, 95% CI: 0.25, 0.49, P < .001. Our model showed an area under the receiving operator curve (AUROC) of 78%, a sensitivity of 73%, and a specificity of 83% in predicting the risk of VTE. The importance of the predictors of VTE, other than the use of statins (model importance = 0.1), were age (model importance of 0.72), BMI (model importance of 0.24), and biological sex (model importance of 0.02). CONCLUSION Statins were significantly associated with a lower rate of VTE in our population of patients who sustained an ankle fracture. LEVELS OF EVIDENCE 3.
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Affiliation(s)
- Nour Nassour
- Foot & Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bardiya Akhbari
- Foot & Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Noopur Ranganathan
- Foot & Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ahmed Tawakol
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Rachel P Rosovsky
- Division of Hematology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Daniel Guss
- Foot & Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Foot and Ankle Division, Department of Orthopaedic Surgery, Massachusetts General Hospital, Newton Wellesley Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher W DiGiovanni
- Foot & Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Foot and Ankle Division, Department of Orthopaedic Surgery, Massachusetts General Hospital, Newton Wellesley Hospital, Harvard Medical School, Boston, Massachusetts
| | - Soheil Ashkani-Esfahani
- Foot & Ankle Research and Innovation Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Foot and Ankle Division, Department of Orthopaedic Surgery, Massachusetts General Hospital, Newton Wellesley Hospital, Harvard Medical School, Boston, Massachusetts
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Obata-Yasuoka M, Ohara R, Hosokawa Y, Nishida K, Abe H, Mayumi M, Ishizu T, Endo-Kawamura N, Hamada H, Satoh T. Obstetric venous thromboembolism: Evaluation of prophylactic approach based on risk scores, D-dimer levels, and ultrasonography findings in a tertiary hospital in Japan. J Obstet Gynaecol Res 2022; 48:2334-2344. [PMID: 35732592 DOI: 10.1111/jog.15332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/22/2022] [Accepted: 06/01/2022] [Indexed: 12/01/2022]
Abstract
AIM Pulmonary embolism remains a leading cause of maternal mortality in developed countries despite developments in venous thromboembolism prophylaxis strategies. This study aimed to evaluate the effectiveness of our approach involving risk-scoring, D-dimer level assessment, and ultrasonography for obstetric venous thromboembolism. METHODS This retrospective cohort study included women who delivered at 22-41 weeks of gestation in The University of Tsukuba Hospital, Japan between January and December 2020. Venous thromboembolism risk (determined according to Japanese guidelines) and D-dimer levels were evaluated within 20 weeks of gestation, 30-34 weeks of gestation, and during the pre-delivery period (36 weeks of gestation or any time before preterm delivery). Compression and color Doppler ultrasonography for lower extremity deep vein thrombosis were performed if D-dimer levels were ≥3.2 μg/mL (for those undergoing cesarean delivery, 1.0 μg/mL). RESULTS Of 1026 women, 6 women had deep vein thrombosis during pregnancy and 1 during the puerperium period. Pulmonary embolism was not observed. The D-dimer screening result was positive for 8 women (2%) within 20 weeks of gestation (deep vein thrombosis was confirmed in 3 of them), 87 women (10%) (no deep vein thrombosis) at 30-34 weeks of gestation, and 367 women (36%) during the pre-delivery period (asymptomatic deep vein thrombosis in one). Based on the Japanese guidelines, 1%, 11%, 33%, and 55% of women had high, intermediate, low, and no postpartum risk factors, respectively. CONCLUSIONS Our approach appears useful for antenatal venous thromboembolism screening in the first trimester. For postpartum prophylaxis, more cost-effective strategies are needed.
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Affiliation(s)
- Mana Obata-Yasuoka
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Rena Ohara
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yoshihiko Hosokawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Keiko Nishida
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Haruna Abe
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Miyuki Mayumi
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Tomoko Ishizu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Naho Endo-Kawamura
- Department of Anesthesiology, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Hiromi Hamada
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Toyomi Satoh
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Anteby R, Verdugo FL, Aaron DG, Polk HC, Qadan M. Perioperative Pharmacologic Prophylaxis of Venous Thromboembolism: A Professional Liability Analysis. J Surg Res 2022; 274:77-84. [DOI: 10.1016/j.jss.2021.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/19/2021] [Accepted: 11/29/2021] [Indexed: 11/16/2022]
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Tafler K, Kuriya A, Gervais N, Leyland N. Guideline No. 417: Prevention of Venous Thromboembolic Disease in Gynaecological Surgery. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:82-96.e1. [PMID: 33878456 DOI: 10.1016/j.jogc.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the use of thromboprophylaxis in gynaecological surgery. TARGET POPULATION All patients undergoing gynaecological surgery for benign or malignant indications. BENEFITS, HARMS, AND COSTS The implementation of this guideline will benefit patients undergoing gynaecological surgery and provide physicians with a standard algorithm for the use of perioperative thromboprophylaxis. EVIDENCE The following search terms were entered into MEDLINE, Google Scholar, and Cochrane in 2017 and 2018: VTE, PE, DVT, thromboprophylaxis, gynaecological surgery, heparin, graduated compression stocking, intermittent pneumatic stocking, obesity, pediatrics, minimally invasive surgery, heparin induced thrombocytopenia, regional anesthesia). Articles included were randomized controlled trials, meta-analyses, systematic reviews, and observational studies. Additional publications were identified from the reference lists of these articles. There were no date limits, but search results were limited to English language articles only. Searches were updated and incorporated into the guideline up to September 2018. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED USERS Gynaecologists and other members of the surgical team. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).
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8
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Lavikainen LI, Guyatt GH, Lee Y, Couban RJ, Luomaranta AL, Sallinen VJ, Kalliala IEJ, Karanicolas PJ, Cartwright R, Aaltonen RL, Ahopelto K, Aro KM, Beilmann-Lehtonen I, Blanker MH, Cárdenas JL, Craigie S, Galambosi PJ, Garcia-Perdomo HA, Ge FZ, Gomaa HA, Huang L, Izett-Kay ML, Joronen KM, Karjalainen PK, Khamani N, Kilpeläinen TP, Kivelä AJ, Korhonen T, Lampela H, Mattila AK, Najafabadi BT, Nykänen TP, Nystén C, Oksjoki SM, Pandanaboyana S, Pourjamal N, Ratnayake CBB, Raudasoja AR, Singh T, Tähtinen RM, Vernooij RWM, Wang Y, Xiao Y, Yao L, Haukka J, Tikkinen KAO. Systematic reviews of observational studies of Risk of Thrombosis and Bleeding in General and Gynecologic Surgery (ROTBIGGS): introduction and methodology. Syst Rev 2021; 10:264. [PMID: 34625092 PMCID: PMC8499502 DOI: 10.1186/s13643-021-01814-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 09/12/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) and bleeding are serious and potentially fatal complications of surgical procedures. Pharmacological thromboprophylaxis decreases the risk of VTE but increases the risk of major post-operative bleeding. The decision to use pharmacologic prophylaxis therefore represents a trade-off that critically depends on the incidence of VTE and bleeding in the absence of prophylaxis. These baseline risks vary widely between procedures, but their magnitude is uncertain. Systematic reviews addressing baseline risks are scarce, needed, and require innovations in methodology. Indeed, systematic summaries of these baseline risk estimates exist neither in general nor gynecologic surgery. We will fill this knowledge gap by performing a series of systematic reviews and meta-analyses of the procedure-specific and patient risk factor stratified risk estimates in general and gynecologic surgeries. METHODS We will perform comprehensive literature searches for observational studies in general and gynecologic surgery reporting symptomatic VTE or bleeding estimates. Pairs of methodologically trained reviewers will independently assess the studies for eligibility, evaluate the risk of bias by using an instrument developed for this review, and extract data. We will perform meta-analyses and modeling studies to adjust the reported risk estimates for the use of thromboprophylaxis and length of follow up. We will derive the estimates of risk from the median estimates of studies rated at the lowest risk of bias. The primary outcomes are the risk estimates of symptomatic VTE and major bleeding at 4 weeks post-operatively for each procedure stratified by patient risk factors. We will apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate evidence certainty. DISCUSSION This series of systematic reviews, modeling studies, and meta-analyses will inform clinicians and patients regarding the trade-off between VTE prevention and bleeding in general and gynecologic surgeries. Our work advances the standards in systematic reviews of surgical complications, including assessment of risk of bias, criteria for arriving at the best estimates of risk (including modeling of the timing of events and dealing with suboptimal data reporting), dealing with subgroups at higher and lower risk of bias, and use of the GRADE approach. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021234119.
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Affiliation(s)
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Rachel J Couban
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Anna L Luomaranta
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville J Sallinen
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ilkka E J Kalliala
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Paul J Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Rufus Cartwright
- Department of Obstetrics and Gynaecology, LNWH NHS Trust, London, UK
| | - Riikka L Aaltonen
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Kaisa Ahopelto
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Karoliina M Aro
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ines Beilmann-Lehtonen
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marco H Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jovita L Cárdenas
- National Center for Health Technology Excellence (CENETEC) Direction of Health Technologies assessment, Mexico City, Mexico
| | - Samantha Craigie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Päivi J Galambosi
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Herney A Garcia-Perdomo
- Division of Urology, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Fang Zhou Ge
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, L8S 4L8, Canada
| | - Huda A Gomaa
- High Institute of Public Health, Alexandria University, Alexandria, Egypt
- Tanta Chest Hospital, Ministry of Health and Population, Tanta, Egypt
| | - Linglong Huang
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Matthew L Izett-Kay
- Urogynaecology Department, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Kirsi M Joronen
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Päivi K Karjalainen
- Department of Obstetrics and Gynecology, Central Finland Central Hospital, Jyväskylä, Finland
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Nadina Khamani
- Department of Obstetrics and Gynecology, Institute of Childrens' Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tuomas P Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti J Kivelä
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tapio Korhonen
- Experts by Experience, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Hanna Lampela
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anne K Mattila
- Central Finland Central Hospital, Department of Surgery, Jyväskylä, Finland
| | - Borna Tadayon Najafabadi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Carolina Nystén
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | - Sanjay Pandanaboyana
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Negar Pourjamal
- Laboratory of Molecular Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Chathura B B Ratnayake
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Auckland City Hospital, Auckland, New Zealand
| | | | - Tino Singh
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Riikka M Tähtinen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
| | - Robin W M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Nephrology & Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yuting Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yingqi Xiao
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- West China School of Nursing/Department of Nursing, West China Hospital, Sichuan University, Chengdu, China
| | - Liang Yao
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Jari Haukka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Clinicum/Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland.
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Tafler K, Kuriya A, Gervais N, Leyland N. Directive clinique no 417 : Prévention de la maladie thromboembolique veineuse en chirurgie gynécologique (In English : Prevention of Venous Thromboembolic Disease in Gynaecological Surgery). JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 44:97-113.e1. [PMID: 33887446 DOI: 10.1016/j.jogc.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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10
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Kadhum M, Elniel AR, Furniss D. Is venous thromboembolism prophylaxis beneficial in upper limb major joint replacement surgery? A systematic review. Shoulder Elbow 2021; 13:119-130. [PMID: 33897843 PMCID: PMC8039759 DOI: 10.1177/1758573219896279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/27/2019] [Accepted: 11/30/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Upper limb arthroplasty is an increasingly used treatment modality for end-stage joint disease of the shoulder, elbow and wrist. Whilst complications have been reported, the risk of venous thromboembolism has received less attention when compared to the lower limb. Guidance to aid clinical decision-making remains limited. This review aims to ascertain whether venous thromboembolism prophylaxis is beneficial after upper limb major joint replacement surgery. METHODS A systematic review was performed in April 2019, utilising EMBASE, MEDLINE, Cochrane and Google Scholar. All clinical studies reporting venous thromboembolism incidence and risk reduction (after prophylaxis) in upper limb joint replacement were included. RESULTS Twenty-four observational studies were identified. The reported incidence of venous thromboembolism ranged from 0.2% to 16% (weighted mean 0.68%) and 0.2% to 0.8% (weighted mean 0.49%) in shoulder and elbow arthroplasty, respectively. No records for wrist arthroplasty were found. In the literature, baseline venous thromboembolism risk of patients without an operation is reported as 0.5%. DISCUSSION There is a lack of good quality evidence regarding the risks and benefits of venous thromboembolism prophylaxis in upper limb major joint replacement surgery. We recommend further research, ideally formal randomised controlled trials to guide recommendations. Although venous thromboembolism is rare in upper limb surgery, surgeons should remain vigilant to this possibility.
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Affiliation(s)
- Murtaza Kadhum
- Nuffield Department of Orthopaedics,
Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of
Oxford, Oxford, UK
| | | | - Dominic Furniss
- Nuffield Department of Orthopaedics,
Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of
Oxford, Oxford, UK
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Nemani A, von zur Mühlen C, Steffen F, Schulte J, Bode C, Krohn-Grimberghe M. Do Inpatients Receive Risk-Based Prophylactic Treatment for Thrombotic Events? Clin Appl Thromb Hemost 2021; 27:1076029621995563. [PMID: 33872084 PMCID: PMC8058795 DOI: 10.1177/1076029621995563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Current guidelines recommend risk-based use of prophylaxis for preventing medical inpatients from venous thromboembolism (VTE). Little is known about the current prescription practice, and even less whether differences between subspecialists like cardiologists, usually treating patients with thrombotic or thromboembolic diseases, and gastroenterologists, treating more patients with gastrointestinal bleeding complications, exist. METHODS We performed a retrospective chart review of patients on cardiology and gastroenterology wards of our university hospital. Patients with a clear indication for anticoagulation and contraindication against antithrombotic treatment were excluded. A total of 450 patients per specialty were included. Quantitative risk assessment models were used to determine the risk of a VTE (Padua Prediction Score (PPS), IMPROVE Score) and bleeding (IMPROVE-Bleeding and HAS-BLED Score). RESULTS The overall rate of VTE prophylaxis was high in both patient populations. Significant more low-risk cardiology compared to gastroenterology patients received drug-based prophylaxis. Furthermore, crucial discrepancies were found in the way individual patients would be classified based on PPS and IMPROVE Score. Finally, not the risk category but the length of hospital stay was best at predicting which patient received prophylaxis.
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Affiliation(s)
- Armin Nemani
- University Heart Center Freiburg – Bad Krozingen, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany
| | - Constantin von zur Mühlen
- University Heart Center Freiburg – Bad Krozingen, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany
| | - Friederike Steffen
- University Heart Center Freiburg – Bad Krozingen, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany
| | - Johannes Schulte
- University Heart Center Freiburg – Bad Krozingen, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany
| | - Christoph Bode
- University Heart Center Freiburg – Bad Krozingen, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany
| | - Marvin Krohn-Grimberghe
- University Heart Center Freiburg – Bad Krozingen, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany
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Mortality risk associated with venous thromboembolism: a systematic review and Bayesian meta-analysis. LANCET HAEMATOLOGY 2020; 7:e583-e593. [PMID: 32735837 DOI: 10.1016/s2352-3026(20)30211-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Venous thromboembolism is associated with increased mortality risk in some populations, but how frequently it is a direct cause of death is unclear. We used data from venous thromboembolism prevention trials to evaluate the causal effect of venous thromboembolism reduction on mortality. METHODS We did a systematic review and meta-analysis of randomised controlled trials (RCTs) evaluating venous thromboembolism prevention. We searched MEDLINE, Embase, PubMed, and Web of Science starting from Jan 1, 1993, to March 19, 2018. We included studies of patients who were at elevated risk of venous thromboembolism and were randomly assigned to either anticoagulant or antiplatelet therapy versus placebo or no treatment. We excluded studies with an active control agent (which might mitigate the lethality of venous thromboembolism) and those for which mortality data were unavailable. We modelled heterogeneity in a Bayesian framework, taking overall mortality as a primary endpoint, and pulmonary embolism, fatal pulmonary embolism, and major bleeding as secondary endpoints. We focused our analyses on studies reporting statistically significant effects of prevention on venous thromboembolism endpoints. We report treatment effects as median risk ratios (RRs), wherein a null effect equals 1, with 95% credible intervals (CrIs). This meta-analysis was registered with PROSPERO, CRD42018089697. FINDINGS From 4229 studies screened, we identified 86 eligible RCTs; 52, with data from over 70 000 patients, were positive, with significantly increased venous thromboembolism risk in patients in control groups versus treatment groups (RR 2·74, 95% CrI 2·32-3·31, p<0·0001). The meta-analysis established that the causal effect of venous thromboembolism prevention on mortality was null (control group mortality was 3391 [9·8%] of 34 537 patients; treatment group mortality was 3498 [9·8%] of 35 795 patients [RR 1·01, 95% CrI 0·97-1·06; p=0·58]) with low heterogeneity (τ 0·02, 95% CrI 0·00-0·07, p=0·89). Patients in control groups had more pulmonary embolism (RR 2·22, 95% CrI 1·78-2·89, p<0·0001) and fatal pulmonary embolism (1·58, 1·14-2·19, p=0·01), but less major bleeding (0·60, 0·47-0·75, p<0·0001) than those in treatment groups. A meta-analysis with the additional 34 negative studies yielded similar results for all endpoints except fatal pulmonary embolism, where evidence of an effect was weaker (1·42, 1·05-1·91, p=0·02). INTERPRETATION The perception that venous thromboembolism is a common cause of mortality should be revised considering the null effect of venous thromboembolism prevention on mortality. Our findings call into question the use of composite endpoints in venous thromboembolism-prevention trials and provide rationale for de-escalation trials. FUNDING None.
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Chahal R, Alexander M, Yee K, Jun CMK, Dagher JG, Ismail H, Riedel B, Burbury K. Impact of a risk‐stratified thromboprophylaxis protocol on the incidence of postoperative venous thromboembolism and bleeding. Anaesthesia 2020; 75:1028-1038. [DOI: 10.1111/anae.15077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2020] [Indexed: 12/13/2022]
Affiliation(s)
- R. Chahal
- Department of Cancer Anaesthesia, Peri‐operative and Pain Medicine Peter MacCallum Cancer Centre Melbourne Vic. Australia
- Centre for Integrated Critical Care University of Melbourne Vic. Australia
| | - M. Alexander
- Peter MacCallum Cancer Centre Melbourne Vic. Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Vic. Australia
| | - K. Yee
- Department of Cancer Anaesthesia, Peri‐operative and Pain Medicine Peter MacCallum Cancer Centre Melbourne Vic. Australia
| | - C. M. K. Jun
- Department of Medicine and Radiology University of Melbourne Vic. Australia
| | - J. G. Dagher
- Department of Medicine and Radiology University of Melbourne Vic. Australia
| | - H. Ismail
- Department of Cancer Anaesthesia, Peri‐operative and Pain Medicine Peter MacCallum Cancer Centre Melbourne Vic. Australia
- Centre for Integrated Critical Care University of Melbourne Vic. Australia
| | - B. Riedel
- Department of Cancer Anaesthesia, Peri‐operative and Pain Medicine Peter MacCallum Cancer Centre Melbourne Vic. Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Vic. Australia
| | - K. Burbury
- Peter MacCallum Cancer Centre Melbourne Vic. Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Vic. Australia
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14
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De León LE, Bravo-Iñiguez CE, Fox S, Tarascio J, Freyaldenhoven S, Lapidot M, Jaklitsch MT, Bueno R. Routine surveillance for diagnosis of venous thromboembolism after pleurectomy for malignant pleural mesothelioma. J Thorac Cardiovasc Surg 2020; 160:1064-1073. [PMID: 32113716 DOI: 10.1016/j.jtcvs.2019.12.115] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 11/18/2019] [Accepted: 12/04/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the incidence of venous thromboembolism and utility of a routine surveillance program in patients undergoing surgery for mesothelioma. METHODS Patients undergoing pleurectomy from May 2016 to August 2018 were included. A standardized surveillance program to look for venous thromboembolism in this group included noninvasive studies every 7 days postoperatively or earlier if symptomatic. All patients received external pneumatic compression sleeves in addition to prophylactic heparin. If deep vein thrombosis or pulmonary embolus was discovered, heparin drip was initiated until conversion to therapeutic anticoagulation. RESULTS A total of 100 patients underwent pleurectomy for mesothelioma. Seven patients were found to have preoperative deep vein thrombosis, and as such only 93 patients were included for analysis. The median age of patients at surgery was 71 years (30-85 years). During the study, 30 patients (32%) developed evidence of thrombosis; 20 patients (22%) developed only deep vein thrombosis without embolism, 3 patients (3%) developed only pulmonary embolism, and 7 patients (7%) developed both deep vein thrombosis and pulmonary embolus. Of the 27 patients who developed deep vein thrombosis, 9 (33%) were asymptomatic at the time of diagnosis, and none of these developed a pulmonary embolus or other bleeding complications. There were 2 (2%) events of major postoperative bleeding related to therapeutic anticoagulation. CONCLUSIONS The incidence of venous thromboembolism is high (32%) among patients undergoing surveillance after pleurectomy for mesothelioma. Up to 33% of patients with deep vein thrombosis are asymptomatic at the time of diagnosis, and the incidence of complications related to anticoagulation is low. Routine surveillance may be useful to diagnose and treat deep vein thrombosis before it progresses to symptomatic or fatal pulmonary embolus.
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Affiliation(s)
- Luis E De León
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Carlos E Bravo-Iñiguez
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Sam Fox
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Jeffrey Tarascio
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Samuel Freyaldenhoven
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Moshe Lapidot
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Michael T Jaklitsch
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Raphael Bueno
- Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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15
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Kim J, Kim HJ, Park S, Kim DK, Kim TH. Predictive Factors of Deep Vein Thrombosis in Gynecologic Cancer Survivors with Lower Extremity Edema: A Single-Center and Retrospective Study. Healthcare (Basel) 2020; 8:healthcare8010048. [PMID: 32120824 PMCID: PMC7151164 DOI: 10.3390/healthcare8010048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/15/2020] [Accepted: 02/25/2020] [Indexed: 11/25/2022] Open
Abstract
This study was conducted to examine predictive factors of deep vein thrombosis (DVT) in gynecologic cancer survivors with lower extremity edema (LEE). In the current single-center, retrospective study, there was a total of 315 eligible patients, including 80 patients with DVT and 235 without DVT. They were therefore divided into two groups: the DVT group (n = 80) and the non-DVT group (n = 235). Then, baseline and clinical characteristics of the patients were compared between the two groups. In our study, distant organ metastasis, advanced stage, lymphadectomy, and amount of intraoperative blood loss had a positive predictive value for the occurrence of DVT in gynecologic cancer survivors presenting LEE. In conclusion, our results indicate that it is necessary to consider the possibility of LEE arising from DVT in gynecologic cancer survivors with advanced-stage cancer, distant organ metastasis, lymphadectomy, and intraoperative blood loss over 1500 mL.
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Affiliation(s)
- Jungin Kim
- Department of Rehabilitation Medicine, Konkuk University Chungju Hospital, Chungju 27478, Korea; (J.K.); (S.P.); (D.K.K.)
| | - Hyun-Jun Kim
- Department of Obstetrics & Gynecology, School of Medicine, Konkuk University, Chungju 27478, Korea;
- Research Institute of Medical Science, Konkuk University School of Medicine, Seoul 05029, Korea
| | - Seunghun Park
- Department of Rehabilitation Medicine, Konkuk University Chungju Hospital, Chungju 27478, Korea; (J.K.); (S.P.); (D.K.K.)
| | - Dong Kyu Kim
- Department of Rehabilitation Medicine, Konkuk University Chungju Hospital, Chungju 27478, Korea; (J.K.); (S.P.); (D.K.K.)
| | - Tae Hee Kim
- Department of Rehabilitation Medicine, Konkuk University Chungju Hospital, Chungju 27478, Korea; (J.K.); (S.P.); (D.K.K.)
- Correspondence: ; Tel.: +82-43-840-8890; Fax: +82-43-840-8968
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16
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Tung EC, Yu SY, Shah K, Kinkade A, Tejani AM. Reassessment of venous thromboembolism and bleeding risk in medical patients receiving VTE prophylaxis. J Eval Clin Pract 2020; 26:18-25. [PMID: 31282101 DOI: 10.1111/jep.13213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The majority of hospitalized nonsurgical medical patients receive pharmacological prophylaxis for venous thromboembolism (VTE), and reassessment of changes in thrombosis and bleeding risk factors during hospital admission may represent an opportunity to discontinue unnecessary or unsafe therapy. The use of validated, clinically derived risk assessment models (RAMs) represents a shift towards an individualized, patient-centred approach to VTE prophylaxis. We are interested in using these tools to assess whether risk categories for VTE and bleeding change during admission and to assess whether such changes result in discontinuation of prophylaxis. Our primary objective was to determine whether VTE and bleed risk categories changed during the course of admission to warrant discontinuation of VTE prophylaxis, using the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE and Bleed RAMs, respectively. Secondary objectives were to determine the number of patients whose risk categorizations for VTE and bleeding warranted discontinuation of VTE prophylaxis and to survey whether prophylaxis was continued or discontinued. METHODS A retrospective review was undertaken for a cross-sectional, randomly selected sample of patients who received VTE prophylaxis while admitted to medical wards in a collection of regional hospitals. RESULTS Of the 351 medical records reviewed, only eight patients (2.3%) changed their VTE risk category and six (1.7%) changed their bleed risk category to warrant discontinuation of VTE prophylaxis. Ninety patients (26%) were at high risk of VTE and low risk of bleed throughout admission, warranting continued VTE prophylaxis. The majority of patients remained at low risk of VTE throughout admission but remained on VTE prophylaxis until discharge. CONCLUSIONS Risk categories for VTE and bleeding for medical patients did not appreciably change throughout hospital admission. Use of VTE RAMs at admission and prior to initiation of therapy should reduce unnecessary prophylaxis in the majority of medical patients who are at low risk of VTE.
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Affiliation(s)
- Elaine C Tung
- Lower Mainland Pharmacy Services, Vancouver, British Columbia, Canada
| | - Shi-Yuan Yu
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kieran Shah
- Lower Mainland Pharmacy Services, Vancouver, British Columbia, Canada
| | - Angus Kinkade
- Lower Mainland Pharmacy Services, Vancouver, British Columbia, Canada
| | - Aaron M Tejani
- Lower Mainland Pharmacy Services, Vancouver, British Columbia, Canada.,Faculty of Medicine, Therapeutics Initiative, University of British Columbia, Vancouver, British Columbia, Canada
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Du W, Zhao X, Nunno A, Li Y, Gu Y. Risk factors for venous thromboembolism in individuals undergoing coronary artery bypass grafting. J Vasc Surg Venous Lymphat Disord 2019; 8:551-557. [PMID: 31619374 DOI: 10.1016/j.jvsv.2019.06.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 06/17/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Venous thromboembolism (VTE) can easily occur after coronary artery bypass grafting (CABG). We assessed the proportion of patients with a diagnosis of VTE after CABG and determined the associated risk factors and complications in these patients. METHODS We assessed all the patients included in the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2015 who had undergone CABG. The demographic characteristics, surgical parameters, and complications were analyzed using single-factor and binary logistic regression analyses to identify the risk factors for VTE after CABG. RESULTS Overall, 8956 patients were identified. Postoperative VTE was found in 1.75% of these patients, with pulmonary embolism and deep vein thrombosis accounting for 0.61% and 1.28%, respectively; 0.15% of the patients had both conditions. The patients who had developed VTE had greater odds of being white and having an American Society of Anesthesiologists classification of ≥5. Multivariate analysis showed that a history of bleeding disorders, congestive heart failure, and operative time of ≥310 minutes were risk factors for the development of postoperative VTE. Patients with VTE had worse outcomes, including greater odds of returning to the operating room, hospitalization, unplanned reoperation, and readmission. The occurrence of VTE was associated with several postoperative complications, including emergency intubation, ventilator time >48 hours, pneumonia, urinary tract infection, peri- and postoperative transfusions, gradual kidney function reduction, acute kidney failure, cardiac arrest necessitating cardiopulmonary resuscitation, myocardial infarction, and septic shock. CONCLUSIONS The overall VTE rate after CABG has been low. However, the condition has been associated with worse 30-day postoperative outcomes and complications. The independent predictors of VTE development included a history of bleeding disorders, congestive heart failure in the 30 days before surgery, and operative time of ≥310 minutes. Understanding these risk factors should aid physicians in the decisions regarding prophylaxis and treatment.
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Affiliation(s)
- Wenting Du
- Department of Geriatrics, Affiliated Longhua Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Aab Cardiovascular Research Institute, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Xiaojie Zhao
- Department of Forensic Medicine, University of Nanjing Medical University, Nanjing, China
| | - Andrew Nunno
- Department of Medical Education, Washington University School of Medicine, St Louis, Mo
| | - Yan Li
- Department of Neurosurgery, University of Rochester School of Medicine and Dentistry, Rochester, NY; Department of Bioinformatics, University of Nanjing Medical University, Nanjing, China
| | - Yun Gu
- Department of Geriatrics, Affiliated Longhua Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China.
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Utilization of the Caprini score in conjunction with thrombodynamic testing reduces the number of unpredicted postoperative venous thromboembolism events in patients with colorectal cancer. J Vasc Surg Venous Lymphat Disord 2019; 8:31-41. [PMID: 31495765 DOI: 10.1016/j.jvsv.2019.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/09/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND The thrombodynamic test (TD) is a novel global test of hemostasis that allows to study the spatial-temporal characteristics of a clot formation in real time under conditions close to natural ones and demonstrates high sensitivity to detect the state of hypercoagulation. The main paraments of the test are the velocity of clot growth, clot's size, and clot density. The objective of this study was to compare the classic Caprini 2005 score and its modified version in association with the results of TD. The goal is to predict postoperative venous thromboembolism (VTE) in surgical patients undergoing surgery for colorectal cancer. METHODS This was a prospective observational clinical study involving 80 patients (33 men and 47 women; mean age, 73.9 ± 7.2 years) who underwent major (79 cases) or minor (1 case) surgery for colorectal cancer. Patients were at high risk for postoperative VTE (ie, a mean Caprini score of 9.9 ± 2.0) and received combined prophylaxis (ie, antiembolic compression stockings and enoxaparin 40 mg once daily) until discharge. Enoxaparin was administered at a fixed time of blood sampling for the TD test. Duplex ultrasound scan was performed to detect postoperative vein thrombosis before and 5 to 7 days after surgery. RESULTS Postoperative vein thrombosis was found in 21 of 80 patients (26.3%; 95% confidence interval, 17.9%-36.8%). Regression analysis and receiver operating characteristic (ROC) curve showed that Caprini scores significantly predicted VTE (P < .0001; area under the curve [AUC] = 0.839 ± 0.045). Analysis of ROC curve coordinates showed that a cutoff point of 11 scores had a sensitivity of 76.2% and a specificity of 74.6%. The results of the TD test showed significant hypercoagulation despite enoxaparin administration in patients with VTE. Regression analysis and ROC curves demonstrated that the following TD parameters had the greatest predictability for postoperative DVT: initial velocity of clot growth (Vin) and clot size (CS) measured at 12 hours after enoxaparin administration (AUC, 0.697 ± 0.063 and AUC, 0.790 ± 0.059, respectively), as well as Vin and CS measured 24 hours after the enoxaparin injection (S = 0.847 ± 0.059 and S = 0.803 ± 0.069, respectively). The cutoff points for VTE prediction at 12 and 24 hours seemed to be a Vin of greater than 62.5 and greater than 64.5 μm/minute (normal range, 35-56 μm/minute) as well as a CS of greater than 1351.5 and greater than 1333.5 μm (normal range, 800-1200 μm), respectively. Identified thresholds for TD parameters have been integrated into Caprini scores under the item "other congenital or acquired thrombophilia." The total Caprini scores were recalculated in patients where one or all TD parameters had exceeded the cutoff followed by reanalysis of the ROC curves. The best predictability was found for Caprini scores considering the elevation of all four TD parameters (AUC, 0.924 ± 0.029) with increased cutoff to a score of 12 with a sensitivity of 85.7% and a specificity of 81.4%. The use of cutoffs for the original and modified scores could be used to calculate the number of patients that were under cutoff but developed with VTE: 10.2% and 5.9%, respectively. CONCLUSIONS Integrating TD parameters into the Caprini score increases the ability to predict postoperative VTE.
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