Risk of venous thromboembolism after endoprosthetic surgeries: lower versus upper extremity endoprosthetic surgeries

Comparison of low molecular weight heparin, aspirin, and their combination for the prevention of thrombosis after total knee arthroplasty in obese patients

Purpose

Patients undergoing total knee arthroplasty (TKA) are at a high risk of thromboembolic events, which is higher in obese patients. Determining the appropriate prophylaxis for venous thromboembolism (VTE) in obese patients is challenging. Therefore, we aimed to compare the effects of low molecular weight heparin (LMWH) with aspirin (ASA) and their combination for the prevention of thromboembolic events after TKA in obese patients.

Methods

In a retrospective study, 245 obese patients with BMIs over 30 who underwent TKA were enroled. Eligible patients were divided into three groups: Group A was given LMWH sodium (Clexane®) for 14 days, Group B was given ASA for 14 days, and Group C was given LMWH sodium (Clexane®) for 5 days and then ASA twice daily for the days between 5 and 14 postoperatively. The primary outcome was the incidence of VTE within three months. Secondary outcomes included routine laboratory evaluations (PT, PTT, INR, Hb, Hct, platelets, BUN and Cr) and adverse effects of ASA and LMWH, such as bleeding, anaemia, thrombocytopenia, and gastrointestinal or neurological symptoms.

Results

Regarding the incidence of DVT and PTE, we did not observe significant differences between groups (p > 0.05). A total of seven symptomatic VTE was observed in six patients. We observed two cases with PE who were in the Clexane group. Moreover, five individuals had DVT in the follow-up: three cases in the Clexane group, one in the ASA group, and one in the ASA + Clexane group, which was not statistically significant (p > 0.05). There were no differences between groups regarding the risk of adverse events and complications.

Conclusion

We found that ASA is not inferior to enoxaparin in reducing VTE after TKA in obese patients. Therefore, given ASA's low cost and greater convenience, it may be considered a reasonable alternative for extended VTE prophylaxis for TKA surgery in obese patients.

Level of Evidence

Level III.

Catheter-related thrombosis after cardiac surgery in patients with both central venous and pulmonary artery catheters inserted into the right internal jugular vein: a single-center, prospective, observational study

Central venous catheters (CVCs) and pulmonary artery catheters (PACs) are widely used in intensive care and perioperative management. The detection and prevention of catheter-related thrombosis (CRT) are important because CRT is a complication of catheter use and can cause pulmonary embolism and bloodstream infection. Currently, there is no evidence for CRT in patients using both CVC and PAC. We conducted a single-center, prospective, observational study to identify the incidence, timing, and risk factors for CRT in patients undergoing cardiovascular surgery and using a combination of CVC and PAC through the right internal jugular vein (RIJV). Out of 50 patients, CRT was observed using ultrasonography in 39 patients (78%), and the median time of CRT formation was 1 day (interquartile range: 1-1.5) after catheter insertion. The mean duration of PAC placement was 3 days (interquartile range: 2-5), and the maximum diameter of CRT was 12 mm (interquartile range: 10-15). In short-axis images, CRT occupied more than half of the cross-sectional area of the RIJV in five patients (10%), and CRT completely occluded the RIJV in one patient (2%). Platelet count, duration of PAC placement, and intraoperative bleeding amount were found to be high-risk indicators of CRT. In conclusion, patients who underwent cardiovascular surgery and using both CVC and PAC had a high incidence of CRT. Avoiding unnecessary PAC placement and early removal of catheters in patients at high risk of developing CRT may prevent the development of CRT.

Venous thromboembolism in patients hospitalized for knee joint replacement surgery

Patients undergoing knee joint replacement (KJR) are at high risk of postoperative venous thromboembolism (VTE), but data on the time trends of VTE rate in this population are sparse. In this analysis of the German nationwide inpatient sample, we included all hospitalizations for elective primary KJR in Germany 2005-2016. Overall, 1,804,496 hospitalized patients with elective primary KJR (65.1% women, 70.0 years [IQR 63.0-76.0]) were included in the analysis. During hospitalization, VTE was documented in 23,297 (1.3%) patients. Total numbers of primary KJR increased from 129,832 in 2005 to 167,881 in 2016 (β-(slope)-estimate 1,978 [95% CI 1,951 to 2,004], P < 0.001). In-hospital VTE decreased from 2,429 (1.9% of all hospitalizations for KJR) to 1,548 (0.9%) cases (β-estimate - 0.77 [95% CI - 0.81 to - 0.72], P < 0.001), and in-hospital death rate from 0.14% (184 deaths) to 0.09% (146 deaths) (β-estimate - 0.44 deaths per year [95% CI - 0.59 to - 0.30], P < 0.001). Infections during hospitalization were associated with a higher VTE risk. VTE events were independently associated with in-hospital death (OR 20.86 [95% CI 18.78-23.15], P < 0.001). Annual number of KJR performed in Germany increased by almost 30% between 2005 and 2016. In parallel, in-hospital VTE rates decreased from 1.9 to 0.9%. Perioperative infections were associated with higher risk for VTE. Patients who developed VTE had a 21-fold increased risk of in-hospital death.

Symptomatic Venous Thromboembolism in Patients with Malignant Bone and Soft Tissue Tumors: A Prospective Multicenter Cohort Study

BACKGROUND

A prospective cohort study was conducted to determine the incidence and risk factors of symptomatic venous thromboembolism (sVTE) during the perioperative period in patients with malignant bone and soft tissue tumors.

METHODS

Patients with newly diagnosed primary malignant bone and soft tissue tumors for whom definitive surgery was planned were consecutively registered among 27 tertiary hospitals specializing in musculoskeletal oncology. Clinicopathological information on each patient was collected prospectively, and careful follow-up was conducted for 6 months after surgery. The study endpoint was the occurrence of sVTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE).

RESULTS

Eleven of 929 patients developed sVTE, including 8 patients with DVT, 2 with PE, and 1 with both, making the incidence of sVTE 1.18%. The median time until the development of sVTE after tumor resection was 11 days, ranging from - 7 to 95 days. Multiple logistic regression analyses revealed that ischemic heart disease as a comorbidity, maximum tumor diameter exceeding 8 cm, and elevated preoperative platelet count were independent risk factors for sVTE.

CONCLUSIONS

The incidence of sVTE in this series of patients with bone and soft tissue sarcomas was 1.18%, which was relatively lower than in previous retrospective studies. We identified the risk factors for sVTE specific to patients with malignant bone and soft tissue tumors, and these included ischemic heart disease, tumor size, and elevation of the preoperative platelet count.

Venous thromboembolism prophylaxis in patients undergoing knee replacements: comparison of real-world outcomes

Background Increasing evidence for the use of the aspirin in patients undergoing an orthopaedic surgery for venous thromboembolism prophylaxis has led to a change in the national guidelines substituting anticoagulants with aspirin. Little is known about the impact of such substitution on real-world outcomes from clinical practice. Objective The study was designed to examine clinical outcomes associated with the use of aspirin and apixaban. Setting Two large-scale general hospitals in West Yorkshire region of England. Method A 1-year observational study among adults who underwent elective knee replacements and received venous thromboembolism prophylaxis within the first 14 days post replacements. Main outcome measure The incidence of postoperative venous thromboembolism, leaking wounds during the hospital stay, and 30-day any readmission for the two drugs. Results A total of 420 patients were included. There was a significant drop in apixaban prescribing (from 80.37 to 10.51%) and increase in aspirin use (from 19.02 to 81.71%) after the implementation of the revised guidelines. There were 52 (12.38%) cases of leaking wound, 16 (3.81%) cases of postoperative venous thromboembolism, 45 (10.71%) cases of 30-day readmission and no case of 30-day major bleeding. The leaking wounds and 30-day readmissions were almost twice more frequent in obese compared to non-obese patients. Multivariate logistic regression found an increased risk of leaking wound with apixaban and postoperative venous thromboembolism and 30-day readmission with aspirin use but the differences were not statistically significant. Conclusion The results suggest aspirin to be as effective as apixaban in preventing venous thromboembolism and readmission. Apixaban usage decreased with a corresponding increase in Aspirin use. The impact of obesity and length of hospital stay need further investigations.