Extended duration chemoprophylaxis for venous thromboembolism following abdominopelvic oncologic surgery

Clot Between a Rock and a Hard Place: Renal Cell Carcinoma with IVC Tumor Thrombus

Renal cell carcinoma (RCC) is the most common renal cancer and constitutes a significant burden of disease. Tumor thrombus is present in approximately 10% of cases at initial diagnosis and impacts the morbidity and mortality of the disease. The primary treatment for RCC involves resection of the tumor. The presence of tumor thrombus, therefore, is not only important for prognosis but also for operative planning. Operative approach, including vascular control and caval closure are important consideration when resecting RCC with inferior vena cava (IVC) tumor thrombus and varies based on the patient presentation, extent of the tumor, and the surgeon's experience. This article presents a patient with RCC with IVC thrombus who ultimately underwent surgical resection with general surgery, vascular surgery, and urology to showcase the multidisciplinary care, surgical considerations, and current management and treatment strategies for RCC with tumor thrombus.

Is Extended-Duration (Post-Hospital Discharge) Venous Thromboembolism Chemoprophylaxis Safe and Efficacious in High-Risk Surgery Patients? A Systematic Review

BACKGROUND

The risk of venous thromboembolism (VTE) persists beyond hospitalization in surgical patients, yet post-hospital discharge chemoprophylaxis regimens are not common. The purpose of this study is to systematically review the literature regarding extended-duration (post-hospital discharge) venous thromboembolism chemoprophylaxis and to determine whether it is warranted in high-risk surgical patients, as determined by its safety and efficacy.

METHOD

We searched four online databases for articles evaluating extended-duration (post-hospital discharge) VTE chemoprophylaxis regimens in surgical patients between the years January 2000 and February 2020. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used. GRADE methodology and the Cochrane Risk of Bias Assessment Tool for Randomized Controlled Trials were used to grade the quality of evidence and assess risk of bias.

RESULTS

Nineteen studies with 10,544 patients were analyzed. The duration for extended-duration VTE chemoprophylaxis ranged from 7 to 42 days. In our study cohort, high-risk patients not prescribed extended-duration VTE chemoprophylaxis had a mean VTE incidence rate of 12.23%, while patients receiving 28-30 days of chemoprophylaxis had a mean VTE incidence rate of 4.37% (p = 0.006). The risk of bleeding events did not correlate with the duration of chemoprophylaxis.

CONCLUSION

Extended-duration VTE chemoprophylaxis in high-risk surgical patients decreased the incidence of thrombotic complications without increasing the risk of bleeding events. Further research is needed to establish guidelines for the optimal duration of VTE chemoprophylaxis in high-risk surgical patients.

LEVEL OF EVIDENCE

III.