Venous thromboembolism prophylaxis in high-risk orthopedic and cancer surgery

Effects and Complications of Apixaban versus Aspirin for Venous Thromboembolism Prophylaxis after Total Hip or Knee Arthroplasty

BACKGROUND

Major orthopaedic procedures, such as total hip arthroplasty (THA) and total knee arthroplasty (TKA), carry risk for thrombotic complications. To reduce the incidence of postoperative venous thromboembolism (VTE), surgical patients are often prescribed antiplatelet or anticoagulant treatment. The objective of this study was to compare rates of VTE events and complications between apixaban and aspirin for VTE prophylaxis following primary THA and TKA.

METHODS

We searched a research network using Current Procedural Terminology and International Classification of Diseases, Tenth Revision codes for patients who underwent a THA or TKA from 2018 to 2023. Patients were then categorized into cohorts of patients who received only aspirin (81 or 325 mg, twice daily) or patients who received only apixaban (2.5 mg, twice daily) for VTE prophylaxis. Odds ratios with 95% confidence intervals were calculated to compare the associations of selected prophylaxis with VTE events and complications, and Chi-square analyses were performed to determine the significance of differences. Statistical significance was defined as a two-sided alpha value < 0.05.

RESULTS

Patients who received apixaban after THA had increased odds of deep vein thrombosis (5.22, 4.60 to 5.93), pulmonary embolism (7.85, 6.55 to 9.41), transfusion (1.5, 1.27 to 1.81), hemarthrosis (1.87, 1.26 to 2.24), myocardial infarction (1.12, 1.03 to 1.23), and readmission (1.18, 1.09 to 1.28) within 90 days after surgery. Patients who received apixaban after TKA had increased odds of deep vein thrombosis (4.57, 4.15 to 5.02), pulmonary embolism (6.05, 5.33 to 6.88), transfusion (1.6, 1.36 to 1.96), hemarthrosis (1.48, 1.03 to 2.12), myocardial infarction (1.42, 1.29 to 1.63), stroke (1.16, 1.09 to 1.53), and readmission (1.84, 1.61 to 2.11) within 90 days after TKA.

CONCLUSIONS

Apixaban is associated with increased odds of thrombotic events and bleeding complications in the postoperative period of THA and TKA compared to aspirin. This highlights the potential risks associated with apixaban use and the importance of using data to guide patient management in the absence of standardized clinical guidelines.

The 2024 Korean Enhanced Recovery After Surgery (ERAS) guidelines for colorectal cancer: a secondary publication

The Korean Enhanced Recovery After Surgery (ERAS) Committee within the Korean Society of Surgical Metabolism and Nutrition was established to develop ERAS guidelines tailored to the Korean context. This guideline focuses on creating the most current evidence-based practice guidelines for ERAS purposes, based on systematic reviews. All key questions targeted randomized controlled trials exclusively, and if fewer than 2 were available, studies employing propensity score matching were also included. Recommendations for each key question were marked with strength of recommendation and level of evidence following internal and external review processes by the committee.

Is Aspirin Safe for Thromboprophylaxis After Surgery for Lower Extremity Neoplastic Pathologic Fractures?

BACKGROUND AND OBJECTIVES

Both malignancy and orthopedic surgery are known risk factors for developing venous thromboembolism (VTE). Therefore, this study aimed to compare VTE rates among patients receiving enoxaparin, apixaban, rivaroxaban, or aspirin (ASA).

METHODS

The Premier Healthcare Database was utilized to identify all patients who underwent surgery for neoplastic pathologic fractures of the lower extremities from 2015 to 2021. Four cohorts based on receipt of ASA, apixaban, enoxaparin, or rivaroxaban were identified. Propensity matching with the enoxaparin cohort as the comparator was performed. Patient demographics, hospital factors, comorbidities, and 90-day complications were compared.

RESULTS

From 2015 to 2021, 3762 patients underwent surgical intervention for neoplastic pathologic fracture of the lower extremities. Enoxaparin recipients showed significantly lower aggregate VTE rates than those on apixaban (p = 0.008) while exhibiting higher VTE occurrence than ASA-treated patients (p = 0.050).

CONCLUSION

Our study demonstrates that the administration of enoxaparin in patients undergoing surgical intervention for neoplastic pathologic fractures of the lower extremities may lead to significantly higher rates of aggregate VTE postoperatively compared to ASA. This data suggests that further research is warranted to determine if surgeons may safely consider using ASA in patients with no other reported risk factors or need for anticoagulation postoperatively, even in active malignancy.

Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review

Importance

Direct oral anticoagulants (DOACs), comprising apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used medications to treat patients with atrial fibrillation and venous thromboembolism. Decisions about how to manage DOACs in patients undergoing a surgical or nonsurgical procedure are important to decrease the risks of bleeding and thromboembolism.

Observations

For elective surgical or nonsurgical procedures, a standardized approach to perioperative DOAC management involves classifying the risk of procedure-related bleeding as minimal (eg, minor dental or skin procedures), low to moderate (eg, cholecystectomy, inguinal hernia repair), or high risk (eg, major cancer or joint replacement procedures). For patients undergoing minimal bleeding risk procedures, DOACs may be continued, or if there is concern about excessive bleeding, DOACs may be discontinued on the day of the procedure. Patients undergoing a low to moderate bleeding risk procedure should typically discontinue DOACs 1 day before the operation and restart DOACs 1 day after. Patients undergoing a high bleeding risk procedure should stop DOACs 2 days prior to the operation and restart DOACs 2 days after. With this perioperative DOAC management strategy, rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) are low and delays or cancellations of surgical and nonsurgical procedures are infrequent. Patients taking DOACs who need emergent (<6 hours after presentation) or urgent surgical procedures (6-24 hours after presentation) experience bleeding rates up to 23% and thromboembolism as high as 11%. Laboratory testing to measure preoperative DOAC levels may be useful to determine whether patients should receive a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure.

Conclusions and Relevance

When patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging. When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.

Aspirin versus low-molecular-weight heparin for thromboprophylaxis after orthopaedic surgery: a systematic review and meta-analysis

The article aimed to compare the efficiency and safety of aspirin with low-molecular-weight heparin (LMWH) for thromboprophylaxis in orthopaedic surgery patients. According to the inclusion and exclusion criteria, PubMed, Embase and Cochrane Library database were searched for studies comparing aspirin and LMWH in venous thromboembolism (VTE) prophylaxis until 25 April 2023. The outcome measures included deep venous thrombosis(DVT)/Pulmonary embolism(PE) events, major bleeding events, wound complications, wound infection and death. Six studies met the requirements of our meta-analysis, including 12 470 patients in the aspirin group and 10 857 patients in the LMWH group. The meta-analysis showed that results showed that LMWH was superior to aspirin in preventing VTE events (odds ratio (OR) 1.44, 95% CI 1.24-1.68, P  < 0.00001), whereas there was no significant difference between them in bleeding events (OR 0.95, 95% CI 0.86-1.05, P  = 0.33), wound complication (OR 0.58, 95% CI 0.28-1.17, P  = 0.13), wound infection (OR 1.12, 95% CI 0.86-1.47, P  = 0.39) and mortality (OR 1.04, 95% CI 0.70-1.55, P  = 0.83). In addition, subgroup analysis showed that compared with aspirin, LMWH was more likely to reduce the incidence of DVT events in orthopaedic surgery patients (OR 1.59, 95% CI 1.33-1.91, P  < 0.00001), whereas there was no advantage in reducing the incidence of PE events (OR 1.22, 95% CI 0.62-2.40, P  = 0.56). Despite the similar safety profiles, this meta-analysis showed that LMWH was significantly superior to aspirin in thromboprophylaxis after orthopaedic surgery. LMWH was still the first-line drug for thrombosis prevention in patients who underwent major orthopaedic surgeries.

Compliance status and influencing factors of anticoagulation therapy in outpatient undergoing major orthopedic surgery

PURPOSE

This study was designed to investigate influencing factors of out-of-hospital anticoagulation therapy compliance among patients undergoing major orthopaedic surgeries.

METHODS

A cross-sectional, descriptive study was conducted from July 2022 to February 2023 among outpatients who underwent major orthopedic surgery in our hospital. Patients (n = 200) were surveyed using the General Information Questionnaire, the General Self-Efficacy Scale, the Specificity of Medication-Taking Beliefs Scale, and the Morisky Medication Adherence Scale. Factors that influenced patient compliance were also determined using univariate and multivariate regression analyses.

RESULTS

One hundred eighty-three valid questionnaires were returned, the compliance with outpatient anticoagulation therapy among patients undergoing major orthopaedic surgeries was good in 56.3% (103/183) of all cases and poor in 43.7% (80/183). Multivariate logistic regression analysis showed that medication duration, adverse effects, self-efficacy and medication beliefs influenced adherence to out-of-hospital anticoagulation therapy in patients undergoing major orthopedic surgery (P < 0.05).

CONCLUSIONS

Poor compliance with out-of-hospital anticoagulation therapy in patients undergoing major orthopedic surgery is mainly associated with a long course of medication, adverse reactions, low self-efficacy and low medication beliefs. Healthcare staff should strengthen post-discharge anticoagulation management based on relevant influencing factors to enhance patient compliance.

Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline

BACKGROUND

The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug.

METHODS

Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines.

RESULTS

A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures.

CONCLUSIONS

Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.

Postoperative Thromboembolism According to the Type of Surgery: A Nationwide Study in the Republic of Korea

Postoperative thromboembolism (TE) is a serious, but preventable, complication in surgical patients. Orthopedic surgery, neurosurgery, and vascular surgery are considered high risk for TE, and current guidelines recommend TE prophylaxis. However, insufficient data exist regarding TE risk in other general surgeries. This study identified the actual incidence and relative risk of postoperative TE in the real world, according to surgery type. Twenty-six surgeries between 1 December 2017 and 31 August 2019 were selected from the Health Insurance Review and Assessment Service database and analyzed for postoperative TE events. Among all patients, 2.17% had a TE event within 6 months of surgery and 0.75% had a TE event owing to anticoagulant treatment. The incidence of total TE events was the highest in total knee replacement (12.77%), hip replacement (11.46%), and spine surgery (5.98%). The incidence of TE with anticoagulant treatment was the highest in total knee replacement (7.40%), hip replacement (7.20%), and coronary artery bypass graft (CABG) surgery (3.81%). Hip replacement, total knee replacement, CABG surgery, spine surgery, and cardiac surgery except CABG surgery, showed relatively higher risks for total claimed venous TE. The relative risk of venous TE with anticoagulant treatment was the highest for hysterectomy, partial hepatectomy, hip replacement, cardiac surgery except CABG surgery, and total knee replacement. The relative risk of arterial TE was the highest for cardiac surgery, total knee replacement, and hip replacement. In the real world, the incidence of postoperative TE events from total knee replacement and those from hip replacement remain high, and some surgeries could have a relatively higher risk of TE than other surgeries. For patients undergoing these surgeries, studies to reduce the incidence of postoperative TE in clinical practice should be conducted.