Prevention of VTE in Orthopedic Surgery Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

Department of Medicine, School of Medicine, Case Western Reserve University, Case and VA Medical Center, 10701 East Blvd, Cleveland, OH 44106, USA.
Chest (Impact Factor: 7.48). 02/2012; 141(2 Suppl):e278S-325S. DOI: 10.1378/chest.11-2404
Source: PubMed


VTE is a serious, but decreasing complication following major orthopedic surgery. This guideline focuses on optimal prophylaxis to reduce postoperative pulmonary embolism and DVT.
The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.
In patients undergoing major orthopedic surgery, we recommend the use of one of the following rather than no antithrombotic prophylaxis: low-molecular-weight heparin; fondaparinux; dabigatran, apixaban, rivaroxaban (total hip arthroplasty or total knee arthroplasty but not hip fracture surgery); low-dose unfractionated heparin; adjusted-dose vitamin K antagonist; aspirin (all Grade 1B); or an intermittent pneumatic compression device (IPCD) (Grade 1C) for a minimum of 10 to 14 days. We suggest the use of low-molecular-weight heparin in preference to the other agents we have recommended as alternatives (Grade 2C/2B), and in patients receiving pharmacologic prophylaxis, we suggest adding an IPCD during the hospital stay (Grade 2C). We suggest extending thromboprophylaxis for up to 35 days (Grade 2B). In patients at increased bleeding risk, we suggest an IPCD or no prophylaxis (Grade 2C). In patients who decline injections, we recommend using apixaban or dabigatran (all Grade 1B). We suggest against using inferior vena cava filter placement for primary prevention in patients with contraindications to both pharmacologic and mechanical thromboprophylaxis (Grade 2C). We recommend against Doppler (or duplex) ultrasonography screening before hospital discharge (Grade 1B). For patients with isolated lower-extremity injuries requiring leg immobilization, we suggest no thromboprophylaxis (Grade 2B). For patients undergoing knee arthroscopy without a history of VTE, we suggest no thromboprophylaxis (Grade 2B).
Optimal strategies for thromboprophylaxis after major orthopedic surgery include pharmacologic and mechanical approaches.

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    • "Administration of low molecular weight heparin (LMWH) is recommended for prophylaxis of venous thromboembolism (VTE) in patients undergoing hip surgery (Falck-Ytter et al. 2012). In this context, heparininduced thrombocytopenia (HIT) type II is a well-known, immune-mediated complication of rare incidence (1–6.5 % in orthopaedic patients, depending on type of heparin), but sometimes fatal outcome (Linkins et al. 2012; Girolami and Girolami 2006; Picker and Gathof 2004). "
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    ABSTRACT: Administration of low molecular weight heparin (LMWH) is recommended for prophylaxis of venous thromboembolism in patients undergoing hip surgery. In this context, heparin-induced thrombocytopenia (HIT) type II is a complication of rare incidence but sometimes fatal outcome. A 52-year old obese patient undergoing antithrombotic therapy with Enoxaparin after hip surgery presented with a painful, swollen leg and thrombocytopenia on day eight after surgery. Medical history showed previous administration of Enoxaparin without complications 2 years ago. Further diagnostic investigation supplied evidence of multiple thromboembolic events and concomitant compartment syndrome. Administration of Enoxaparin was stopped immediately and treatment with Argatroban was initiated. Diagnosis of HIT was confirmed according to current guidelines. Despite interventional thrombectomy and fasciotomy, amputation of both lower limbs had to be performed due to ongoing necroses. After a 30-days-stay at the intensive care unit because of sepsis, respiratory and renal failure, clinical condition improved and the patient could be transferred for rehabilitation. HIT II is known as complication of administration of LMWH in the perioperative setting. Diagnosis results from clinical findings and platelet count. Argatroban is recommended as an alternative therapeutic anticoagulant in HIT II. Inflammation and surgical trauma are discussed as priming factors to increase risk of HIT II. Administration of LMWH may result in HIT II despite prior uneventful drug exposure. Except for immediate diagnosis, only consequent anticoagulation can stop the course of disease. Hence, interdisciplinary awareness is inevitable for early diagnosis and accurate therapy to prevent from a catastrophic clinical course.
    SpringerPlus 08/2015; 4(1):421. DOI:10.1186/s40064-015-1174-5
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    • "The thromboprophylaxis after major orthopedic surgery including THR is a well-accepted treatment, but the duration of the treatment has been a matter of debate for years [10]. The most recent version of the American College of Chest Physicians (ACCP) guidelines, from 2012, recommends use of anticoagulation drugs for a minimum of 10 to 14 days with grade 1B evidence and suggests extending prophylaxis for up to 35 days with grade 2B evidence [11]. The National Institute for Health and Care Excellence (NICE) guidelines from 2012 also recommended prophylaxis for 28-35 days, depending on the summary of product characteristics for the individual agent being used [12], whereas the guidelines from the American Academy of Orthopedic Surgeons (AAOS) from 2011 recommend individual assessment of the most optimal duration of thromboprophylaxis without any elaboration regarding which THR patients might benefit from extended prophylaxis [13]. "
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    ABSTRACT: Clinical trials have provided evidence about efficacy and safety of extended thromboprophylaxis among total hip replacement (THR) patients. There is a lack of evidence on effectiveness and safety of extended treatment in unselected patients from routine clinical practice. We examined the effectiveness and safety of short (1-6 days) and standard (7-27 days) compared with extended (≥28days) thromboprophylaxis using population-based design. Among all primary THR procedures performed in Denmark from 2010 through 2012 (n=16,865), we calculated adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for risk of symptomatic venous thromboembolism (VTE) and major bleeding, in addition to net clinical benefit, defined as the number of VTE avoided minus the number of excess bleeding events occurring among patients prescribed short-term and standard versus extended treatment. The 90-day risks of VTE were 1.1% (short), 1.4% (standard), and 1.0% (extended), yielding aHRs of 0.83 (95% CI: 0.52-1.31) and 0.82 (95% CI: 0.50-1.33) for short and standard versus extended treatment. The risk of major bleeding was 1.1% (short), 1.0% (standard), and 0.7% (extended), resulting in aHRs of 1.64 (95% CI: 0.83-3.21) and 1.24 (95%CI: 0.61-2.51) for short and standard versus extended thromboprophylaxis. Direct comparison between benefits and harms using net clinical benefit analyses did not favor any of the three treatment durations. The same results were found for VTE or death. In a real-word observational cohort of unselected THR patients, we observed no difference in the risks of symptomatic VTE, VTE/ death or bleeding with respect to thromboprophylaxis duration. Copyright © 2014 Elsevier Ltd. All rights reserved.
    Thrombosis Research 12/2014; 135(2). DOI:10.1016/j.thromres.2014.11.029 · 2.45 Impact Factor
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    • "It is recommended that patients undergoing total hip or knee arthroplasty surgery receive a minimum of 10–14 days of antithrombotic therapy because they are at high risk of postoperative VTE. Treatment can reduce the risk of deep-vein thrombosis (DVT) by 50–60 % and pulmonary embolism (PE) by up to 66 % [42]. "
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    ABSTRACT: Edoxaban is a once-daily oral anticoagulant that rapidly and selectively inhibits factor Xa in a concentration-dependent manner. This review describes the extensive clinical development program of edoxaban, including phase III studies in patients with non-valvular atrial fibrillation (NVAF) and symptomatic venous thromboembolism (VTE). The ENGAGE AF-TIMI 48 study (N = 21,105; mean CHADS2 score 2.8) compared edoxaban 60 mg once daily (high-dose regimen) and edoxaban 30 mg once daily (low-dose regimen) with dose-adjusted warfarin [international normalized ratio (INR) 2.0–3.0] and found that both regimens were non-inferior to warfarin in the prevention of stroke and systemic embolism in patients with NVAF. Both edoxaban regimens also provided significant reductions in the risk of hemorrhagic stroke, cardiovascular mortality, major bleeding and intracranial bleeding. The Hokusai-VTE study (N = 8,292) in patients with symptomatic VTE had a flexible treatment duration of 3–12 months and found that following initial heparin, edoxaban 60 mg once daily was non-inferior to dose-adjusted warfarin (INR 2.0–3.0) for the prevention of recurrent VTE, and also had a significantly lower risk of bleeding events. Both studies randomized patients at moderate-to-high risk of thromboembolic events and were further designed to simulate routine clinical practice as much as possible, with edoxaban dose reduction (halving dose) at randomisation or during the study if required, a frequently monitored and well-controlled warfarin group, a well-monitored transition period at study end and a flexible treatment duration in Hokusai-VTE. Given the phase III results obtained, once-daily edoxaban may soon be a key addition to the range of antithrombotic treatment options. Electronic supplementary material The online version of this article (doi:10.1007/s40265-014-0261-1) contains supplementary material, which is available to authorized users.
    Drugs 07/2014; 74(11). DOI:10.1007/s40265-014-0261-1 · 4.34 Impact Factor
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