Perioperative thromboembolism

The annual incidence of VTE following surgery is estimated to be 70,000 to 600,000.

The appropriate use of VTE prophylaxis in postoperative patients is safe and effective, but the incidence of VTE remains high. 

Primary VTE prophylaxis is underused.

Postoperative VTE can be reduced by early ambulation, mechanical methods, and pharmacoprophylaxis with antiplatelet and anti-thrombotic agents. 

Pharmacoprophylaxis carries the potential risk of bleeding.

The incidence of VTE following general surgery varies with the patient and surgery specific characteristics: the presence of malignancy or inflammatory bowel disease and emergency surgery associated with increased risk.

VTE following an elective laparoscopic appendectomy in the healthy patient is 0. 5% compared with 6% in a patient requiring emergent appendecomy or who has inflammatory bowel disease.

The risk for postoperative bleeding in general surgery related to pharmacoprophylaxis requiring a change of care occurs in less than 3% of patients.

Prophylaxis for a VTE in general surgery is based on patient in surgery specific risks with consideration of the estimated bleeding risk.

VTE rates following bariatric surgery range between 0.3% and 2.2%, and less invasive operations may be associated with lower risk.

VTE risk and bariatric surgery is increased with open operations, bypass versus adjustable band surgery, longer operation of duration of three hours or greater, revision surgery, and postoperative anastomotic leak.

There is variable risk of VTE with urologic surgeries ranging from 0.3 to 15. 7%, but overall most nonmalignant  urologic surgeries are associated with a low risk of VTE.

VTE rates following GYN operations range from 0.4% to 6.5%,and risk factors include open surgery, underlying malignancy, perioperative blood transfusion, and previous pelvic radiation.

Extended duration of thromboprophylaxis for several days or weeks after the hospital dismissal have demonstrated a reduction in VTE in patients undergoing abdominal or pelvic operations compared with placebo, without increases in bleeding.

Extended duration thromboprophylaxis is suggested for patients undergoing operations for abdominal or pelvic malignancies because of the high rate of VTE due to restricted mobility, obesity, history of VTE.

The rate of VTE in patients following plastic and reconstructive operation ranges between 0.5 and 7.7%. 

In such cases the type of operation and anesthesia have an impact on the risk of postoperative VTE. 

High-risk operations include: breast reconstruction, body contouring, abdominoplasty, major operations of the lower extremity, head and neck cancer operations, and operations lasting greater than 60 minutes.

Bleeding risk associated with the use of chemoprophylaxis increases the rates of hematoma requiring reoperation in less than 1% of plastic surgery operations.

The incidence of VTE following ear nose and throat operation is low.

The risk of VTE following cardiac surgery varies with the surgical techniques and use of cardio pulmonary bypass.

The use of intraoperative anti-platelet and ant–thrombotic medication reduces the risk of VTE following cardiac operations.

The risk of postoperative symptomatic thrombosis from cardiac surgery ranges from 0.5% to 3%.

Others have found that post cardiac surgery thrombosis rates are three times higher than that of the general surgery population.

A large observation study found no differences in the rate of VTE and major bleeding in patient’s receiving no prophylaxis, mechanical prophylaxis or subcutaneous heparin following coronary artery bypass graft suggesting pharmacoprophylaxis should be reserved for only the highest risk patients.

The rate of VTE following vascular surgery ranges from 0.2% to 4.2%.

The intraoperative use of anti-platelet and antithrombotic therapy reduces the risk of postoperative VTE in vascular surgery.

Risk factors for post vascular surgery VTE include: pre-operative steroid use, hypoalbuminemia, poor preoperative functional status, postoperative complications of prolonged mechanical ventilation, perioperative transfusion, postoperative pneumonia, and wound infections.

Pharmacoprophylaxis is considered in patients with moderate and high risk of VTE to prevent postoperative vascular surgery VTE.

The use of routine thrombosis prophylaxis in patients after total hip and knee arthroscopy has decreased rates of pulmonary embolus to less than 0.2% of patients.

The CRISTAL study compared aspirin for thromboprophylaxis with enoxaparin, a low molecular weight heparin,  after primary total hip or knee arthroscopy for osteoarthritis and was found that the VTE rate was significantly lower with enoxaparin compared to aspirin (1.82% versus 3.5%): there was a greater number of the below knee DVT events in the aspirin group.

However, the rates postoperative mortality of 0.1% was low for both prophylactic anticoagulant and aspirin, and the incidence of clinically important VTE was low with aspirin,as well,  suggesting that major thrombolic events after total joint arthroplasty are uncommon with aspirin.

Surgical procedures for trauma are high risk for both postoperative VTE and bleeding: 8.7% have VTE without prophylaxis, and the risk of bleeding following trauma surgery is estimated to be 3.4 to 4.7%.

Pharmacoprophylaxis is recommended for all trauma patients with consideration of a combined mechanical and pharmacological prophylaxis in patients at high risk for VTE.

Following neurosurgery the rate of VTE depends on the type of operation and associated comorbidities.

Craniotomy and non-traumatic intracranial hemorrhage are high risk for VTE, whereas most elective operations of the spine are considered low risk, less than 1%.

Risk factors of postoperative VTE with neurosurgery include perioperative iMmobility and paresis as well as complicated or prolonged procedures.

Mechanical and pharmacological prophylaxis is effective in preventing VTE following operations of the spine and brain.

Pharmacoprophylaxis should be initiated within 72 hours of surgery (24-48 hours).


Leave a Reply

Your email address will not be published. Required fields are marked *