What are the indications for prophylaxis against venous thromboembolism (VTE)?

Updated: Nov 05, 2020
  • Author: Vera A De Palo, MD, MBA, FCCP; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
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Answer

Multimodal prophylaxis

Multimodal VTE prophylaxis typically includes the following:

  • Discontinuance of procoagulant medications
  • VTE risk stratification
  • Regional anesthesia
  • IV bolus of UFH before femoral preparation
  • Rapid mobilization
  • Use of pneumatic compression devices
  • Chemoprophylaxis tailored to the patient's risk of VTE

In a study that included 257 patients with a proven history of VTE (DVT, PE, or both) who underwent 277 primary elective THAs, Gonzalez Della Valle et al assessing the safety and efficacy of multimodal prophylaxis within the first 120 postoperative days and the mortality during the first year. [81] Multimodal prophylaxis was found to be safe and effective. Very few patients developed VTE (2.5%) or died of suspected or confirmed PE; thus, postoperative anticoagulation should be prudent. Mortality during the first year was mostly unrelated to either VTE or bleeding.

Postoperative risk

The results of one study suggested that routine postdischarge prophylaxis should be considered for high-risk patients. The study evaluated the risk of postdischarge VTE in patients who had undergone cancer surgery. Using data from 44,656 patients who underwent surgery for nine cancers, the results showed that VTE occurred post discharge at an overall rate of 33.4%. VTE was significantly more likely after gastrointestinal, lung, prostate, and ovarian/uterine operations. [82]

For patients undergoing major orthopedic surgery, the ACCP evidence-based guidelines recommended the use of either LMWH; fondaparinux; dabigatran, apixaban, and rivaroxaban (for total hip arthroplasty or total knee arthroplasty but not for hip fracture surgery); low-dose UFH; adjusted-dose VKA; aspirin (all grade 1B evidence); or an intermittent pneumatic compression device (grade 1C evidence) for a minimum of 10-14 days rather than no antithrombotic prophylaxis. [83]

Elderly surgical patients are at increased risk for VTE. In September 2017, the European Society of Anesthesiology published guidelines for VTE prophylaxis in this population (see Guidelines). [84]

Prophylactic practice

In a survey of members of the American Association of Hip and Knee Surgeons, more than 70% of survey participants reported that their primary hospital now mandates prophylaxis for VTE. The survey looked at VTE protocols for lower-extremity total joint surgery. LMWH was considered to be the most efficacious for prophylaxis, but aspirin was considered to be the easiest to use, with the lowest risks of bleeding and wound drainage. Warfarin was the most used agent in hospital prophylaxis, and 90% of respondents targeted an INR of 1.6-2.5. [85]

A randomized, double-blind phase III study comparing rivaroxaban with SC enoxaparin found that the primary outcome of composite of any DVT, nonfatal PE, or death from any cause up to day 17 after surgery occurred in 67 (6.9%) of 965 patients who received oral rivaroxaban 10 mg/day as compared with 97 (10.1%) of 959 patients who were given enoxaparin 30 mg SC every 12 hours for the prevention of VTE after total knee arthroplasty. [86]

Pooled data from four phase III studies comparing rivaroxaban (10 mg/day) with SC enoxaparin (either 40 mg once daily or 30 mg every 12 hours) for VTE after total hip or knee arthroplasty showed that the composite of symptomatic VTE and all-cause mortality was  lower in the rivaroxaban group (29/6183 rivaroxaban patients [0.5%] vs 60/6200 enoxaparin patients [1.0%]). This reduction in symptomatic VTE plus all-cause mortality was consistent across all prespecified subgroups. There were no statistically significant differences in major bleeding or nonmajor clinically relevant bleeding. [87]

After reviewing the published literature, the American College of Physicians (ACP) determined that it would not support the use of measures for universal VTE prophylaxis in patients if such measures were performed without regard to risk. [88] It was reported in the study that in nonsurgical patients, heparin prophylaxis had no significant effect on mortality and led to more bleeding and bleeding events, which suggested that it was of little or no benefit overall. In addition, no improvements in clinical outcomes were found with mechanical prophylaxis, which also resulted in an increase in lower-extremity skin damage in stroke patients.


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