What are the AACP guidelines for prevention and treatment of 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

In 2012, the American College of Chest Physicians (ACCP) published the ninth edition of its guidelines on antithrombotic therapy and prevention of thrombosis (updated from the eighth edition published in 2009). [35]  ACCP guidelines providing recommendations for the prevention of VTE in orthopedic surgery patients addressed therapy and prevention. [83]  Recommendations included the following:

  • In patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA), use of one of the following is recommended for a minimum of 10-14 days rather than no antithrombotic prophylaxis: LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose UFH (LDUH), adjusted-dose vitamin K antagonist (VKA), aspirin (all grade 1B), or an intermittent pneumatic compression device (IPCD) (grade 1C)
  • In patients undergoing hip fracture surgery (HFS), use of one of the following is recommended rather than no antithrombotic prophylaxis for a minimum of 10 to 14 days: LMWH, fondaparinux, LDUH, adjusted-dose VKA, aspirin (all grade 1B), or an IPCD (grade 1C)
  • For patients undergoing major orthopedic surgery (THA, TKA, HFS) and receiving LMWH as thromboprophylaxis, it is recommended to start either 12 hr or more preoperatively or 12 hr or more postoperatively rather than within 4 hr or less preoperatively or 4 hr or less postoperatively (grade 1B)
  • In patients undergoing THA or TKA, irrespective of the concomitant use of an IPCD or length of treatment, LMWH is suggested in preference to the other agents recommended as alternatives: fondaparinux, apixaban, dabigatran, rivaroxaban, LDUH (all grade 2B), adjusted-dose VKA, or aspirin (all grade 2C)
  • In patients undergoing HFS, irrespective of the concomitant use of an IPCD or length of treatment, LMWH is suggested in preference to the other agents recommended as alternatives: fondaparinux, LDUH (grade 2B), adjusted-dose VKA, or aspirin (all grade 2C)
  • For patients undergoing major orthopedic surgery, it is suggested to extend thromboprophylaxis in the outpatient period for up to 35 days from the day of surgery rather than for only 10-14 days (grade 2B)
  • In patients undergoing major orthopedic surgery, dual prophylaxis with an antithrombotic agent and an IPCD is suggested during the hospital stay (grade 2C)
  • In patients undergoing major orthopedic surgery and increased risk of bleeding, an IPCD or no prophylaxis is suggested rather than pharmacologic treatment (grade 2C)
  • In patients undergoing major orthopedic surgery and who decline or are uncooperative with injections or an IPCD, use of apixaban or dabigatran (alternatively, rivaroxaban or adjusted-dose VKA if apixaban or dabigatran are unavailable) is recommended rather than alternative forms of prophylaxis (all grade 1B)
  • In patients undergoing major orthopedic surgery, it is suggested not to use inferior vena cava (IVC) filter placement for primary prevention over no thromboprophylaxis in patients with an increased bleeding risk or contraindications to both pharmacologic and mechanical thromboprophylaxis (grade 2C)
  • For asymptomatic patients following major orthopedic surgery, it is recommended not to perform Doppler (or duplex) ultrasonography (DUS) screening before hospital discharge (grade 1B)
  • No prophylaxis is suggested rather than pharmacologic thromboprophylaxis in patients with isolated lower-leg injuries requiring leg immobilization (grade 2C)
  • For patients undergoing knee arthroscopy without a history of prior VTE, no thromboprophylaxis is suggested rather than prophylaxis (grade 2B)

An update in 2016 addressed 12 topics from the ninth edition guidelines, as well as three new topics. [91]


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