Aspirin as Venous Thromboembolism Prophylaxis in Total Joint Arthroplasty

A Narrative Review of the Current Evidence

Dustin Rinehart, MD; Tyler Youngman, MD; Michael Huo, MD

Disclosures

Curr Orthop Pract. 2021;32(4):383-389. 

In This Article

Abstract and Introduction

Abstract

The utilization of aspirin (acetylsalicylic acid ASA) as primary prophylaxis for venous thromboembolism (VTE) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) in the United States has increased in concordance with the number of arthroplasty procedures being completed. The available literature regarding dosage, duration, efficacy, and safety varies considerably. This review assessed the recent published literature for both the efficacy and safety of aspirin as VTE prophylaxis. Overall, the rates of symptomatic VTE found in the literature ranged from 0.1% to 4.1%, of deep vein thrombosis (DVT) 0.1% to 3.0%, and of pulmonary embolism (PE) 0.1% to 1.5%. As for secondary outcome measures, the rate of major bleeding from either a gastrointestinal source or at the surgical site ranged from 0% to 3.2%, and the rate of transfusion between 7.0% to 20.0%. Among the studies that reported the infection rates, it ranged from 0.1% to 6.1%. The 90-day mortality rate was 0% to 0.23%. The available data and evidence remain inconclusive with regard to ASA dosage or the duration for patients after TKAs and THAs. However, ASA appears to be an effective option for VTE prevention when utilized as part of a multimodal approach to prophylaxis that includes early mobilization and mechanical compression devices.

Introduction

The volume of total joint arthroplasty in the United States (US) is estimated to increase to nearly 600,000 total hip arthroplasties (THAs) and more than 3 million total knee arthroplasties (TKAs) annually by 2030.[1] One of the more prevalent and potentially fatal complications of THAs and TKAs is venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). The clinical incidence of VTE has been reduced significantly using appropriate thromboembolic prophylaxis. It is estimated that 1% of patients would develop VTE after surgery.[2] Historically, the incidence of VTE was as high as 40% or higher after total joint arthroplasty surgeries.[3]

At present in the US, there are two evidence-based guidelines with regard to VTE prophylaxis after total joint arthroplasty surgeries. These are the guidelines from the American College of Chest Physicians (ACCP) and the American Academy of Orthopaedic Surgeons (AAOS).[3–5] Although there are agreements between the two guidelines, there remain differences and controversies. The ACCP recommends the use of one of the following for either THA or TKA: low molecular weight heparin, fondaparinux, or warfarin with target INR 2.5. Notably they recommend against the use of aspirin (acetylsalicylic acid ASA) for VTE prophylaxis.[3] The AAOS recommendations include some form of VTE prophylaxis, including ASA, with agent selection through surgeon discretion. The AAOS tends to place an emphasis on surgical wound complications and other adverse events of chemoprophylaxis,[5] thus leading to a differing opinion from ACCP on the use of ASA. ASA works by inhibiting cyclooxygenase-1 in platelets, resulting in the prevention of platelet aggregation and deposition.[6] The rise of ASA began in the late 1980s and early 1990s with the Pulmonary Embolism Prevention Trial Collaborative Group being one of the first to demonstrate the effectiveness of ASA in prevention of VTE after elective arthroplasty.[7] There are a variety of reasons for the increased popularity of ASA: ease of dosing, low cost, and no required blood monitoring. The use of ASA continued to rise in conjunction with advances in anesthesia practices, arthroplasty techniques, and rapid mobilization protocols.

The use of any chemoprophylaxis inherently needs to be both efficacious in VTE prevention and be free from postoperative complications such as bleeding and infection. There has been an evolution of a variety of chemoprophylaxis used for VTE prevention in both THAs and in TKAs over the past 5 decades. Much controversy remains with regard to the use of ASA in this patient population. The purpose of this review was to examine the data from the most current orthopaedic publications with regard to the efficacy and the safety of using ASA after total joint arthroplasty surgeries.

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