This review provides guidance for optimal venous thromboembolism (VTE) prophylaxis strategy and recommends including thrombosis- and bleeding-risk assessment in preoperative evaluation for all patients. It updates existing guideline recommendations based on recent studies across multiple surgical specialties.

Key Takeaway

  • Of note, VTE is a serious and possibly fatal complication in case of surgical interventions.
  • Strategies currently adopted for postoperative VTE management are unable to eradicate the risk of VTE.
  • Judicious prophylactic management (mechanical or pharmacological prophylaxis) can significantly reduce the risk of VTE (particularly in high-risk patients or with high-risk operations), but there should be a cautious balance between benefit vs risk.
  • Thoughtful risk stratification is critical for determining the optimal VTE prophylaxis strategy.
  • Bartlett et al. recommend that all patients should undergo thrombosis- and bleeding-risk assessment during preoperative evaluation.

Why This Matters

  • Using antithrombotic therapy for prevention of VTE may be associated with excess postoperative bleeding risk.
    • Bartlett et al. discuss VTE risk assessment models, along with patient- and operation-specific risk factors for postoperative bleeding.

  • Various guidelines available for postoperative VTE prevention are either outdated or do not address specific population groups or surgical specialties.

    • This review article updates existing guideline recommendations based on recent studies across various surgical specialties.

Key Highlights

Primary VTE prophylaxis is underutilized

  • In this review article, Bartlett et al. illustrate their approach for postoperative VTE prevention. However, recommendations presented in this article are limited to adult, nonpregnant patients.

Key approach to perioperative VTE prophylaxis*

  • Before hospital admission*: (1) Full history and physicalexamination — assess baseline VTE risk (Caprini score),operation-specific risk, and other unaccounted risk factors;assess patients bleeding risk , procedure-specific bleeding risk,and other unaccounted risk factors; and (2) address modifiablerisk factors (thrombosis/bleeding risk) *

  • Hospital admission*: (1) Preoperative — initiate prophylaxis strategy (mechanical, pharmacological, or combined), if indicated; (2) intraoperative — address modifiable risk factors, and regular reassessments of VTE and bleeding risk (transition to a more/less aggressive prophylaxis as indicated); (3) postoperative — address modifiable risk factors§

  • Hospital discharge*: (1) Consider extended duration prophylaxis, if indicated ; and (2) patient/family education (signs/symptoms [seek help for symptoms]/conservative measures to prevent VTE [ambulation/avoid dehydration])

Risk factors for major postoperative bleeding

  • Amongst some surgical specialties, there is significant variability in VTE and bleeding risk, demanding special considerations for applying VTE prophylaxis

  • Key general risk factors: Bleeding; severe renal or hepatic failure; thrombocytopenia; acute stroke; uncontrolled hypertension; lumbar puncture, anesthesia (within previous 4 hours or next 12 hours); use of anticoagulants, antiplatelets, NSAIDs, thrombolytic drugs; cardiac surgery; craniotomy; spinal surgery/trauma; and reconstructive procedures (free flap)

  • Procedure specific risk factors : (1) Abdominal surgery — male sex, preoperative hemoglobin level <13 g/dL, malignancy, complex surgery; (2) pancreaticoduodenectomy — sepsis, pancreatic leak, sentinel bleed; (3) hepatic resection — number of segments, concomitant extrahepatic organ resection, primary liver malignancy, preoperative anemia/thrombocytopenia; (4) cardiac surgery — older age, BMI >25 kg/m2 , concomitant antiplatelet therapy, nonelective surgery, longer bypass time, placement ≥5 grafts, operation other than CABG; (5) thoracic surgery — pneumonectomy, extended resection, primary or metastatic malignancy; (6) orthopedic surgery — difficult to control surgical bleeding, extensive surgical dissection, revision surgery; (7) trauma surgery — severe head injuries, conservatively managed liver or spleen injuries, spinal column fracture with epidural hematoma, pelvic fractures

Prophylaxis recommendations (stratified by surgical specialty/estimated VTE Risk)

(1) Very low risk of VTE (Caprini score 0): No additional prophylaxis; (2) low risk of VTE (Caprini 1–2): mechanical or pharmacological prophylaxis; and (3) moderate (Caprini 3–4) to high risk of VTE (Caprini ≥5): pharmacological prophylaxis either alone or in combination with mechanical prophylaxis

  • Patients at high risk of bleeding: Mechanical prophylaxis until risk of bleeding is reduced (pharmacological prophylaxis can be reconsidered)

  • Caprini score not validated: Prophylaxis based on individual and procedure-specific risk factors (continued until patient is ambulatory or until hospital dismissal [longer durationscan be considered])

  • Key pharmacological prophylactic agents included ¶,§ : Heparins (low-molecular-weight [LMWH]/low-dose unfractionated  [LDUH]); vitamin K antagonists; direct oral anticoagulants; pentasaccharides; and aspirin

  • In most surgery types ¶,§ , LMWH prophylaxis was recommended for moderate/high risk VTE and average bleeding risk

    • Enoxaparin§ : Recommended for abdominal surgery, total hip arthroplasty, total knee arthroplasty, hip fracture surgery

For full details (Bartlett et al.):* Table1; † figure;‡ table 3;§ table 5 (prophylaxis options/compliance/duration/dosing/general or specific considerations); table 4/section on extended prophylaxis (strategy per surgery type).

    1. Bartlett MA, Mauck KF, Stephenson CR, Ganesh R, Daniels PR. Perioperative Venous Thromboembolism Prophylaxis. Mayo Clin Proc. 2020;95(12):2775–2798. doi: 10.1016/j.mayocp.2020.06.015. PMID: 33276846

MAT-BH-2200810/v1/Oct 2022