VTE prevention in surgical settings: A top priority in clinicians checklist. Episode 1 - Dr. Abhay Bhave and Prof. Juan Arcelus

This edition of the podcast will focus upon:
•    Incidence of VTE among patients undergoing surgery
•    Type of surgeries which pose a higher post-operative risk of VTE
•    Utilization of universally accepted and validated risk assessment tools for patients undergoing surgery
•    Practical tips on managing the fine balance between thrombosis risk and risk of bleeding

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Transcription

00:00 - 00:24

Unknown

Welcome to VTE Unplugged, a brand new podcast series curated by Sanofi. Today, let's listen to Professor Juan Arcelus in conversation with Dr. Abhay Bhave, as they discuss on an interesting topic of VTE prevention in surgical settings, a top priority in clinician’s checklist.

00:28 - 02:20

Dr. Abhay Bhave

Hello friends, I'm Dr. Abhay Bhave. I'm a hematologist and hemato oncologist practicing in Mumbai, India. It is my absolute pleasure to welcome you back for ongoing series of podcast sessions, titled VTE Unplugged, which is an educational initiative by Sanofi India, which will bring together experts in the field of venous thromboembolism to talk in several interesting and at times controversial aspects.

 

Today, we will be focusing on another topic of great interest titled VTE prevention in surgical settings, a top priority in a clinician's checklist. And it is a great honor to have Professor Juan Arcelus,Chairman of the Department of Surgery at the University of Granada Medical School in Spain, who has research interests in the risk assessment, epidemiology, diagnosis, prevention and follow-up of VTE that’s venous thromboembolism, particularly in surgical patients. He has more than 150 papers in peer review journals, written 32 book chapters, and is a frequent review of a several journals, including the journal of thrombosis and hemostasis, the annals of surgery just among others. And he's a member of the International Board of JAMA Surgery since the last decade. Professor Arcelus has been a panelist in the 9th ACCP guidelines for antithrombotic and thrombolytic therapy, and also the 2013 and 2015 updates of the ASCO guidelines on the prevention and treatment of VTE in cancer patients. He was also a panelist for the last 2019 edition of the ASCO guidelines on the management of VTE. Professor Juan Arcelus, I welcome you on behalf of all our listeners.

02:21 - 02:22

Professor Juan Arcelus

Thank you. My pleasure.

02:24 - 02:37

Dr. Abhay Bhave

So, can we begin with the questions where I think the first question which everyone has in their mind, professor, is to ask you, what is the incidence of VTE among your patients who are going to undergo surgery.

02:38 - 04:32

Professor Juan Arcelus

Thank you very much. Well, as I said, that it's a pleasure to participate here. I want to thank you of course, between my interviewer and Sanofi for making this possible. So, when we talk about incidents, we must be very careful because the large majority of postoperative DVTs particularly are asymptomatic. Indeed, in the 70s, 80s, there were a lot of studies with the screening tools like fibrinogen, isotopictest, venography and then came ultrasound, showing that in patients without prophylaxis undergoing major abdominal surgery, you could expect between 20%, 30% of DVTs identified by these techniques mainly in the, in the lower legs, in major orthopedic surgery, the rate could go up to 50%. However, in current practice, international daily practice. Now the incidents of symptomatic VTE in patients undergoing high risk surgeries, cancer surgery, major orthopedic, bariatric, etcetera, it's around 2% in the first month, but if you prolong the follow-up and that's very important, at least for three months in some oncological surgeries, these incidents are insist of symptomatic DVT, or can go up to 6%, 8% at the three months. So, VTE remains a problem. Today we focus more on symptomatic than asymptomatic, but as I said that 2% at one month is a very, very universal rate, despite prophylaxis, although that prophylaxis could have different levels of quality.

04:33 - 04:53

Dr. Abhay Bhave

Thank you, Professor for that. So, if you're going to face VTE in surgeries, then do you feel that there are certain surgeries or certain procedures that the treating physicians or the surgeons must perceive as a higher risk for getting a VTE in that operative phase?

04:54 - 07:14

Professor Juan Arcelus

Yeah. That's a very pertinent question. Thank you very much, Dr. Bhave. Yeah, of course. There are some operations that probably you don't need to look for other risk factors, you know, if you undergo major orthopedic surgery, meaning by that total, total hip arthroplasty, total knee arthroplasty, or hip fracture surgery, that's a very high risk situation. Major cancer surgery, particularly abdominal pelvic is a high risk situation almost by itself. We not as we will probably come in later bariatric surgery, or I would also say surgery in very obese patients is a high risk surgery.

 

We have emerging evidence very interesting in the last 20 years that inflammatory bowel disease, particularly colectomies in patients with ulcerative colitis has a risk equivalent to the colorectal cancer surgery. So, that'sanother surgery that we need to pay attention, of course, major trauma surgery from the point of view of joints and bones, or even solid organs, like the spleen, liver, etcetera, these patients, sometimes they have a combination of different injuries.That's a high risk situation. We have there a major release of tissue factor in mobility, probably the femur, in the femur with a large fracture, etcetera, that increased the risk.

 

And also, I want to warn here that some so-called minor risks surgeries like abdominal wall, laparoscopic cholecystectomy, even appendectomy, intestinal extraction. Those are not considered the risky operations, but we must always do take into consideration the risks associated to the patient undergoing this operation. I think we will discuss about that later. So, there's a list I mentioned are there main, of course we could add nearer surgery. We can add other procedures, but those are the probably today, the ones associated with higher rates of VTE. Thank you.

07:15 - 07:48

Dr. Abhay Bhave

Thank you, Professor. That was really interesting and some good points came out of that. Now that we know that there's a risk of VTE in our patients.Can you please tell us, how we should go about doing a risk assessment? Because we believe that we've got two ways of doing the risk stratification, the RogersScore and the Caprini Score. So, audience would love to know from you and your thoughts, when should we apply these scores and is one better than the other, or one should use one system for a specific type of cohort of patients?

07:50 - 13:16

Professor Juan Arcelus

Well, thank you. Indeed, this is a very interesting complimentary question to the previous one. The previous one you were asking about the procedures. I mentioned that the patient is important. Here we go. Yes, we have to, we have to know not only that how risk is the operation, but how risk is the patient from an intrinsic perspective? We could say, the factors in hearing to the patient, once that come with the patient to the hospital, the weight, the age, past history of VTE, the disease that makes the patient susceptible candidate to surgery, but also what we do with the patient apart from the hour, in mobility, central lines complications, that we are not able to avoid length of hospital stay, etcetera. As you mentioned, the ACCP adapted and adopted two scores, the Rogers and the Caprini. The Rogers Score, I don’t know your experience in India, but I haven't seen any center in Spain using the Rogers Score. I don't think it has really been adopted by many hospitals. And I think there are two reasons. Number one, the proper model declares that is for moderate risk surgery, moderate thrombotic risk, and also it needs some lab resultsI think. So, it’s more complicated. It was nicely designed. There was a large cohort of patients with their evasion cohort and validation cohort, but I don't think it has been really adopted and accepted. On the contrary, the Caprini Score. And first of all, I want to declare my conflict of interest regarding the Caprini Score since I was his fellow from 1989 to 1992 in Chicago. And I helped him to develop this, the first publication ever done with the Caprini Score. Two of them came inseminars in thrombosis in 1991 in medical and surgical patients. And I was part of that story. So, I'm very proud that this has been validated in over a hundred patients in different surgical populations, even in medical populations.

 

However, when we talk of the Caprini Score, which one, because of course the Caprini Score has been evolving during the time. Probably I would recommend the audience to use the adaptation of the ACCP to the 2005 Cabrini Model. That was the one that was validated in 8,000 patients by Vinita Bahl (ph) and co-workers in the paper published in annals of surgery. So, the classical 2000 Caprini Score considers high risk when the patient has a score, total score of five. Of course, many, many high risk surgical patients, it's very easy that they reach five. So, we will have a lot of patients from either of high risk, probably because that will mean probably VT rate over 2%.

 

There is a trend from United States, it’s a little bit empirically, particularly from the Boston Medical Center that are doing a terrific job with the Caprini Score. There is a trend to shift a little bit to the right, the cutting point for high risk. And Panucci published a paper saying that from seven on, it would be wise to use pharmacological prophylaxis. And in the US now some hospitals, if you have over nine, they consider that you deserve pharmacological prophylaxis. And even in some centers, empirically they're correlating the score with the need for prolonged prophylaxis. And now the reset committee, we meet almost every week virtually with Caprini and the Boston Medical Center and the American Venous Forum. We're trying to update the Caprini Score, including new factors that are very important, like the length of surgery, you know, considering two points over 45 minutes, most operations, most major operations last more than 45 minutes.

 

So now there are new cutting points, new BMI cutting points, length of hospital stay, postoperative complications. So, I think the Caprini too has been, as I said, validated in many, many, many, actually in the latest in this month, annals of surgery.There is a very interesting paper by Lovastaufin (ph) Moscow about the addition of intermittent pneumatic compression to pharmacological prophylaxis, depending on the Caprini Score. So, we need to improve the Caprini Score. There are applications based onyour mobile phone that made very, very easy. It's not such a time consuming procedure to score a patient with the Caprini Score. So, I hope in a couple of years, we will have a new, hopefully prospectively revised Caprini Score. Thank you.

13:17 - 13:49

Dr. Abhay Bhave

Thank you very much Prof. That was a really lovely insight into the scoring system. And I think we are much more comfortable using the Caprini and I didn't realize you were part of the initial Caprini scoring system. So, congratulations for that. But while we agree to use these risk assessment tools, many of us surgeons are a little bit worried about the bleeding events. So, how do you evaluate whether a person will not have bleeding when you're going to use some thromboprophylaxis? How do you look at it?

13:50 - 17:34

Professor Juan Arcelus

Oh yeah, this is the other side of the coin. You know, this is a balance when you're talking of thrombosis, I’m leaving this scale. So, the more aggressive you are trying to avert any DVT, of course, you're going probably to overdose the patient or prolong, you know, unnecessarily. And you can go to the other side. Also any surgical procedure by definition implies, I believe in risk. The problem we have with bleeding assessment in surgical patients is that as far as I know, we don't have a seriously prospectively validated score. On the contrary, our colleagues in the medical field who have been much behind as surgeons in the field of VTE thing that the first trial ever published in VTE prevention was done in 1975, the first important trial on medical patients with enoxaparin prophylaxis by Professor Senoma (ph) were done in the late 80s.

 

So however, for bleeding, because they have these comorbidities, they have these elderly patients. Of course, they are very much concerned with bleeding problems and they have the signed tools to try to assess the risk towards the major risk of DVT and also of bleeding likely improve model for example saying that I think we need to teach our juniors, our students, and junior residents to bring a notebook in their white coats with the table provided in the 2012 9th AACP guideline the chapter I took part, there is a table very interesting that on top has the personnel risk factors for bleeding related to the patient, you know, active bleeding, bleeding tendency, thrombocytopenia, severe hypertension, renal failure, liver failure. That’s always that they need to keep in mind. And also that table in that chest supplement includes a list of surgeries with potential for bleeding.

 

Needless to say that an intracranial surgery, you cannot accept that there's a slightest bleeding inside the cranium because of the devastating consequences, but pancreatic surgery, prostate surgery, cardiac surgery, vascular surgery. So, you need to apply like Joe Caprini says, when you don't have a guideline, look for a doctor, we are doctors and you have to apply your clinical reasoning, and this should be done on continuous daily basis, you know, the risks, the potential bleeding risk is not the same on the first postoperative data and on the seventh post-operative day is not the same if the patient has to be re-operated, the perception of the bleeding is the patient has an open drain, drainage, it’s not the same that if the patient doesn't have it. So, the nice guidelines very popular in the UK also include a list of potential contraindications for the use of anticoagulants based on the potential for bleeding. So, I'm sorry. I cannot recommend any, any validated score for bleeding, but I can recommend this list of logical and well-proven situations where you should be careful, or you should just avoid any anticoagulant on board.

17:35 - 17:48

Dr. Abhay Bhave

Thank you, Professor Juan Arcelus. I think what you've told us is that clotting and bleeding events in a surgical patient, and they might be moving targets and we have to be careful and keep a watch on what's happening to our patient bedside.

17:54 - 18:03

Unknown

Thank you for joining us today. Watch out this space as we bring to you next part of the ongoing discussion between Professor Juan Arcelus and Dr. Abhay Bhave.

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