Ariel E. Saldaña, Ronald J. Pérez.
Response/Recommendation: It appears that coadministration of aspirin (ASA) with pneumatic compression devices (PCD) may be more effective than ASA alone in prevention of venous thromboembolism (VTE) following total joint arthroplasty (TJA).
Strength of Recommendation: Moderate.
Rationale: Multiple studies in the literature have analyzed the concomitant use of ASA and PCD in prevention of VTE1–17. Two studies have specifically evaluated the question on hand11,18.
The study by Snyder et al., was a randomized control trial (level II) that assessed the difference in the rate of deep venous thrombosis (DVT) following total knee arthroplasty (TKA) using ASA-based prophylaxis with or without extended use of mechanical PCD therapy. One hundred patients undergoing TKA, were placed on ASA for three weeks and were randomized to receive PCD during hospitalization only or extended use at home up to six weeks post-operatively. Lower extremity Duplex venous ultrasonography was used to diagnose DVT at different time intervals. The rate of DVT was significantly lower for patients receiving extended use of PCD at 0% compared to 23.1% for those with inpatient use of PCD (p < 0.001)11.
Another study by Daniel et al., was a retrospective review (level III) of the clinical records of 463 consecutive patients undergoing primary total hip arthroplasty (THA) (487 procedures) to determine the incidence of DVT. In 258 procedures, (244 patients) PCD were not used, whereas, in 229 procedures (219 patients) bilateral PCD were utilized. Doppler ultrasound screening for DVT was performed in all patients between the fourth and sixth post-operative days. No symptomatic calf or DVT. Asymptomatic DVT was detected in 25 patients (10.2%) in the cohort not receiving PCD and ten patients (4.6%) receiving PCD (p = 0.03)18.
In another study (Level II) Colwell Jr, et al., evaluated the effectiveness of a mobile compression device with or without ASA compared with current pharmacological protocols for prophylaxis against VTE in patients undergoing elective primary unilateral arthroplasty. Among 3,060 patients in the entire cohort, 28 patients (0.92%) had VTE of which 23 patients (0.72%) developed DVT, and five (0.16%) developed pulmonary embolism (PE). The rate of symptomatic VTE among the cohort receiving mobile compression device was similar in patients receiving mobile compression devices compared to those receiving chemoprophylaxis6.
The study by Sharrock et al., (level III) performed a systematic review to determine the incidence of all-cause mortality and PE in patients undergoing TJA. They found that the incidence of all-cause mortality non-fatal PE was higher in patients receiving low-molecular-weight heparin (LMWH) compared to those receiving ASA and PCD. Group A than in Group B (0.41 vs. 0.19%) and (0.60 vs. 0.35%), respectively. The latter study provided further support for the use of PCD and ASA as VTE prophylaxis in patients undergoing TJA10.
Crawford et al., retrospectively reviewed the incidence of symptomatic VTE in 1,131 patients undergoing outpatient primary TKA who used a portable PCD as part of their VTE prevention protocol. An ASA-based VTE prophylaxis was used in patients who had a standard-risk for VTE. High-risk patients received a stronger chemoprophylaxis for two weeks followed by ASA for four weeks. PCD were worn for 23 hours/day for 14 days. They concluded that the use of portable PCD as part of a multimodal VTE prophylaxis protocol led to a very low rate of symptomatic VTE events in patients undergoing outpatient primary TKA5.
In another level III evidence study, Khatod et al., examined whether a best prophylactic agent exists for the prevention of post-operative PE and whether the type of anesthesia affects the rates of PE. Patients received either mechanical prophylaxis alone (N = 1,533), ASA alone (N = 934), warfarin (n = 6,063), LMWH (n = 7,202) with or without mechanical prophylaxis. No clinical differences were detected in the rate of VTE between different types of prophylaxis or the types of anesthesia. Notably, in the ASA group, 874 patients also received PCD, and 60 patients did not have PCD. In this small cohort size, there was no difference in the rate of PE, or mortality between the two groups2.
Based on the available literature, it appears that coadministration of PCD with ASA is likely to reduce the rate of VTE further in patients undergoing TJA.
1. Deirmengian GK, Heller S, Smith EB, Maltenfort M, Chen AF, Parvizi J. Aspirin Can Be Used as Prophylaxis for Prevention of Venous Thromboembolism After Revision Hip and Knee Arthroplasty. The Journal of Arthroplasty. 2016;31(10):2237-2240. doi:10.1016/j.arth.2016.03.031
2. Khatod M, Inacio MCS, Bini SA, Paxton EW. Prophylaxis Against Pulmonary Embolism in Patients Undergoing Total Hip Arthroplasty. Journal of Bone and Joint Surgery. 2011;93(19):1767-1772. doi:10.2106/JBJS.J.01130
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6. Colwell CW, Froimson MI, Anseth SD, et al. A Mobile Compression Device for Thrombosis Prevention in Hip and Knee Arthroplasty. Journal of Bone and Joint Surgery. 2014;96(3):177-183. doi:10.2106/JBJS.L.01031
7. Nam D, Nunley RM, Johnson SR, Keeney JA, Barrack RL. Mobile Compression Devices and Aspirin for VTE Prophylaxis Following Simultaneous Bilateral Total Knee Arthroplasty. The Journal of Arthroplasty. 2015;30(3):447-450. doi:10.1016/j.arth.2014.10.018
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10. Sharrock NE, Gonzalez Della Valle A, Go G, Lyman S, Salvati EA. Potent Anticoagulants are Associated with a Higher All-Cause Mortality Rate After Hip and Knee Arthroplasty. Clinical Orthopaedics & Related Research. 2008;466(3):714-721. doi:10.1007/s11999-007-0092-4
11. Snyder MA, Sympson AN, Scheuerman CM, Gregg JL, Hussain LR. Efficacy in Deep Vein Thrombosis Prevention With Extended Mechanical Compression Device Therapy and Prophylactic Aspirin Following Total Knee Arthroplasty: A Randomized Control Trial. The Journal of Arthroplasty. 2017;32(5):1478-1482. doi:10.1016/j.arth.2016.12.027
12. Patel AR, Crist MK, Nemitz J, Mayerson JL. Aspirin and compression devices versus low-molecular-weight heparin and PCD for VTE prophylaxis in orthopedic oncology patients. J Surg Oncol. 2010;102(3):276-281. doi:10.1002/jso.21603
13. Westrich GH, Bottner F, Windsor RE, Laskin RS, Haas SB, Sculco TP. VenaFlow Plus Lovenox vs VenaFlow Plus Aspirin for Thromboembolic Disease Prophylaxis in Total Knee Arthroplasty. The Journal of Arthroplasty. 2006;21(6):139-143. doi:10.1016/j.arth.2006.05.017
14. Gonzalez Della Valle A, Shanaghan KA, Nguyen J, et al. Multimodal prophylaxis in patients with a history of venous thromboembolism undergoing primary elective hip arthroplasty: safety, efficacy, and one-year survival. The Bone & Joint Journal. 2020;102-B(7_Supple_B):71-77. doi:10.1302/0301-620X.102B7.BJJ-2019-1559.R1
15. Vulcano E, Gesell M, Esposito A, Ma Y, Memtsoudis SG, Gonzalez Della Valle A. Aspirin for elective hip and knee arthroplasty: a multimodal thromboprophylaxis protocol. International Orthopaedics (SICOT). 2012;36(10):1995-2002. doi:10.1007/s00264-012-1588-4
16. Polkowski GG, Duncan ST, Bloemke AD, Schoenecker PL, Clohisy JC. Screening for Deep Vein Thrombosis After Periacetabular Osteotomy in Adult Patients: Is It Necessary? Clinical Orthopaedics & Related Research. 2014;472(8):2500-2505. doi:10.1007/s11999-014-3614-x
17. Arsoy D, Giori NJ, Woolson ST. Mobile Compression Reduces Bleeding-related Readmissions and Wound Complications After THA and TKA. Clin Orthop Relat Res. 2018;476(2):381-387. doi:10.1007/s11999.0000000000000041
18. Daniel J, Pradhan A, Pradhan C, et al. Multimodal thromboprophylaxis following primary hip arthroplasty: THE ROLE OF ADJUVANT INTERMITTENT PNEUMATIC CALF COMPRESSION. The Journal of Bone and Joint Surgery British volume. 2008;90-B(5):562-569. doi:10.1302/0301-620X.90B5.19744