Alberto D. Delgado-Martinez, Laura Lopez-Cuquerella, Ryan M. Cox, Sommer Hammoud.
Response/Recommendation: There is insufficient evidence to support or recommend against using aspirin as venous thromboembolism (VTE) prophylaxis in upper extremity surgery. It may be most beneficial for high-risk patients undergoing more complex reconstructive surgery.
Strength of the Recommendation: Limited.
Rationale: There is a paucity of literature regarding venous thromboembolic (VTE) prophylaxis in upper limb surgery1,2. In general, the risk of VTE following upper limb surgical procedures is considered low2–5.
Most of the clinical guidelines do not recommend or mention VTE prophylaxis following upper limb procedures the American Academy of Orthopaedic Surgeons (AAOS), the American College of Chest Physicians (ACCP), the European Society of Anaesthesia (ESA)1,2,6. Nonetheless, The National Institute for Health and Care Excellence (NICE) and the British Society for Surgery of the Hand (BSSH) have described a set of risk factors and prophylaxis indications for VTE following upper extremity surgery7,8. There are recommendations that only longer duration surgeries (more than 90 minutes of general anesthesia) of the upper should be considered for chemical thromboprophylaxis when associated with another personal intrinsic risk factor7,8.
There are few studies directly investigating aspirin (ASA) as a VTE chemoprophylactic agent after upper limb surgery. Most studies analyzing upper limb postoperative VTE prophylaxis are retrospective series with no uniform pattern of prophylaxis. Regarding rotator cuff repair, the only direct comparative study between aspirin 81 mg/daily vs. no chemoprophylaxis is a retrospective case-control study carried out on 914 patients9. Both groups received mechanical prophylaxis. Low rates of symptomatic VTE were found, with no differences between the ASA (0.93%) and non-ASA groups (0.66%). For shoulder arthroplasty, Kirsch et al., reported a rate of 0.63% for symptomatic VTE after 2,394 primary shoulder arthroplasties treated with 81 mg ASA daily for 6 weeks postoperatively10. One large series of upper limb procedures, with nearly 50% of patients without prophylaxis, found a similar rate of symptomatic VTE of 0.53%11. For proximal humeral fractures, one study on 163 patients treated for proximal humerus fracture without chemical prophylaxis (only mechanical prophylaxis) found a rate of symptomatic VTE of 3.3%12.
References
1. Jenny J-Y, Pabinger I, Samama CM, ESA VTE Guidelines Task Force. European guidelines on perioperative venous thromboembolism prophylaxis: Aspirin. Eur J Anaesthesiol. 2018;35(2):123-129. doi:10.1097/EJA.0000000000000728
2. Aibinder WR, Sanchez-Sotelo J. Venous Thromboembolism Prophylaxis in Shoulder Surgery. Orthop Clin North Am. 2018;49(2):257-263. doi:10.1016/j.ocl.2017.11.012
3. Kadhum M, Elniel AR, Furniss D. Is venous thromboembolism prophylaxis beneficial in upper limb major joint replacement surgery? A systematic review. Shoulder Elb. 2021;13(2):119-130. doi:10.1177/1758573219896279
4. Flevas DA, Megaloikonomos PD, Dimopoulos L, Mitsiokapa E, Koulouvaris P, Mavrogenis AF. Thromboembolism prophylaxis in orthopaedics: an update. EFORT Open Rev. 2018;3(4):136-148. doi:10.1302/2058-5241.3.170018
5. Sindhu KK, Cohen B, Blood T, Gil JA, Owens B. Upper Extremity Deep Venous Thrombosis Prophylaxis After Elective Upper Extremity Surgery. Orthopedics. 2018;41(1):21-27. doi:10.3928/01477447-20170824-04
6. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-e325S. doi:10.1378/chest.11-2404
7. VTE Guidelines | The British Society for Surgery of the Hand. Accessed September 27, 2021. https://www.bssh.ac.uk/professionals/vte_guidelines.aspx
8. National Guideline Centre (UK). Venous Thromboembolism in over 16s: Reducing the Risk of Hospital-Acquired Deep Vein Thrombosis or Pulmonary Embolism. National Institute for Health and Care Excellence (UK); 2018. Accessed September 27, 2021. http://www.ncbi.nlm.nih.gov/books/NBK493720/
9. Alyea E, Gaston T, Austin LS, et al. The Effectiveness of Aspirin for Venous Thromboembolism Prophylaxis for Patients Undergoing Arthroscopic Rotator Cuff Repair. Orthopedics. 2019;42(2):e187-e192. doi:10.3928/01477447-20181227-05
10. Kirsch JM, Gutman M, Patel M, et al. Low-dose aspirin and the rate of symptomatic venous thromboembolic complications following primary shoulder arthroplasty. J Shoulder Elbow Surg. 2021;30(7):1613-1618. doi:10.1016/j.jse.2020.09.030
11. Day JS, Ramsey ML, Lau E, Williams GR. Risk of venous thromboembolism after shoulder arthroplasty in the Medicare population. J Shoulder Elbow Surg. 2015;24(1):98-105. doi:10.1016/j.jse.2014.09.025
12. Heyer JH, Parker RL, Lynch T, Parry T, Neviaser AS. Rate of venous thromboembolism after surgical treatment of proximal humerus fractures. Arch Orthop Trauma Surg. 2021;141(3):403-409. doi:10.1007/s00402-020-03505-4