Crispiana Cozowicz, Jashvant Poeran, Stavros Memtsoudis.
Response/Recommendation: Following major orthopaedic surgery venous thromboembolism (VTE) prophylaxis -initiated in-hospital- should be continued for 14 to 35 days after patient discharge.
Strength of Recommendation: Strong.
Rationale: The occurrence of VTE, including deep venous thrombosis (DVT) and pulmonary embolism (PE) is a relatively major source of perioperative morbidity, mortality and healthcare cost in lower joint arthroplasty surgery.1-3 Hence, numerous organizations, including the American Academy of Orthopaedic Surgeons (AAOS), have provided guidelines for prevention of VTE following total joint arthroplasty4. However, a general consensus on the type and the duration of VTE prophylaxis following orthopaedic procedures remains disputed.2,5,6.
Guidelines by the American College of Chest Physicians (ACCP) recommend the use of chemo-thromboprophylaxis for a minimum of ten days after total hip arthroplasty (THA) and total knee arthroplasty (TKA) in addition to early mobilization7. In previous trials, VTE prophylaxis was mostly given until hospital discharge, ranging from 7 to 14 days. Meanwhile, however, the length of hospitalization for most major orthopaedic surgeries has significantly decreased, rendering VTE prophylaxis limited to the hospitalization period insufficient8.
Moreover, several studies have shown a second peak in the rate of postoperative DVT incidence in the late postoperative period, after termination of chemothromboprophylaxis3.
This delayed thromboembolism suggests that VTE risk extends beyond the hospitalization period8-11. The underlying mechanism may be based on the assumption that surgery-induced activation of the coagulation and fibrinolysis cascade at a local and systemic level persists for an extended period10. While the optimal duration for VTE prophylaxis remains uncertain, it has been suggested that this second risk period may occur between the second and the fifth postoperative week9,10. Moreover, coagulation indicators in the plasma have shown that a substantial hypercoagulability is sustained until day 35 after THA, despite the verified lack of thrombosis at hospital discharge12,13. Continuation of thromboprophylaxis after discharge, however, appears to significantly reduce the incidence of DVT and PE in major orthopaedic surgery11,14.
Given the growing body of evidence in support of persisting thromboembolic risk after hospital discharge in major orthopaedic surgery, we conducted a systematic review and meta-analysis on the direct comparative effectiveness of extended (versus short-term or in-hospital) VTE prophylaxis.
The current body of evidence consists of 19 randomized controlled trials (RCT) of high to moderate quality and one non-randomized study. Summaries and meta-analyses can be found in the Appendix. Pooled meta-analysis of RCT only, demonstrated that VTE prophylaxis, when extended for up to 6 weeks beyond hospital discharge, significantly reduced the risk for the occurrence of symptomatic and asymptomatic DVT compared to short-term regimens. The odds of a postoperative DVT were reduced by 64% in THA and by 28% in TKA recipients with VTE prophylaxis extended for several weeks beyond hospital discharge. Statistical heterogeneity within the study sample was low, despite individual trial differences with regards to duration of prophylaxis (2 – 6 weeks) and variations of utilized anticoagulant drugs (unfractionated heparin, low-molecular-weight heparin, and oral anticoagulants). The benefit of extended VTE prophylaxis was observed without an increased risk for major bleeding. More research is needed to establish the comparative effectiveness between individual anticoagulant medications15.
Notably, cohort studies arguing against the need for out of hospital prophylaxis are of low-quality evidence16,17.
Reference:
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