69 – Does the type (DVT vs. PE) or timing (remote vs. recent) of prior VTE influence the risk of subsequent VTE following orthopaedic procedures?

Brendan Gleason, Camilo Restrepo, William J. Hozack.

Response/Recommendation: While it seems a reasonable assumption that patients with a history of venous thromboembolism (VTE) are at higher risk of post-operative VTE, there is little high-quality literature available regarding the effect of type or timing of prior VTE on subsequent VTE risk.

Strength of Recommendation: Limited.

Rationale: It is well understood that surgical patients are at increased risk of VTE^1–10.  A collection of systematic reviews, consensus opinions, meta-analysis, and personal opinion statements all suggest that patients with a history of VTE are at a higher risk of subsequent VTE after orthopaedic procedures^1–5,8,11.  Based on one systematic review, these patients are up to 6 times more likely to develop symptomatic VTE after total joint arthroplasty (TJA) and have higher rehospitalization rates than average¹².  Unfortunately, little high-quality data is available specifically addressing patients with a history of VTE as most prospective trials evaluating VTE prophylaxis exclude patients with a history of VTE^13,14.

As such, there is no concrete evidence to suggest whether the time interval or type of VTE affects the risk of subsequent VTE following orthopaedic surgical procedures.  One of the largest studies of orthopaedic patients with a history of VTE found multimodal thromboprophylaxis to be effective in this population but they did not analyze the relative risk of subsequent VTE conferred by remote vs recent clot or deep venous thrombosis (DVT) vs. pulmonary embolism (PE)15.  A large retrospective study by Ahmed et al., demonstrated that personal history of VTE was significantly associated with postoperative VTE but did not report the type or timing of prior VTE9.  One study on non-surgical patients with prior VTE, demonstrated an increased risk of recurrent VTE as time passed. In this study, the risk of recurrent VTE was 17.5% after 2 years, 24.6% after 5 years, and 30.3% after 8 years16.  Finally, a recent study evaluating risk-stratified VTE prophylaxis included patients with history of VTE in their high-risk cohort but did not report whether patients had history of DVT or PE¹⁷.

Given the lack of data on the subject, it is not possible to answer the question as to whether prior history of DVT and/or PE and the timing of these VTE events (remote vs. recent) definitely influence the risk of subsequent VTE following orthopaedic procedures.  Studies directly addressing the question of how the type and timing of prior VTE affects the risk of subsequent VTE after orthopaedic surgery are recommended.

References:

1.         Haas S. Recommendations for prophylaxis of venous thromboembolism: International Consensus and the American College of Chest Physicians Fifth Consensus Conference on antithrombotic therapy. Curr Opin Pulm Med. 2000;6(4):314-320. doi:10.1097/00063198-200007000-00011

2.         Haas S. Prevention of venous thromboembolism: recommendations based on the International Consensus and the American College of Chest Physicians Sixth Consensus Conference on Antithrombotic Therapy. Clin Appl Thromb Hemost. 2001;7(3):171-177. doi:10.1177/107602960100700301

3.         Prandoni P, Sabbion P, Tanduo C, Errigo G, Zanon E, Bernardi E. Prevention of venous thromboembolism in high-risk surgical and medical patients. Semin Vasc Med. 2001;1(1):61-70. doi:10.1055/s-2001-14542

4.         Heit JA. Low-molecular-weight heparin: the optimal duration of prophylaxis against postoperative venous thromboembolism after total hip or knee replacement. Thromb Res. 2001;101(1):V163-173. doi:10.1016/s0049-3848(00)00388-1

5.         Krotenberg R. Current recommendations for extended out-of-hospital thromboprophylaxis following total hip arthroplasty. Am J Orthop (Belle Mead NJ). 2004;33(4):180-184.

6.         Hull RD, Pineo GF. Extended prophylaxis against venous thromboembolism following total hip and knee replacement. Haemostasis. 1999;29 Suppl S1:23-31. doi:10.1159/000054109

7.         Berliner S, Shapira I. [Arthroscopy, deep vein thrombosis and pulmonary embolism]. Harefuah. 2008;147(10):779-780, 838.

8.         Azboy I, Barrack R, Thomas AM, Haddad FS, Parvizi J. Aspirin and the prevention of venous thromboembolism following total joint arthroplasty: Commonly asked questions. Bone and Joint Journal. 2017;99B(11):1420-1430. doi:10.1302/0301-620X.99B11.BJJ-2017-0337.R2

9.         Ahmed O, Kim YJ, Patel MV, Luu HH, Scott B, Cohen K. Efficacy and Safety of Mechanical IVC Filtration for Preventing Pulmonary Embolism in High-Risk Orthopedic Patients Undergoing Total Hip or Knee Arthroplasty. J Arthroplasty. 2021;36(7):2586-2590. doi:10.1016/j.arth.2021.02.042

10.       Dua A, Desai SS, Lee CJ, Heller JA. National Trends in Deep Vein Thrombosis following Total Knee and Total Hip Replacement in the United States. Ann Vasc Surg. 2017;38:310-314. doi:10.1016/j.avsg.2016.05.110

11.       Kunutsor SK, Barrett MC, Whitehouse MR, Blom AW. Venous thromboembolism following 672,495 primary total shoulder and elbow replacements: Meta-analyses of incidence, temporal trends and potential risk factors. Thromb Res. 2020;189:13-23. doi:10.1016/j.thromres.2020.02.018

12.       White RH, Gettner S, Newman JM, Trauner KB, Romano PS. Predictors of rehospitalization for symptomatic venous thromboembolism after total hip arthroplasty. N Engl J Med. 2000;343(24):1758-1764. doi:10.1056/NEJM200012143432403

13.       Parvizi J, Huang R, Restrepo C, et al. Low-Dose Aspirin Is Effective Chemoprophylaxis Against Clinically Important Venous Thromboembolism Following Total Joint Arthroplasty: A Preliminary Analysis. J Bone Joint Surg Am. 2017;99(2):91-98. doi:10.2106/JBJS.16.00147

14.       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. Clin Orthop Relat Res. 2008;466(3):714-721. doi:10.1007/s11999-007-0092-4

15.       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. Bone Joint J. 2020;102-B(7_Supple_B):71-77. doi:10.1302/0301-620X.102B7.BJJ-2019-1559.R1

16.       Giordano NJ, Jansson PS, Young MN, Hagan KA, Kabrhel C. Epidemiology, Pathophysiology, Stratification, and Natural History of Pulmonary Embolism. Tech Vasc Interv Radiol. 2017;20(3):135-140. doi:10.1053/j.tvir.2017.07.002

17.       Peng H-M, Chen X, Wang Y-O, et al. Risk-Stratified Venous Thromboembolism Prophylaxis after Total Joint Arthroplasty: Low Molecular Weight Heparins and Sequential Aspirin vs Aggressive Chemoprophylaxis. Orthop Surg. 2021;13(1):260-266. doi:10.1111/os.12926