David Campbell, Kirill Lobastov, Zbigniew Krasiński.
Response/Recommendation: The presence of varicose veins increases the risk of postoperative venous thromboembolism (VTE) by approximately 3 times in patients undergoing major orthopedic procedures (Strong). A history of superficial venous thrombosis (SVT) increases the risk of postoperative VTE by 5-10 times in patients undergoing lower limb orthopaedic surgery (Limited). Acute SVT further increases the risk of VTE, and elective orthopaedic procedures should be postponed for at least 3 months if possible (Limited).
Strength of Recommendation: Limited.
Rationale: There is a strong association between varicose veins (VV) and VTE in the general population. VV are associated with an increased deep venous thrombosis (DVT) incidence by 5-7 times and pulmonary embolism (PE) incidence by 1.7 times1,2. VV are one of the most common risk factors for VTE in non-orthopaedic surgical and medical inpatients3–8. VV are included in the Caprini risk assessment model for postoperative VTE9 as well as the VTEstimator10.
The presence of VV can increase the risk of venous thromboembolism after major orthopaedic procedures by a varying extent of 1.5-15 times. Three large database studies included a risk assessment of VV, which were recorded in 0.2% to 0.3% of the cohort. This incidence is low compared to the population prevalence of 19%11. The study by Parvizi et al., that analyzed 1.7 million arthroplasty patients in the U.S. reported a VTE odds ratio [OR] of 1.53 for patients with VV, prompting the authors to include VV in their risk assessment tool10. Fuji et al., reported VTE risk factors in 37,000 Japanese patients undergoing lower extremity orthopaedic surgery; the presence of VV increased the risk of PE (OR 10.9, 95% confidence interval [CI] 2.5-47.5) and DVT (OR 3.3, 95% CI 0.8-13.3)12. The Scottish Arthroplasty Project included 109,223 patients and reported an increased risk of DVT after total hip arthroplasty (THA) in patients with untreated VV13. The DVT rate was 0.8% in patients who had previously undergone VV surgery and those with no previous VV diagnosis, compared to 3.1% with those with untreated VV. There was no significant difference in PE rates following THA and no difference in DVT or PE following total knee arthroplasty (TKA) in patients with VV, treated VV or no history of VV.
Prospective observational studies reported increased VTE risk with VV, although most studies included relatively few patients with VV and obtained wide CI. Markovic-Denic L et al., studied 499 THA and TKA patients and found an increased VTE risk of VTE (OR 3.1, 95% CI 1.03-9.5) in patients with VV14. In Asian patients undergoing major orthopaedic surgery without thromboprophylaxis, VV were recorded in 4.3% of 2,420 patients, and this increased the risk of VTE by 3.6 times (95% CI, 1.2-1.06)15. A meta-analysis by Zhang et al., found that the presence of VV was associated with a 2.7 (95% CI, 1.1-7.1) fold increase of VTE after THA and TKA16. Another meta-analysis by Tan et al., reported a risk elevation of 3.1 times (95% CI, 1.1-8.5) following surgical treatment of fractures below the hip in the presence of VV17. For knee arthroscopy, the incidence of symptomatic postoperative VTE was low (0.1-0.25%), and no association with VV was found18,19.
There is no consensus on the need for preliminary surgical treatment of varicose veins to reduce the risk of postoperative VTE. Limited evidence suggests that patients with treated VV may normalize their VTE risk after THA and TKA13,20. This risk may be mitigated by VTE prophylaxis, although current studies on VTE prophylaxis for orthopaedic procedures did not analyze the efficacy of preventive measures in this small subgroup of patients with VV and hence no conclusion can be drawn. The intervention for VV can increase VTE risk by itself21, and the risk of symptomatic PE remains elevated for up to 18 weeks22. The minimal time interval between intervention for VV and orthopaedic surgery has not yet been determined; however, it seems prudent to defer elective surgery at least 3 months.
SVT is an inflammatory process that obstructs the superficial veins of the lower extremities. SVT can extend into the deep veins and lead to PE. Thrombosis of superficial veins provoked by chemical and mechanical injury of the vascular wall, such as surgical trauma, is usually benign and self-limited23. Conversely, spontaneous SVT is considered a benign self-limited disorder but has been shown to be associated with the risk of concomitant DVT and PE in 18% and 7% of non-surgical patients, respectively24. Superficial thrombosis is most likely to affect patients with VV, accounting for up to 90% of all cases of SVT25. Thrombus usually propagates in the deep veins through saphenous vein junctions and/or perforating veins26. However, up to 42% of all patients have a DVT that is not contiguous with SVT, particularly on the contralateral limb in 17%, hence suggesting SVT may be an underlying indicator of thrombophilia26,27.
VTE risk is greatest during the first 3 months following diagnosis but remains significantly increased compared to controls even after 5 years28. Current evidence suggests an underlying thrombophilia that requires anticoagulation prior to elective surgery, although the duration of treatment and period of increased VTE risk have not been established. In practice, it may be preferable to defer elective orthopaedic surgery by at least 3 months from the time of SVT diagnosis. The same recommendation was developed for interventions to remove VV after SVT29. In patients with VV and a history of SVT, removal of varicosities prior to orthopaedic surgery could be considered.
A past history of SVT is an independent risk factor for future DVT or PE28. Recurrent SVT is associated with a 2.3-2.5-fold increased risk of further VTE30,31. The risk of VTE recurrence is equivalent to that after proximal DVT32, with an OR of 5.5 (95% CI, 4.8 – 6.4) compared to controls33. VTE risk increased to 9.3 times when combined with an additional mild thrombotic risk factor, 31.4 times when combined with a strong risk factor, and increased to 42.5 times (95% CI, 10-118) with surgery33.
For lower limb orthopaedic surgery, the estimated increase in VTE risk is 5-10 times in patients with a history of spontaneous SVT16,17. A history of SVT was hence included in the Caprini risk assessment model version of 201034 and needs to be assessed in tandem with the presence of VV in order to calculate individual risk for postoperative VTE.
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