Prevention of venous thromboembolism after surgery

• Published in: Cleveland Clinic journal of medicine Vol. 76; no. Suppl 4; pp. S45 - S52
• Main Author: Michota, Franklin A
• Format: Journal Article
• Language: English
• Published: United States Cleveland Clinic 01-11-2009
• Subjects: Heparin, Low-Molecular-Weight - therapeutic use; Humans; Postoperative Complications - prevention & control; Practice Guidelines as Topic; Quality Indicators, Health Care; Quality of Health Care; Risk Factors; Surgical Procedures, Operative - adverse effects; Thrombin - antagonists & inhibitors; United States; Venous Thromboembolism - etiology; Venous Thromboembolism - prevention & control; United States
• ISSN: 0891-1150; 1939-2869
• DOI: 10.3949/ccjm.76.s4.08

Most surgical patients who require hospitalization are at high risk for venous thromboembolism (VTE) and should receive VTE
prophylaxis, usually including pharmacologic prophylaxis. Nevertheless, rates of appropriate perioperative thromboprophylaxis
remain stubbornly low, though an expansion in quality-improvement efforts has led to widespread hospital implementation of
prophylaxis strategies in recent years. This article reviews important principles and recent developments in perioperative
VTE prophylaxis, with a focus on key recommendations and changes in the 2008 update of the American College Chest Physicians’
(ACCP) evidence-based guidelines on antithrombotic therapy.
KEY POINTS
Effective October 1, 2009, the Centers for Medicare and Medicaid Services is refusing to reimburse for hospital treatment
of a primary diagnosis of deep vein thrombosis or pulmonary embolism following recent (within 30 days) hip or knee replacement
surgery.
Mechanical methods of thromboprophylaxis are not effective unless used for at least 18 to 20 hours a day.
The latest ACCP guidelines recommend extended pharmacologic VTE prophylaxis for up to 28 days in select high-risk patients
undergoing general or gynecologic surgery. Extended prophylaxis of varying duration is recommended for patients undergoing
major orthopedic procedures.
Aspirin alone is not recommended for perioperative VTE prophylaxis in any patient group by the ACCP or the International Union
of Angiology.
Patients with renal impairment have fewer anticoagulant options and may require dose adjustment. Weight-based dosing appears
to be safe and effective for obese surgical patients.
New selective and orally administered direct thrombin inhibitors and oral direct factor Xa inhibitors may soon be available
for perioperative VTE prophylaxis.