Perioperative VTE Prophylaxis

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Recommendation for Thoracic Surgery Perioperative VTE Prophylaxis.

Background:

It is now widely accepted that the true incidence of post-op VTE following lung and esophageal resection is largely under-reported. A large range of incidence has been reported, with variations mainly related to different detection methods, type and duration of prophylaxis, and the subclinical nature of a significant proportion of VTE occurrence. Thoracic surgery poses an increased risk of postop VTE given the high prevalence of oncologic surgery, the protracted post-operative recovery, and the direct manipulation of the lung and pulmonary vascular anatomy.

CATS Recommendations

CATS members continue to be involved in research evaluating the optimal method and duration for post-thoracic surgery VTE prophylaxis. The committee recognizes however the paucity of high-level evidence in this field. As higher level evidence emerges, CATS hopes that a unified approach to postop VTE prophylaxis can serve as a starting point to adopt new guidelines for in-hospital and post discharge care.

  1. Post Thoracic surgery in-hospital prophylaxis = LMWH or LDUH +/- mechanical compression
  2. No recommendation for extended prophylaxis = use at surgeon’s discretion
  3. Symptomatic postop VTE = Thrombosis referral + therapeutic anticoagulation

Summary of the Evidence

  • Most data is based on retrospective single-institution cohort studies.
    • Results are challenged by the retrospective nature of the studies, dependence on symptomatic diagnosis and not asymptomatic screening, and lack of recognition of de novo PE without DVT
    • Estimates of postop incidence: 5-15.2%
  • More recent research has evaluated prevalence of post-lung resection VTE using screening strategies in a prospective fashion
    • Prospective screening studies
      • CTPA 7-15 days postop = prevalence of 14%
      • B/L Doppler U/S + CTPA @ 30-days postop = prevalence 12.1%
    • 23% of VTE occur post-discharge & Post-pneumonectomy peak incidence à >7 days postop
    • Cohort of 2,373 cancer patients identified that 40% of VTE occurred >21 days post discharge
  • Canadian Delphi Survey including CATS members (Journal Thorac Dis. 2017 Jan; 9(1)80-87)
    • Strong agreement in identifying risk factors for VTE, and which of those factors may potentially influence the decision for extended post-hospital discharge prophylaxis.
    • Limited agreement on the type of prophylaxis (pharmacological, mechanical and/or both), as well as the initiation and duration of thromboprophylaxis—indicating high degree of variability
    • The only reliable factor of agreement was the use of LMWH in hospital

ACCP 9th Edition Guidelines for Thoracic Surgery

  • Moderate risk for VTE + not high bleeding risk à LDUH or LMWH (Grade 2B), or MCS (Grade 2c)
  • High risk for VTE + not high bleeding risk à LDUH or LMWH (Grade 1B) + MCS (Grade 2C)
  • High risk for Major bleeding à MCS with optimally applied IPC (Grade 2C)
  • No recommendation for extended post-discharge prophylaxis.