Venous Thromboembolism in Plastic Surgery: Where Are We Now?

The majority of hospitalized nonsurgical medical patients receive pharmacological prophylaxis for venous thromboembolism (VTE), and reassessment of changes in thrombosis and bleeding risk factors during hospital admission may represent an opportunity to discontinue unnecessary or unsafe therapy. The use of validated, clinically derived risk assessment models (RAMs) represents a shift towards an individualized, patient-centred approach to VTE prophylaxis. We are interested in using these tools to assess whether risk categories for VTE and bleeding change during admission and to assess whether such changes result in discontinuation of prophylaxis. Our primary objective was to determine whether VTE and bleed risk categories changed during the course of admission to warrant discontinuation of VTE prophylaxis, using the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE and Bleed RAMs, respectively. Secondary objectives were to determine the number of patients whose risk categorizations for VTE and bleeding warranted discontinuation of VTE prophylaxis and to survey whether prophylaxis was continued or discontinued. A retrospective review was undertaken for a cross-sectional, randomly selected sample of patients who received VTE prophylaxis while admitted to medical wards in a collection of regional hospitals. Of the 351 medical records reviewed, only eight patients (2.3%) changed their VTE risk category and six (1.7%) changed their bleed risk category to warrant discontinuation of VTE prophylaxis. Ninety patients (26%) were at high risk of VTE and low risk of bleed throughout admission, warranting continued VTE prophylaxis. The majority of patients remained at low risk of VTE throughout admission but remained on VTE prophylaxis until discharge. Risk categories for VTE and bleeding for medical patients did not appreciably change throughout hospital admission. Use of VTE RAMs at admission and prior to initiation of therapy should reduce unnecessary prophylaxis in the majority of medical patients who are at low risk of VTE.

Objective: To determine the risk profile of venous thromboembolism (VTE) and evaluate VTE prophylaxis implementation of the hospitalized cancer patients in the DissolVE 2 study. Methods: The data of hospitalized cancer patients in the DissolVE 2 study were analyzed. The risk distribution of VTE, preventive measures and in-hospital VTE events of hospitalized patients with tumors were described by percentage and 95% confident interval (CI). Results: A total of 1 535 cancer patients were included. According to the Padua score, 826 (53.8%) patients were at low risk of VTE, while 709 (46.2%) patients were at high VTE risk. VTE events occurred in 4 low-risk patients (0.5%; 95%CI: 0.1%, 1.2%) and 5 high-risk patients (0.7%; 95%CI: 0.2%, 1.6%). The overall incidence was 0.6% (9/1 535, 95%CI: 0.3%, 1.1%). Among patients with high VTE risk, 666 (93.9%) did not receive any VTE prophylaxis, and only 11 (1.6%) patients received appropriate VTE prophylaxis. Among patients who received VTE prevention, no VTE event was observed. Conclusions: Nearly half of the hospitalized cancer patients are at high risk of VTE, but most of them don't receive VTE prophylaxis. The results reflect the insufficient management of VTE risk for hospitalized cancer patients in China, and improvement of awareness and practice of VTE prophylaxis is urgently needed.

Sir: It was with great interest that we read the comments by Swanson regarding venous thromboembolism in body contouring patients. The author has highlighted a number of critiques of our recent study entitled “Venous Thromboembolism in Body Contouring: An Analysis of 17,774 Patients from the National Surgical Quality Improvement Databases.”1 We will address each point sequentially. The author first challenges the inclusion of patients undergoing breast contouring procedures, as these patients tend to be younger, thinner, and with shorter operative times. In response to this critique, we draw attention to our study’s statistical methodology. All variables that approached statistical significance in a case-control analysis were included in a bootstrap analysis. Subsequently, a logistic multivariate regression analysis was performed using variables identified in the bootstrap procedure. Notably, these processes have been published on extensively, and validated as tools for deriving prognostic models.2–4 The particularly important component of this methodology is that patient age, body mass index, and anatomical region undergoing contouring (e.g., breast, trunk) were all analyzed independently in sequential multivariate regression models. This allows for discerning between risk associated with procedure type and patient characteristics. The author’s second critique is the high incidence of obesity in our cohort, which he posits is indicative of a large number of bariatric patients. The author cites his own study of 322 body contouring patients to establish the “normal” rate of obesity in a body contouring cohort as 20 percent.5 Our previous work with the National Surgical Quality Improvement Program databases, for the years 2005 to 2010, included a cohort of 1797 patients, and identified approximately 10 percent of the same patients as the current study, and corroborates an obesity incidence of approximately 50 percent.6 In addition, the diversity of this cohort, and the subsequent inclusion of the World Health Organization obesity classification in the venous thromboembolism risk score, permits this tool to be applicable to a wider range of patients, allowing for a better characterization of risk associated with increased body mass index. Dr. Swanson also draws attention to a higher than expected prevalence of wound class and American Society of Anesthesiologists physical status. In response to this point, there is not much that can be said, other than the national data regarding body contouring do not align with the author’s clinical experience. One factor that may be leading to the discrepancy appreciated by the author, though, is the Current Procedural Terminology coding of panniculectomy—an operation that may be performed in sicker patients. Importantly, though, as in the previous points, these factors were all included in our analysis, so the risk imparted by such factors was analyzed independently. Lastly, Dr. Swanson challenges the capability of venous thromboembolism risk stratification as a whole, and the notion of providing venous thromboembolism prophylaxis based on said stratifications. In response to the idea that we cannot reliably predict who will develop a venous thromboembolism, we would like to call attention to multiple articles showing that the Caprini score can identify and predict an approximately 20-fold variation in venous thromboembolism risk.7–10 Gould et al. characterize the American College of Chest Physicians practice guidelines for the prevention of venous thromboembolism, which stratify patients using Rogers and Caprini scores, recommending chemoprophylaxis for patients with venous thromboembolism risk of approximately 3 percent or greater who are not at increased risk for major bleeding complications.12 Venous thromboembolism remains a difficult entity to study and a troubling complication to surgeons, patients, and the health system alike. The relative infrequency of venous thromboembolism events necessitates highly powered studies developed by leveraging multi-institutional data to detect clinically important and statistical differences. We sincerely thank Dr. Swanson for his important critiques, but we maintain that the National Surgical Quality Improvement Program databases represent a powerful and effective tool with which to study and model venous thromboembolism events to better deliver risk data to our patients and to help inform clinical decision-making. These databases, just like other national databases, have limitations that must be disclosed and considered in the context of interpreting the findings. In summary, we believe that by using the National Surgical Quality Improvement Program Databases we have generated a useful tool for assessing venous thromboembolism risk in body contouring patients, and shown that in the presence of certain risk factors, the incidence of venous thromboembolism increases dramatically. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Ari M. Wes, B.A. Jason D. Wink, M.D., M.T.R. Stephen J. Kovach, M.D. John P. Fischer, M.D. Division of Plastic Surgery Hospital of the University of Pennsylvania Philadelphia, Pa.

While venous thromboembolism (VTE) risk assessment and prophylaxis is well established for medical and surgical in-patients, there is a paucity of evidence, and therefore guidelines, in this area for psychogeriatric in-patients. We wished to determine VTE incidence, risk, and use of prophylaxis, in a psychogeriatric in-patient population. Retrospective audit of consecutive psychogeriatric patients aged 65 years and over admitted to Bankstown Hospital over a 3-year period, 2007-2009. Using an adapted VTE risk scoring system, patients were assigned as low, medium, or high VTE risk. A total of 192 patients were included in the study. Mean age was 79.1 ± 7.0 years. Out of the total, 55.2% of patients had diagnosis of dementia, and 33.3% had depression. Overall, 81.8% (157/192) were assessed as low risk, and 18.2% (35/192) as medium risk. Also, 16.7% (32/192) received VTE prophylaxis. Four new VTE events occurred in medium-risk group, and one in low-risk group (p = 0.004). Overall VTE incidence was 10.5/10,000 patient-days, but 44.2 per 10,000 in medium-risk group. VTE risk score was predictive of VTE events - IRR 6.02 (95% Confidence Intervals (CI) = 1.76-20.7, p = 0.004) for every one-point increment in risk. Depression was associated with significantly higher VTE occurrence (6.3% in those with diagnosis vs. 0.8% without, p = 0.043). Using a VTE risk scoring system adapted for psychogeriatric in-patients, those assessed to be at medium risk had a significantly increased rate of VTE. On this basis, we would recommend VTE prophylaxis be prescribed for psychogeriatric in-patients assessed to be at medium and high level of risk.

Process Improvement in Prophylaxis for Venous Thromboembolism

Venous thromboembolism (VTE) is the most common cause of preventable mortality following colorectal surgery (CRS), occurring in about 2% of patients. As a result, prophylaxis including discharge chemoprophylaxis is recommended. While VTE risk assessment tools are available, the consistent adoption and utilization of these tools remains elusive. Our study objectives were to determine the utilization and impact of risk adjusted VTE prophylaxis in CRS patients. CRS cases performed between 1/1/2016 and 5/31/2021 were retrospectively analyzed. Caprini score and implemented VTE prophylaxis measures were determined. The primary outcome measure was receiving Caprini guideline indicated VTE prophylaxis. Secondary outcomes included VTE and bleeding. Categorical variables were compared by chi-square and Fisher's exact tests, and continuous variables by Kruskal-Wallis test. Logistic regression models were used to determine predictors of receiving appropriate VTE prophylaxis or experiencing postoperative VTE and bleeding. 10,422 CRS cases were analyzed and 90.6% were high risk for VTE. In-hospital appropriate prophylaxis rates in low, moderate, high, and very high-risk category patients were 91.2%, 56.1%, 61.0%, and 63.1%, respectively. Inpatient VTE was reduced by 75% in those receiving appropriate VTE prophylaxis. At discharge, 5.8% of patients received appropriate prophylaxis, in whom there were no VTE events at 30- and 90 days from discharge. Increasing Caprini score positively correlated with VTE risk in both the inpatient and discharge cohorts, but inversely correlated with the likelihood of receiving appropriate prophylaxis at discharge (OR .31, P <.0001). Caprini guideline indicated VTE prophylaxis in CRS patients reduced VTE events without increasing bleeding complications.

Objectives: Venous thromboembolic events are devastating complications that may arise following spine surgery with rates ranging from 0% to 14% in the literature. Orthopedic procedures increase the risk of thromboembolic events, and diagnosis is often challenging due to the varying presentations. Most research on venous thromboembolism (VTE) and international standards emphasizes that prevention such as mechanical prophylaxis is more crucial than therapy. This study aimed to assess the effectiveness of pneumatic compressive devices in preventing VTE in spinal surgery patients. Methods: This retrospective cohort study assessed the outcomes of mechanical prophylaxis in the form of pneumatic devices in 547 patients at our institution over five years from 2016 to 2021. Above-knee pneumatic compression stockings were applied before, during, and after surgery with patient outcomes being recorded. Results: Data was collected from 547 patients, who underwent elective spinal surgery at our center between January 2016 and January 2021. The mean age was 47.27 years (±20.84), and most patients were male (63.1%). Most patients were classified as having a low risk (35.6%) or mild risk (43.5%) of VTE determined by the Caprini score. Following spinal surgery, only one patient in our cohort experienced post-operative VTE (0.18%). Conclusion: Pneumatic compression effectively prevents VTE in patients undergoing elective spine surgery. Although pharmacologic prophylaxis has traditionally been used to prevent VTE, pneumatic compressive devices represent an alternative or supplementary approach to reduce the risk of VTE further.

Venous thromboembolism (VTE) remains the number one preventable cause of hospital acquired mortality and morbidity. Each year, more than 12million patients are at risk for VTE. The delivery of appropriate and timely VTE prophylaxis is still suboptimal in many healthcare institutions and can lead to increased readmissions, morbidity, as well as costs. To clarify this issue further, we performed a retrospective case control study at our institution to determine if poor adherence to the VTE prophylaxis guidelines could lead to an increase in VTE events. This was a retrospective case control study conducted at Winthrop-University Hospital from January 2007 to December 2011. Exclusion criteria were age < 18 and concurrent use of anticoagulant agents. Out of 322 cases of hospital acquired VTE or readmission with VTE within 30 days of discharge, 289 cases were selected for final analysis and paired with age and sex matched controls. Patients with a hospital acquired VTE or a readmission for VTE within 30 days of discharge had a significantly reduced rate of VTE prophylaxis when compared to the control group (54.0 vs. 79.2 %, p < 0.0001). The VTE risk assessment rate was also lower in the VTE group (77.2 vs. 85.5 %, p = 0.035). No difference was noted in the time to prophylaxis administration between the two groups (34.8 vs. 33.1h, p = 0.34). Lastly, sequential compression device (SCD) documentation rate was not different: 68/116 (58.6 %) vs. 44/87 (50.6 %), p = 0.32, between the two arms. Low adherence to the American College of Chest Physician (ACCP) guidelines for VTE prophylaxis correlated with an increase in hospital acquired VTE. The decreased adherence may be linked to a lower VTE risk assessment rate, and other barriers including incorrect identification of contraindications to pharmacologic prophylaxis, and poor documentation of mechanical prophylaxis. There was no difference in SCD documentation rate and timeliness to administration of initial thromboprophylaxis between the two groups. Future studies are needed to reassess adherence and documentation rates after system-wide improvements.

Identification of Medical Patients Who Should Receive Venous Thromboembolism Prophylaxis.

To evaluate the prevalence of risk for venous thromboembolism (VTE) and the proportion of at-risk patients who receive appropriate thromboprophylaxis among inpatients in acute hospital care settings in Oman. A related objective was to evaluate the type and time of initiation of VTE prophylaxis. This multicenter, cross-sectional study was conducted in three tertiary hospitals in Oman. The study included acutely ill medical and surgical inpatients admitted from August to September 2022. VTE risk assessment and prophylaxis were assessed based on the 2012 recommendations of the American College of Chest Physicians (ACCP). A total of 384 patients were enrolled, 240 were medical patients and 144 were surgical patients. As per the ACCP criteria, 179 (74.6%) of medical and 92 (63.9%) of surgical patients were at risk for VTE and required prophylaxis. Appropriate prophylaxis was received by 142 (79.3%) at-risk medical and 70 (76.1%) at-risk surgical patients. In cases where pharmacological prophylaxis was contraindicated, mechanical prophylaxis was markedly underused. For medical patients, the median day of initiating VTE prophylaxis was day one of admission. For surgical patients, the median day of initiating VTE prophylaxis was postoperative day one. The majority of hospitalized patients in Oman are at risk of VTE. However, a significant minority of patients do not receive the required pharmacological or mechanical prophylaxis. We recommend the development of a national VTE risk assessment and guiding tool with a facility for monitoring compliance.

Incidence and risk factors of venous thromboembolism in neurosurgical patients after implementing a screening protocol: a retrospective cohort study of a tertiary center

Risk stratification and prevention of venous thromboembolic disease in cancerology

INTRODUCTION: Venous thromboembolism (VTE) is a source of significant morbidity and mortality in surgical patients. Prediction models have been developed to determine VTE risk in plastic surgery patients including the Davison risk score1 and the 2005 Caprini risk score2. This retrospective study evaluates the incidence of symptomatic VTE in breast reconstruction and the efficacy of current models in predicting VTE in different methods of breast reconstruction. METHODS: Breast reconstruction patients by a single surgeon were retrospectively evaluated. One hundred consecutive TRAM reconstructions, one hundred consecutive implant reconstructions, and fifty consecutive latissimus reconstructions were identified. These surgical reconstructions all took place over a ten year period in which VTE chemoprophylaxis was not routinely performed. Each patient’s chart was reviewed for the parameters needed to calculate the 2005 Caprini risk score and the Davison risk score. Outpatient follow up, operative notes, and other procedures were also reviewed. Fisher’s exact test was used to calculate differences in VTE incidence and risk factor incidence. ANOVA test was used to compare mean risk scores between the reconstruction groups. RESULTS: The TRAM reconstruction group had a significantly higher VTE rate (6%) than the implant (0%) or the latissimus (0%) reconstruction groups (p<0.01). There was no significant difference (p>0.05) in the 2005 Caprini risk scores or the Davison risk scores between the TRAM, implant, and latissimus reconstruction groups (Figure 1). The Davison risk score and the 2005 Caprini score stratified the majority of patients as “high risk” with a calculated risk score ≥5 (Davison score 64.8%, 2005 Caprini score 86%). Interestingly, the VTE rate among “high risk” patients in each group was not statistically different from the overall VTE rate of each reconstruction group (p>0.05).Figure 1: Mean 2005 Caprini risk score and mean Davison risk score by breast reconstruction type. (p>0.05).CONCLUSION: TRAM reconstruction is associated with a higher VTE rate than both implant reconstruction and latissimus reconstruction. Implant and latissimus reconstruction patients appear at low risk for VTE even in the presence of many “high risk” features. Overall, neither the 2005 Caprini risk score nor the Davison risk score demonstrated effective VTE risk stratification in breast reconstruction patients. Current and future VTE prediction models should take into account the specific surgical procedure to more accurately determine VTE risk.

Background. Venous thromboembolism (VTE) is regarded as the most preventable cause of inpatient death in hospital settings globally. VTE can be prevented through the provision of non-pharmacological and/or pharmacological thromboprophylaxis following individualised risk screening. The Caprini risk assessment model (RAM) offers a validated and well-established approach for VTE risk assessment in medical inpatients. Literature findings describe a trend towards inappropriate and under-prescribing of thromboprophylaxis in this population. Together with concerns regarding clinicians’ perceived importance of VTE risk assessment, the need to clarify these aspects of practice is evident. Objectives. To describe VTE risk assessment and prophylaxis practices of medical practitioners in public sector hospitals in Western Cape Province, South Africa (SA). Methods. A retrospective, cross-sectional study design was employed in the medical wards of two district hospitals and one regional hospital in the Cape Town metropole, Western Cape. Medical folders of adult medical inpatients admitted between January and July 2020 were reviewed to assess VTE risk using the Caprini RAM. Thromboprophylaxis therapy prescribed and contraindications to chemoprophylaxis were also evaluated. Results. Of 380 patients included in the review, 51.6% were female, and the average age was 52.1 years (range 18 - 96); 21.3% had their weight recorded, while none had their height documented. Infectious disease was the predominant diagnosis (49.2%) detected in the sample. Common VTE risk factors identified included bed rest/restricted mobility for &lt;72 hours (76.3%) and serious infection (67.4%). A total of 97.1% of patients (n=369) were found to be at moderate or higher risk of VTE (Caprini score ≥2). Of this at-risk group, 24.1% were eligible to receive chemoprophylaxis, yet no prescription for thromboprophylaxis was identified. Seventy percent of patients (n=266) were prescribed chemoprophylaxis, with enoxaparin accounting for 98.5% of regimens. Contraindications to chemoprophylaxis were recorded in 13.4% of patients. Conclusions. Although rates of VTE prophylaxis in medical inpatients may be improving, thromboprophylaxis still remains critically underutilised in this population. This study highlighted a consequence of this trend, with inappropriate chemoprophylaxis prescribing becoming more evident. Mechanical prophylaxis prescribing in medical inpatients is lacking, despite the associated benefits. RAMs should be adapted for the SA setting, where infectious diseases are prevalent. Future research should assess RAM use by clinicians, as this could provide insight into improving RAM uptake and thromboprophylaxis prescribing.

Although venous thromboembolism (VTE) is a potentially serious and life-threatening complication, there is no widely accepted protocol to guide VTE prophylaxis in adult degenerative spinal surgery, and pharmacologic overtreatment may result in hemorrhagic complications. Previously, we published the VTE Prophylaxis Risk/Benefit Score, an evidence-based algorithm that balances the risk and consequences of thrombotic versus hemorrhagic complications by taking consideration of patient-related risks, procedure-related risks, and the risk of neurological compromise to guide VTE prophylaxis. To objective of this study was to validate the VTE Prophylaxis Risk/Benefit Score. From January 1, 2016, to December 31, 2017, VTE Prophylaxis Risk/Benefit Scores and corresponding prophylaxes were prospectively assigned. When indicated, chemoprophylaxis was dosed 24 to 36 hours postoperatively to allow for adequate surgical hemostasis. Patients were retrospectively evaluated for immediate and short-term complications. The Fisher exact test compared incidence of complications by VTE prophylaxis. Multinomial logistic regression modeled the probability of complication by prophylaxis type, demographics, and comorbidities. Significance was set at P < .05. Of the 266 patients who met inclusion criteria, 79.3% were given mechanical prophylaxis alone and 20.7% were given combined mechanical and chemical prophylaxis. Complications including VTE (0.38%), delayed wound healing or infection (2.26%), and hematoma (0.75%) were observed at rates similar to or lower than previously published studies with increased utilization of chemoprophylaxis. Use of chemoprophylaxis and continuation of perioperative aspirin were significantly associated with the development of a hemorrhagic complication. No patient developed persistent neurologic deficit from hematoma or pulmonary embolism. The VTE Prophylaxis Risk/Benefit Score comprehensively considers the risk of thrombotic, wound, and bleeding complications and is an effective tool for determining appropriate thromboprophylaxis in adult degenerative spinal surgery. 3.