Defining Incidence and Risk Factors of Venous Thromboemolism after Hepatectomy

Abstract

Background The incidence of venous thromboembolism (VTE) among patients undergoing hepatic surgery is poorly defined, leading to varied use of VTE prophylaxis among surgeons. We sought to define the incidence of VTE after liver surgery and identify risk factors associated with VTE. Methods Incidence of VTE and associated risk factors within 90 days of hepatic resection between 2006 and 2012 at a major academic center was analyzed. Risk factors for VTE were identified using univariate and multivariate analyses. Results A total of 599 patients were included in the study cohort; 30 (5.0 %) had a prior history of VTE. The indications for surgery were malignant (90.8 %) and benign lesions (9.2 %). The majority of patients underwent a minor hepatectomy (<3 Couinaud segments; n =402, 67.1 %) while 195 (32.6 %) patients underwent a major hepatectomy (≥3 Couinaud segments). Three hundred seven (51.3 %) patients were started on VTE chemoprophylaxis preoperatively with 407 (67.8 %) patients receiving VTE chemoprophylaxis within 24 h of surgery. Twenty-eight (4.7 %) patients developed VTE; 20 (3.3 %) had deep venous thrombosis (DVT), 11 (1.8 %) had pulmonary embolism (PE), and three (0.5 %) developed both DVTand PE. Among the VTE patients, 23 (82.1 %) had received VTE chemoprophylaxis. On multivariate analyses, history of VTE (odds ratio [OR] 4.51, 95 % confidence interval [CI] 1.81–17.22, P =0.03), prolonged operative time (OR 1.17 per additional hour, 95 % CI 1.04–1.32, P =0.009), and increased length of stay (LOS) (OR 1.07, 95 % CI 1.02–1.12, P =0.01) were independent risk factors for VTE. Conclusion VTE within 90 days of hepatic resection is common, occurring in nearly one in 20 patients. Most VTE events occurred among patients who received current best practice prophylaxis for VTE. More aggressive strategies to identify and reduce the risk of VTE in patients at highest risk of VTE, including those with a history of VTE, extended operative time, and prolonged LOS, are warranted.

Alterations in coagulation following major liver resection

“…In another series of 599 patients undergoing liver resection, the incidence of venous thromboembolism was 4.7% overall, with no significant difference for patients with malignant versus benign conditions. It was noted that patients who have a major liver resection were less likely to receive pharmacological thromboprophylaxis because of a raised INR, yet the incidence of venous thromboembolism in this series was 14.3% in patients with a peak postoperative INR ≥ 1.5, compared to 3.6% in patients with a peak INR ≤ 1.5 [16]. It has also been demonstrated that patients undergoing liver resection have some of the highest rates of venous thromboembolism for any surgical procedure [17].…”

Hypercoagulability following major partial liver resection ‐ detected by thrombomodulin‐modified thrombin generation testing

“…Furthermore, routine thrombosis prophylaxis should not be withheld in patients undergoing liver resection, as this may result in higher rates of venous thromboembolism in post‐operative liver disease patients. More extensive prophylaxis may even be required as VTE rates are still substantial in those patients receiving optimal routine thromboprophylaxis …”

Efficacy and safety of pharmacological venous thromboembolism prophylaxis following liver resection: a systematic review and meta-analysis

“…Studies providing original data on VTE incidence after hepatectomy both in the presence and absence of chemical thromboprophylaxis were eligible for inclusion. Using these criteria five studies were identified, one of which evaluated the outcome of perioperative chemical thromboprophylaxis 7 and four the outcome of postoperative prophylaxis. [8][9][10][11] These five studies comprise the final study group.…”