Fixed or Weight-Tiered Enoxaparin After Thoracic Surgery for Venous Thromboembolism Prevention

Pannucci, Christopher J.; Fleming, Kory I.; Bertolaccini, Corinne; Moulton, Lauren; Stringham, James C.; Barnett, Shari; Lin, Jules; Varghese, Thomas K.

doi:10.1016/j.athoracsur.2019.12.058

Cited by 6 publications

(7 citation statements)

References 21 publications

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“…The University of Utah conducted eight distinct trials meeting inclusion criteria between 2015 and 2019; collectively, 985 surgical patients were enrolled (Table 1). Patient populations included reconstructive surgery (3 trials; N = 507), 18,28,29 thoracic surgery (2 trials; N = 198), 30,31 colorectal surgery (1 trial; N = 116), 32 orthopedic surgery (1 trial; N = 109), 33 and trauma surgery (1 trial, N = 55) 34 (Table 2).…”

Section: Resultsmentioning

confidence: 99%

Low Anti-Factor Xa Level Predicts 90-Day Symptomatic Venous Thromboembolism in Surgical Patients Receiving Enoxaparin Prophylaxis

Pannucci¹,

Fleming

Varghese

et al. 2020

Annals of Surgery

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Objective: To examine the relationship between enoxaparin dose adequacy, quantified with anti-Factor Xa (aFXa) levels, and 90-day symptomatic venous thromboembolism (VTE) and postoperative bleeding. Summary Background Data: Surgical patients often develop "breakthrough" VTE events-those which occur despite receiving chemical anticoagulation. We hypothesize that surgical patients with low aFXa levels will be more likely to develop 90-day VTE, and those with high aFXa will be more likely to bleed. Methods: Pooled analysis of eight clinical trials (N = 985) from a single institution over a 4 year period. Patients had peak steady state aFXa levels in response to a known initial enoxaparin dose, and were followed for 90 days. Survival analysis log-rank test examined associations between aFXa level category and 90-day symptomatic VTE and bleeding. Results: Among 985 patients, 2.3% (n = 23) had symptomatic 90-day VTE, 4.2% (n = 41) had 90-day clinically relevant bleeding, and 2.1% (n = 21) had major bleeding. Patients with initial low aFXa were significantly more likely to have 90-day VTE than patients with adequate or high aFXa (4.2% vs 1.3%, P = 0.007). In a stratified analysis, this relationship was significant for patients who received twice daily (6.2% vs 1.5%, P = 0.003), but not once daily (3.0% vs 0.7%, P = 0.10) enoxaparin. No association was seen between high aFXa and 90-day clinically relevant bleeding (4.8% vs 2.9%, P = 0.34) or major bleeding (3.6% vs 1.6%, P = 0.18). Conclusions: This manuscript establishes inadequate enoxaparin dosing as a plausible mechanism for breakthrough VTE in surgical patients, and identifies anticoagulant dose adequacy as a novel target for process improvement measures.

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Section: Resultsmentioning

confidence: 99%

Low Anti-Factor Xa Level Predicts 90-Day Symptomatic Venous Thromboembolism in Surgical Patients Receiving Enoxaparin Prophylaxis

Pannucci¹,

Fleming

Varghese

et al. 2020

Annals of Surgery

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“…SQ enoxaparin with respect to afXa levels and VTE prevention in the postoperative surgical patient is a topic of active investigation. 13,[21][22][23][24][25][26][27][28][29] Regarding the general plastic surgery inpatient, Pannucci et al identified that standard enoxaparin dosing led to low afXa levels, and that low afXa level predicted 90-day VTE risk. 2 Still, how this relates specifically to the free flap patient has yet to be investigated.…”

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confidence: 99%

“…SQ enoxaparin with respect to afXa levels and VTE prevention in the postoperative surgical patient is a topic of active investigation. 13 21 22 23 24 25 26 27 28 29…”

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confidence: 99%

Standard Fixed Enoxaparin Dosing for Venous Thromboembolism Prophylaxis Leads to Low Peak Anti-Factor Xa Levels in Both Head and Neck and Breast Free Flap Patients

Ambani

Bengür

Varelas

et al. 2022

J Reconstr Microsurg

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Introduction Venous thromboembolism (VTE) is a serious complication, particularly in cancer patients undergoing free flap reconstruction. Subcutaneous enoxaparin is the conventional prophylaxis for VTE prevention, and serum anti-factor Xa (afXa) levels are being increasingly used to monitor enoxaparin activity. In this study, free flap patients receiving standard enoxaparin prophylaxis were prospectively followed to investigate postoperative afXa levels and 90-day VTE and bleeding-related complications. Methods Patients undergoing free tissue transfer during an 8-month period were identified and prospectively followed. Patients received standard fixed enoxaparin dosing at 30 mg twice daily in head and neck (H&N) and 40 mg daily in breast reconstructions. Target peak prophylactic afXa range was 0.2 to 0.5 IU/mL. The primary outcome was the occurrence of 90-day postoperative VTE- and bleeding-related events. Independent predictors of afXa level and VTE incidence were analyzed for patients that met the inclusion criteria. Results Seventy-eight patients were prospectively followed. Four (5.1%) were diagnosed with VTE, and six (7.7%) experienced bleeding-related complications. The mean afXa levels in both VTE patients and bleeding patients were subprophylactic (0.13 ± 0.09 and 0.11 ± 0.07 IU/mL, respectively). Forty-six patients (21 breast, 25 H&N) had valid postoperative peak steady-state afXa levels. Among these, 15 (33%) patients achieved the target prophylactic range: 5 (33%) H&N and 10 (67%) breast patients. The mean afXa level for H&N patients was significantly lower than for breast patients (p = 0.0021). Patient total body weight was the sole negative predictor of afXa level (R 2 = 0.47, p < 0.0001). Conclusion Standard fixed enoxaparin dosing for postoperative VTE prophylaxis does not achieve target afXa levels for the majority of our free flap patients. H&N patients appear to be a particularly high-risk group that may require a more personalized and aggressive approach. Total body weight is the sole negative predictor of afXa level, supporting a role for weight-based enoxaparin dosing.

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“…Optimal enoxaparin dosing was examined in a series of clinical trials conducted by the senior author. [38][39][40][41] One trial enrolled 94 hospitalized plastic surgery patients, all of whom received enoxaparin 40 mg once daily beginning 8 hours after surgery. Patients had peak and trough steady-state aFXa levels drawn, with real-time dose adjustment as necessary.…”

Section: Low-molecular-weight Heparinmentioning

confidence: 99%

Unfractionated Heparins, Low-Molecular-Weight Heparins, and Indirect Factor Xa Inhibitors in Plastic and Reconstructive Surgery: An Evidence-Based Review

Othman

Bertolaccini

Pannucci³

2023

Plastic &Amp; Reconstructive Surgery

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Venous thromboembolism can present with devastating complications and sequalae, particularly in the surgical patient. Current data support prophylactic anticoagulant use in high-risk hospitalized patients, defined as those with a Caprini Risk Assessment Model score of 7 or greater. The most frequently used chemoprophylaxis agents include unfractionated heparin, low-molecular-weight heparin, and indirect factor Xa inhibitors. The authors review the mechanisms of action, metabolism, reversal agents, indications, contraindications, advantages, and disadvantages of these medications in plastic and reconstructive surgery.

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Fixed or Weight-Tiered Enoxaparin After Thoracic Surgery for Venous Thromboembolism Prevention

Cited by 6 publications

References 21 publications

Low Anti-Factor Xa Level Predicts 90-Day Symptomatic Venous Thromboembolism in Surgical Patients Receiving Enoxaparin Prophylaxis

Low Anti-Factor Xa Level Predicts 90-Day Symptomatic Venous Thromboembolism in Surgical Patients Receiving Enoxaparin Prophylaxis

Standard Fixed Enoxaparin Dosing for Venous Thromboembolism Prophylaxis Leads to Low Peak Anti-Factor Xa Levels in Both Head and Neck and Breast Free Flap Patients

Unfractionated Heparins, Low-Molecular-Weight Heparins, and Indirect Factor Xa Inhibitors in Plastic and Reconstructive Surgery: An Evidence-Based Review

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