Multimodal prophylaxis in patients with a history of venous thromboembolism undergoing primary elective hip arthroplasty

Abstract

Aims We studied the safety and efficacy of multimodal thromboprophylaxis in patients with a history of venous thromboembolism (VTE) who undergo total hip arthroplasty (THA) within the first 120 postoperative days, and the mortality during the first year. Multimodal prophylaxis includes discontinuation of procoagulant medications, VTE risk stratification, regional anaesthesia, an intravenous bolus of unfractionated heparin prior to femoral preparation, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient’s risk of VTE. Methods Between 2004 to 2018, 257 patients with a proven history of VTE underwent 277 primary elective THA procedures by two surgeons at a single institution. The patients had a history of deep vein thrombosis (DVT) (186, 67%), pulmonary embolism (PE) (43, 15.5%), or both (48, 17.5%). Chemoprophylaxis included aspirin (38 patients), anticoagulation (215 patients), or a combination of aspirin and anticoagulation (24 patients). A total of 50 patients (18%) had a vena cava filter in situ at the time of surgery. Patients were followed for 120 days to record complications, and for one year to record mortality. Results Postoperative VTE was diagnosed in seven patients (2.5%): DVT in five, and PE with and without DVT in one patient each. After hospitalization, three patients required readmiss-ion for evacuation of a haematoma, one for wound drainage, and one for monitoring of an elevated international normalized ratio (INR). Seven patients died (2.5%). One patient died five months postoperatively of a PE during open thrombectomy. She had discontinued anticoagulation. One patient died of a haemorrhagic stroke while receiving Coumadin. PE or bleeding was not suspected in the remaining five fatalities. Conclusion Multimodal prophylaxis is safe and effective in patients with a history of VTE. Postoperative anticoagulation should be prudent as very few patients developed VTE (2.5%) or died of suspected or confirmed PE. Mortality during the first year was mostly unrelated to either VTE or bleeding. Cite this article: Bone Joint J 2020;102-B(7 Supple B):71–77.

The deep vein thrombosis of lower limb after total hip arthroplasty: what should we care

“…The results of our study are consistent with the findings of previous studies. BMI is a factor that affects the occurrence of DVT after surgery, which has been confirmed by many studies[ 28 – 30 ]. The guidelines set BMI ≥ 30 kg/m 2 as an influencing factor of DVT.…”

Recommendations from the ICM-VTE: General

“…Their chemoprophylaxis was grouped into ASA, anticoagulation other than ASA, or combined. They were unable to draw conclusions on the efficacy of different chemoprophylaxis regimens based on the small numbers involved and the selection biases of choosing medications 1298 .…”

Effects and safety of intraoperative intermittent pneumatic compression for preventing postoperative venous thromboembolism: a meta-analysis

“…This metaanalysis was unable to analyze the bleeding risk of IPC due to the lack of included data. Compared with anticoagulants in previous studies [44,45], IPC can reduce the incidence of bleeding events, but it is not yet possible to draw a certain conclusion on the incidence of major bleeding events and mortality [46]. This may be related to the insufficient number of studies and the different anticoagulants use in the researches.…”