Safety of early orthopedic surgery in patients with intermediate/low- or low-risk pulmonary embolism

Abstract

Background: Preoperative pulmonary embolism (PE) is one of the comorbidities in patients with hip fracture. However, previous studies have not identified the optimal timing of surgery in these patients, who might require early surgery. This study aimed to investigate the safety and clinical feasibility of early surgery in patients with hip fracture and acute PE. Methods: The medical records of 156 patients with hip fracture, who were suspected to have PE and underwent pulmonary computed tomography angiography at Asan Medical Center from January 2008 to December 2017, were retrospectively reviewed. After excluding patients who were diagnosed with PE during the postoperative period, the baseline characteristics and clinical course were compared between patients preoperatively diagnosed with PE (PE group) and patients without PE during the hospital stay (non-PE group). Adverse outcomes were evaluated during 3 months postoperatively. Results: The baseline characteristics were not different between the PE group (n=90) and the non-PE group (n=50). All patients in the PE group were classified as having an intermediate/low or low risk according to the European Society of Cardiology guidelines and underwent surgery within 30 days after the PE diagnosis (median duration: 2 days). None of the patients in both groups developed symptomatic venous thromboembolism (VTE) during the follow-up. Moreover, there were no statistically significant differences in major bleeding, clinically relevant nonmajor (CRNM) bleeding, transfusion amount, bleeding site, and length of hospital stay between the PE and non-PE groups. Conclusions: Our results suggest that early surgery might be a reasonable treatment option in patients with hip fracture and acute PE.

Recommendations from the ICM-VTE: General

“…In a retrospective cohort study, Kim et al, found no significant difference in major or non-major bleeding, transfusion rates or length of stay at 3-month follow-up in hip fracture patients diagnosed with PE pre-operatively relative to a non-PE patient cohort with suspected VTE 2169 . Of note, 95.6% of the PE cohort received therapeutic anticoagulation postprocedure 2169 , hence suggesting that peri-operative empirical treatment of VTE may be safe even if early surgery is advocated. However, peri-operative major and non-major bleeding rates remained significant, which were 21.1% and 13.3%, respectively, at 3-month follow-up in the PE cohort 2169 Indeed, the proportion of non-PE patients administered therapeutic anticoagulation for suspected VTE pre-operatively was not reported and may have confounded the comparison in this study.…”

“…In a retrospective cohort study, Kim et al, found no significant difference in major or non-major bleeding, transfusion rates or length of stay at 3-month follow-up in hip fracture patients diagnosed with PE pre-operatively relative to a non-PE patient cohort with suspected VTE 2169 . Of note, 95.6% of the PE cohort received therapeutic anticoagulation post-procedure 2169 , hence suggesting that peri-operative empirical treatment of VTE may be safe even if early surgery is advocated.…”

“…Of note, 95.6% of the PE cohort received therapeutic anticoagulation postprocedure 2169 , hence suggesting that peri-operative empirical treatment of VTE may be safe even if early surgery is advocated. However, peri-operative major and non-major bleeding rates remained significant, which were 21.1% and 13.3%, respectively, at 3-month follow-up in the PE cohort 2169 Indeed, the proportion of non-PE patients administered therapeutic anticoagulation for suspected VTE pre-operatively was not reported and may have confounded the comparison in this study. Bose et al, found that the incidence of major bleeding events, recurrent VTE and death in post-operative patients initiated on treatment for PE within a 90-day period was 12%, 4% and 9%, respectively 2170 , demonstrating a clear association with increased morbidity.…”

“…Treatment with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) may be more useful for patients with acute VTE requiring non-elective surgery 855 . In the setting of an acute or active DVT or PE, stopping UFH or LMWH treatment for a period of time for a patient to undergo surgery is feasible and carries low risk 856,857 . To limit undesirable anticoagulant effects intraoperatively, LMWH should be held for 24 hours or reduced by 50% the evening prior to surgery 822,855 while UFH should be discontinued 4 - 6 hours prior to procedure 858 .…”

Submassive Pulmonary Embolism Complicating Small Bowel Obstruction

“…There is precedence for early surgical intervention in patients with low-intermediate risk pulmonary embolism. A retrospective cohort study of 140 patients who underwent orthopedic surgery found no difference in major bleeding episodes between the PE and non-PE groups when operated on within 30 days of diagnosis (21.1% vs 16%; p=0.463) [ 5 ]. Furthermore, there was no significant difference in bleeding risk or duration of hospitalization when controlling for patients with an inferior vena cava filter placement.…”