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Prevention of postoperative venous thromboembolism. Risk assessment and methods of prophylaxis

[La prévention de la thromboembolie veineuse postopératoire. Évaluation du risque et méthodes de prophylaxie]

Serge Motte, MD PhD^*, Charles Marc Samama, MD PhD, Joanne Guay, MD FRCPC, Jeanne Barré, MD, Jeanne-Yvonne Borg, MD^¶ and Nadia Rosencher, MD^||

^* From the Service de Pathologie Vasculaire, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Belgique;
Département d’Anesthésie-Réanimation, Centre Hospitalier Universitaire Avicenne, Assistance Publique Hôpitaux de Paris, Bobigny, France;
Département d’Anesthésie-Réanimation, Centre Hospitalier Universitaire Maisonneuve-Rosemont, Montreal, Quebec, Canada;
Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire Robert Debré, Reims, France;
^¶ Unité Fonctionnelle d’Hémostase, Centre Hospitalier Universitaire Charles Nicolle, Rouen, France; and the
^|| Département d’Anesthésie-Réanimation, Centre Hospitalier Universitaire Cochin, Paris, France.

Address correspondence to: Dr. Serge Motte, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, B 1070 Bruxelles, Belgique, Phone: 00 32 2 5554292; Fax: 00 32 2 5553536; E-mail: smotte{at}ulb.ac.be

Purpose: To describe risk assessment models that have been developed to stratify patients into different risk levels of postoperative venous thromboembolism (VTE) and then to review the different methods of prophylaxis and to outline the evidence supporting their effectiveness and safety.

Source: Our review of the literature is focused on consensus documents, recent large randomized trials and meta-analyses.

Principal findings: The risk of VTE is determined by the type of surgery and underlying patient factors. Risk assessment models are useful in stratifying patients into different VTE risk levels. However, multiple risk factors are often present in the same patient and in practice the evaluation of their relative contribution to the overall risk remains difficult. A variety of prophylactic strategies including physical and pharmacological methods have been shown to be effective in different patient groups. Patients with a moderate or high risk of VTE should receive prophylaxis consisting of an antithrombotic agent, unless contraindicated, used alone or in combination with a mechanical method. Recommendations concerning which prophylaxis to use and how intensive it should be are based mainly on data from trials using surrogate endpoints, and do not translate easily into practical decisions aiming to reduce the incidence of symptomatic events.

Conclusion: Although risk assessment models and recommendations provided by consensus documents are of practical assistance, a decision concerning any patient is best made by combining recommendations of the literature with clinical judgment, including individual patient risk factors for thrombosis and bleeding.

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