Balancing the Risks and Benefits of Thromboprophylaxis in Patients Undergoing Podiatric Surgery
2009; Elsevier BV; Volume: 135; Issue: 4 Linguagem: Inglês
10.1378/chest.08-2799
ISSN1931-3543
Autores Tópico(s)Central Venous Catheters and Hemodialysis
ResumoSurgery and immobility are recognized as important acquired risk factors for the development of venous thromboembolism (VTE).1Geerts WH Berquist D Pineo GF et al.Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition).Chest. 2008; 133: 381S-453SAbstract Full Text Full Text PDF PubMed Scopus (3687) Google Scholar Providing thromboprophylaxis to patients at moderate-to-high VTE risk has thus become an important patient safety initiative.2Maynard G Stein J Preventing hospital-acquired venous thromboembolism: a guide for effective quality improvement.Available at: http://www.ahrq.gov/qual/vtguide/Google Scholar Equally important has been a growing interest in identifying patients at low risk for VTE who do not need thromboprophylaxis, and who potentially may be unnecessarily subjected to the risks, costs, and inconvenience associated with thromboprophylaxis. Patients undergoing orthopedic procedures of the hip and knee are recognized as a high-risk population, with VTE incidence rates of 40 to 50% in the absence of thromboprophylaxis.1Geerts WH Berquist D Pineo GF et al.Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition).Chest. 2008; 133: 381S-453SAbstract Full Text Full Text PDF PubMed Scopus (3687) Google Scholar Thus, in the recent 2008 CHEST supplement on antithrombotic and thrombolytic therapy,1Geerts WH Berquist D Pineo GF et al.Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition).Chest. 2008; 133: 381S-453SAbstract Full Text Full Text PDF PubMed Scopus (3687) Google Scholar a grade 1A or 1B recommendation in favor of thromboprophylaxis was made for patients undergoing elective hip and knee arthroplasty and hip fracture surgery. In contrast, patients undergoing podiatric surgery, including below-knee, ankle, and foot surgeries, remain a relatively understudied population, in whom the risk/benefit ratio of thromboprophylaxis remains uncertain. Podiatric procedures have similarities with orthopedic procedures including leg surgery, the potential for vascular injury, and some degree of postoperative immobilization. Given the high-quality evidence supporting thromboprophylaxis in orthopedic patients, one might predict that thromboprophylaxis may be appropriate for podiatric patients. However, on closer examination, there are differences in podiatric procedures that place these patients at lower risk of VTE. Patients undergoing orthopedic procedures of the hip and knee may experience traumatic injury or manipulation of the deep veins of the lower extremity, which may predispose them to deep vein thrombosis (DVT) of the leg. Orthopedic procedures are typically longer in duration and may involve the use of a tourniquet, both of which are factors that increase venous stasis in the lower extremities. In contrast, podiatric procedures do not involve the proximal deep veins and rarely involve the calf veins. Even if thrombi develop within the calf veins, these infrequently extend into the proximal venous system, rarely embolize to cause pulmonary embolism (PE), and in many cases are not thought to be clinically significant.3Kearon C Natural history of venous thromboembolism.Circulation. 2003; 107: I22-I30PubMed Google Scholar In the current issue of CHEST (see page 917), Felcher et al4Felcher A Mularski R Mosen D et al.Incidence and risk factors for venous thromboembolic disease in podiatric surgery.Chest. 2009; 135: 917-922Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar describe the incidence and risk factors for VTE in patients undergoing podiatric surgery. These authors utilized a large comprehensive database to analyze 7,264 patients undergoing 16,804 podiatric surgical procedures. In total, there were 22 symptomatic VTE events, almost equally divided between symptomatic DVT and symptomatic PE, for an overall incidence of postprocedure VTE of 0.30%. The following three factors were independently associated with VTE: a history of VTE; the use of hormone replacement therapy or oral contraceptives; and obesity. The study also confirmed the additive effect of VTE risk factors after podiatric surgery; patients who had both received hormone replacement therapy or used oral contraceptives and were obese had an incidence of VTE approaching 5%. While other common VTE risk factors (active cancer, hypercoagulable states, and advanced age) were not independent predictors of VTE, patients with two or more of these risk factors had a VTE rate of 1.1%. The authors also reviewed the existing literature on the occurrence of VTE in podiatric surgery. The incidence of DVT after podiatric surgery ranged from 0.22 to 4.0%, and the incidence of PE ranged from 0 to 0.15%.5Slaybaugh R Beasley B Massa E Deep venous thrombosis risk assessment, incidence, and prophylaxis in foot and ankle surgery.Clin Podiatr Med Surg. 2003; 20: 269-289Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 6Mizel M Temple T Michelson J et al.Thromboembolism after foot and ankle surgery: a multicenter study.Clin Orthop Relat Res. 1998; 348: 180-185Crossref PubMed Google Scholar, 7Solis G Saxby T Incidence of DVT following surgery of the foot and ankle.Foot Ankle Int. 2002; 23: 411-414Crossref PubMed Scopus (110) Google Scholar, 8Hanslow S Grujic L Slater H et al.Thromboembolic disease after foot and ankle surgery.Foot Ankle Int. 2006; 27: 693-695Crossref PubMed Scopus (63) Google Scholar, 9Radl R Kastner N Aigner C et al.Venous thrombosis after hallux valgus surgery.J Bone Joint Surg Am. 2003; 85-A: 1204-1208Crossref PubMed Scopus (41) Google Scholar, 10Wukich D Waters D Thromboembolism following foot and ankle surgery: a case series and literature review.J Foot Ankle Surg. 2008; 47: 243-249Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 11Lapidus L Ponzer S Elvin A et al.Prolonged thromboprophylaxis with dalteparin during immobilization after ankle fracture surgery.Acta Orthop. 2007; 78: 528-535Crossref PubMed Scopus (103) Google Scholar In comparison, Felcher et al4Felcher A Mularski R Mosen D et al.Incidence and risk factors for venous thromboembolic disease in podiatric surgery.Chest. 2009; 135: 917-922Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar found a lower rate of DVT (0.16%). The difference in DVT rates is probably due, in part, to the choice of end point. The study by Felcher et al4Felcher A Mularski R Mosen D et al.Incidence and risk factors for venous thromboembolic disease in podiatric surgery.Chest. 2009; 135: 917-922Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar used symptomatic, objectively confirmed VTE, whereas some previous studies7Solis G Saxby T Incidence of DVT following surgery of the foot and ankle.Foot Ankle Int. 2002; 23: 411-414Crossref PubMed Scopus (110) Google Scholar, 9Radl R Kastner N Aigner C et al.Venous thrombosis after hallux valgus surgery.J Bone Joint Surg Am. 2003; 85-A: 1204-1208Crossref PubMed Scopus (41) Google Scholar, 11Lapidus L Ponzer S Elvin A et al.Prolonged thromboprophylaxis with dalteparin during immobilization after ankle fracture surgery.Acta Orthop. 2007; 78: 528-535Crossref PubMed Scopus (103) Google Scholar have used radiographically or venographically defined end points, which detect asymptomatic thrombi of questionable clinical significance. When considering an intervention such as VTE prophylaxis that is intended for prevention as opposed to treatment, the risks and benefits must be carefully weighed. The efficacy of thromboprophylaxis has been established for orthopedic populations; presumably it would be similarly effective in podiatric patients. In patients who are at high risk for VTE, the benefits of thromboprophylaxis will generally outweigh the risks. However, in patients who are at low risk for VTE, the risk/benefit ratio may not be obvious. Bleeding, although infrequent, is increasingly recognized to be associated with adverse outcomes, increased cost, and, potentially, an inability to resume therapy with needed anticoagulants. Thus, an accurate and careful evaluation of a patient's thrombotic risk is essential to avoid unnecessary or potentially harmful administration of medications. The data from Felcher et al4Felcher A Mularski R Mosen D et al.Incidence and risk factors for venous thromboembolic disease in podiatric surgery.Chest. 2009; 135: 917-922Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar is reassuring and suggest that thromboprophylaxis is not required for the average podiatric patient. Those with a history of VTE or those who have the combination of hormone therapy and obesity may benefit from a discussion regarding the use of thromboprophylaxis. Despite the low incidence of VTE, all patients should be counseled regarding the signs and symptoms of VTE, and the steps to take should these signs and symptoms occur. Future prospective studies randomizing podiatric patients to receive thromboprophylaxis, perhaps stratified by the risk factors identified above, would yield useful clinical information.
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