Extended-duration thromboprophylaxis after CRS/HIPEC

Khan S, et al. Incidence, Risk Factors, and Prevention Strategies for Venous Thromboembolism after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol. 2019 Jul;26(7):2276-2284.

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“A policy change was made in February 2010 to discharge all patients post-CRS/HIPEC with 14 days of additional pharmacothromboprophylaxis, which consisted of low-molecular-weight heparin in 327 of 447 (73%) cases (Supplemental Figure). The 60-day VTE rate decreased from 10.2 to 4.9% after this policy was instituted (p = 0.10, Fig. 2).”

“This policy is in accordance with established guidelines indicating the need for a total of 4 weeks of pharmacothromboprophylaxis in high-risk patients after abdominal or pelvic surgery for cancer. [2,21] Given that patients have an average length of stay of nearly 2 weeks, discharging them on 14 days of pharmacothromboprophylaxis fulfills this duration.”

Suppl Table 1

Felder S, et al. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev. 2019 Aug 26;8:CD004318.

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Prolonged thromboprophylaxis with LMWH significantly reduces the risk of VTE compared to thromboprophylaxis during hospital admittance only, without increasing bleeding complications or mortality after major abdominal or pelvic surgery. This finding also holds true for DVT alone, and for both proximal and symptomatic DVT. The quality of the evidence is moderate and provides moderate support for routine use of prolonged thromboprophylaxis. Given the low heterogeneity between studies and the consistent and moderate evidence of a decrease in risk for VTE, our findings suggest that additional studies may help refine the degree of risk reduction but would be unlikely to significantly influence these findings. This updated review provides additional evidence and supports the previous results reported in the 2009 review.

Farge D, Frere C, Connors JM, et al. 2019 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. Lancet Oncol. 2019 Oct;20(10):e566-e581.

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Extended-duration (4 weeks) thromboprophylaxis: The 2016 ITAC guidelines for extended prophylaxis with LMWH for patients with cancer undergoing laparotomy and laparoscopic surgery remains unchanged, with four new supporting meta-analyses changing the grade of the recommendation from grade 1B to 1A. In the first meta-analysis, [63] extended-duration prophylaxis (2–6 weeks) significantly reduced the risk of any VTE (2·6% vs 5·6%, RR 0·44, 95% CI 0·28–0·70) and proximal deep vein thrombosis (1·4% vs 2·8%, RR 0·46, 0·23–0·91), but not symptomatic pulmonary embolism (0·8% vs 1·3%, RR 0·56, 0·23–1·40). There was no significant increase in major bleeding (1·8% vs 1·0%, RR 1·19, 0·47–2·97). In the second meta-analysis, [62] extended-duration thromboprophylaxis was associated with a significant decrease in the incidence of deep vein thrombosis (RR 0·57, 95% CI 0·39–0·83), without a significant increase in bleeding (RR 1·48, 0·78–2·8). Three observational studies (two prospective and one retrospective) provided evidence for extended-duration prophylaxis after radical cystectomy64, 65 and liver resection. [66] There is strong evidence to support extending the duration of prophylaxis for 4 weeks after cancer surgery provided that patients are not at high risk of bleeding. A third meta-analysis [67] reported that extended-duration prophylaxis significantly reduced the risk for all VTE (OR 0·38, 95% CI 0·26–0·54), all reported cases of deep vein thrombosis (0·39, 0·27–0·55), and proximal deep vein thrombosis (0·22, 0·10–0·47), with a non-significant reduction in symptomatic VTE (0·30, 0·08–1·11) and a non-significant increase in major bleeding (1·10, 0·67–1·81). A fourth meta-analysis provided corroborating findings from the third meta-analysis. [68]” (Farge, et al., 2019, p. e574)

See also: Gould MK, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e227S-e277S. doi: 10.1378/chest.11-2297.

More PubMed results on extended-duration thromboprophylaxis.

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