VTE Recurrence Risk Following Surgery

Study Questions:

What is the risk of recurrent venous thromboembolism (VTE) following surgery in patients with a prior history of VTE?

Methods:

Using a population-based cohort study of patients with prior VTE, patients were followed between March 1999 and April 2010. Patients with surgery following a first VTE event were identified. Kaplan-Meier analysis was used to estimate the cumulative incidence of recurrent VTE. Cox regression was used to calculate hazard ratios (HRs) for developing recurrent VTE in patients with and without surgery.

Results:

The authors followed 2,741 patients (mean age 48.4 [standard deviation, 12.8] years, 54.0% women) with a history of VTE for a median of 5.7 years (interquartile range, 3.0-7.2 years). Of these, 580 (15.5%) underwent surgery and 601 (16.1%) developed a recurrent VTE event. The 1-month cumulative incidence of recurrent VTE following surgery was 2.1% (95% confidence interval [CI], 1.2%-3.6%). This increased to 3.3% (2.1%-5.1%) at 3 months and 4.6% (3.1%-6.6%) at 6 months. Risk of VTE recurrence at 6 months ranged from 2.3%-9.3% depending on the type of surgery. Factor V Leiden mutation (HR, 3.4; 95% CI, 1.6-7.4) and male sex (HR, 2.7; 95% CI, 1.3-5.8) were both independently associated with VTE recurrence following surgery as compared to patients who did not undergo surgical procedures.

Conclusions:

The authors concluded that surgery was associated with an increased risk of recurrent VTE at 1, 3, and 6 months postoperative. High-risk patients include those undergoing cancer-related, major orthopedic, and gastrointestinal surgeries, those with factor V Leiden mutations, and men.

Perspective:

Surgical procedures are known to be associated with increased risk of VTE. This is particularly true for patients with a prior history of VTE. This study confirms that certain surgical procedures (e.g., cancer-related, major orthopedic) are associated with higher VTE risk than others (e.g., outpatient, vascular). However, some of those differences may be attributed to more aggressive use of anticoagulants during and after vascular surgery. Important findings from this study are that men and those with known thrombophilias (e.g., factor V Leiden) are at higher risk of VTE recurrence postoperatively. However, a key limitation of this study is a lack of data on the use of VTE prophylaxis. Nonetheless, this study reinforces the important role of aggressive VTE prophylaxis for high-risk surgical patients, including those with prior VTE events. It is unclear if testing for thrombophilia prior to surgery would change management or outcomes in these patients. Future studies should explore the role of thrombophilia testing preoperatively in patients with prior VTE and the impact of various VTE prophylactic strategies stratified by postoperative VTE recurrence risk.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism, Cardiac Surgery and Arrhythmias, Interventions and Vascular Medicine

Keywords: Anticoagulants, Cardiac Surgical Procedures, Factor V, Factor V Deficiency, Mutation, Neoplasms, Outpatients, Risk Factors, Secondary Prevention, Thrombophilia, Vascular Diseases, Vascular Surgical Procedures, Venous Thromboembolism


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