ESTS/AATS Guidelines for Prevention of Cancer-Associated VTE: Key Points

Shargall Y, Wiercioch W, Brunelli A, et al.
Joint 2022 European Society of Thoracic Surgeons and The American Association for Thoracic Surgery Guidelines for the Prevention of Cancer-Associated Venous Thromboembolism in Thoracic Surgery. J Thorac Cardiovasc Surg 2023;165:794-824.

The following are key points to remember from the joint 2022 European Society of Thoracic Surgeons (ESTS) and the American Association for Thoracic Surgery (AATS) Guidelines for the Prevention of Cancer-Associated Venous Thromboembolism (VTE) in Thoracic Surgery:

  1. VTE is a potentially fatal but preventable postoperative complication. Thoracic oncology patients undergoing surgical resection represent among the highest-risk group for postoperative VTE.
  2. The guideline panel issued recommendations for patients undergoing lobectomy/segmentectomy, pneumonectomy or extended lung resection, or esophagectomy. In general, the guideline recommendations are quite similar for all included surgical procedures.
  3. The guideline panel suggests that using parenteral anticoagulation (particularly low molecular weight heparin) over no thromboprophylaxis or use of a direct oral anticoagulant (DOAC). They note that DOAC use should only occur in the setting of a clinical trial.
  4. The guideline panel suggests that pharmacologic thromboprophylaxis continue for 28-35 days rather than be limited to in-hospital duration only when the patient is at moderate-high risk of VTE. Patients at low risk of VTE can be given a limited in-hospital course of chemoprophylaxis.
  5. Postoperative VTE risk can be estimated using the Caprini score. Patients with a score of 0-4 are considered low risk, 5-8 at intermediate/moderate risk, and ≥9 at high risk.
  6. The guideline panel also suggests using combined pharmacologic and mechanical thromboprophylaxis postoperatively. If a patient is not receiving chemoprophylaxis, the guideline panel still recommends that mechanical prophylaxis (intermittent pneumatic compression or graded compression stockings) be given.
  7. The guideline panel did not make a recommendation of the use of immediate preoperative versus immediate postoperative chemoprophylaxis due to a lack of evidence about benefits and uncertainly in risk of bleeding. The panel did consider that mechanical prophylaxis would be given immediately preoperatively.
  8. One key area of difference is in the recommendation for routine postoperative screening for VTE. The guideline panel suggests against routine screening for postoperative VTE in patients with lobectomy/segmentectomy. However, the guideline panel suggests screening for postoperative VTE in patients undergoing pneumonectomy, extended lung resections, and esophagectomy.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Cardio-Oncology, 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, Cardiotoxicity, Chemoprevention, Esophagectomy, Hemorrhage, Heparin, Low-Molecular-Weight, Neoplasms, Pneumonectomy, Postoperative Complications, Secondary Prevention, Thoracic Surgery, Vascular Diseases, Venous Thromboembolism

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