Prevention of venous thromboembolism in orthopedic surgery with vitamin K antagonists: a meta‐analysis

Abstract

Summary. Background: The benefit-to-risk ratio of vitamin K antagonists (VKA), relative to active comparators, especially low-molecular-weight heparins (LMWH), for preventing venous thromboembolism in patients undergoing major orthopedic surgery is debated. Objectives: We performed a meta-analysis of all randomized trials in orthopedic surgery comparing adjusted doses of VKA to control treatments. Patients and methods: An exhaustive literature search, both manual and computer-assisted, was performed. Studies were selected on the basis of randomization procedure (VKA vs. a control group). At least one of the following outcome measures was to be evaluated: deep vein thrombosis (DVT), pulmonary embolism (PE), death, major hemorrhage or wound hematoma. Four reviewers assessed each article to determine eligibility for inclusion and outcome measures. Results: VKAs were more effective than placebo or no treatment in reducing DVT [567 patients, relative risk (RR) ¼ 0.56, 95% confidence interval (CI) 0.37, 0.84, P < 0.01] and clinical PE (651 patients, RR ¼ 0.23, 95% CI 0.09, 0.59, P < 0.01). These results were obtained at the cost of a higher rate of wound hematoma (162 patients, RR ¼ 2.91, 95% CI 1.09, 7.75, P ¼ 0.03). VKAs were also more effective than intermittent pneumatic compression (534 patients, RR ¼ 0.46, 95% CI 0.25, 0.82, P ¼ 0.009) in preventing proximal DVT. In contrast, VKAs were less effective than LMWH in preventing total DVT and proximal DVT (9822 patients, RR ¼ 1.51, 95% CI 1.27, 1.79, P < 0.001; and 6131 patients, RR ¼ 1.51, 95% CI 1.04, 2.17, P ¼ 0.028, respectively). The differences between VKA and LMWH in major hemorrhage and wound hematoma were not significant. Conclusions: In patients undergoing major orthopedic surgery, VKAs are less effective than LMWH, without any significant difference in the bleeding risk.

Fondaparinux combined with intermittent pneumatic compression vs. intermittent pneumatic compression alone for prevention of venous thromboembolism after abdominal surgery: a randomized, double‐blind comparison

“…à P = 0.502 (two-sided FisherÕs exact test). asymptomatic deep vein thrombosis and decrease in symptomatic events with the use of antithrombotic agents [3,[26][27][28][29][30][31][32][33], supporting the view that asymptomatic deep vein thrombosis is a valid surrogate outcome measure in venous thromboembolism studies [34]. It is worth noting that, in our study, fondaparinux reduced by 86% the rate of proximal deep vein thromboses, which are more prone to embolize than calf vein thrombi.…”

Coagulation and Fibrinolysis Markers and Their Use for the Prediction of High Risk Patients with Venous Thromboembolism Following Total Hip Arthroplasty

“…Approaches to assessing individual risks of hospitalized patients for VTE can be applied to determine whether anticoagulant drugs are indicated for thromboprophylaxis [5][6][7]. These assessments, however, are usually complex and difficult to use in everyday practice [8].…”

Incidence and Risk Factors for Pulmonary Embolism After Primary Musculoskeletal Tumor Surgery

“…In patients undergoing major orthopaedic surgery, combined treatment with chemoprophylaxis, mechanical prophylaxis, and early mobilization reduces the risk of VTE [6,15]. Most patients with musculoskeletal sarcoma are considered to be at high risk for VTE, and therefore receive mechanical prophylaxis, with or without anticoagulation therapy, to prevent postoperative VTE [4,13,16,18,22].…”