Thromboembolic and major bleeding events in relation to perioperative bridging of vitamin K antagonists in 649 fast-track total hip and knee arthroplasties

Abstract

Background — The benefit of preoperative bridging in surgical patients with continuous anticoagulant therapy is debatable, and drawing of meaningful conclusions may have been limited by mixed procedures with different thromboembolic and bleeding risks in most published studies.Patients and methods — This was an observational cohort treatment study in consecutive primary unilateral total hip and knee arthroplasty patients between January 2010 and November 2013 in 8 Danish fast-track departments. Data were collected prospectively on preoperative comorbidity and anticoagulants in patients with preoperative vitamin K antagonist (VKA) treatment. We performed 30-day follow-up on in-hospital complications and re-admissions through the Danish National Patient Registry and patient records.Results — Of 13,375 procedures, 649 (4.7%) were in VKA patients with a mean age of 73 (SD 9) years and a median length of stay of 3 days (IQR: 2–4). Preoperative bridging was used in 430 (67%), while 215 (33%) were paused. Of 4 arterial thromboembolic events (ATEs) (0.6%), 2 were in paused patients and 2 were in bridged patients (p = 0.6). Of 3 venous thromboembolic events (VTEs) (0.5%), 2 were in paused patients and 1 was in a bridged patient (p = 0.3). Of 8 major bleedings (MBs) (1.2%), 1 was in a paused patient and 7 were in bridged patients (p = 0.3), 5 of whom received therapeutic bridging. Similar results were found in a propensity-matched cohort.Interpretation — In contrast to recent studies in mixed surgical procedures, no statistically significant differences in ATE, VTE, or MB were found between preoperative bridging and pausation of VKA patients. However, the higher number of thromboembolic events in paused patients and the higher number of major bleedings in bridged patients warrant more extensive investigation.

Comparative efficacy and safety of anticoagulants for prevention of venous thromboembolism after hip and knee arthroplasty

“… 2003 , Miyagi et al. 2007 ), although recent development of fast-track surgery may have reduced postoperative VTE (Jorgensen and Kehlet 2017 ). The incidence of symptomatic VTE was estimated to be as high as 4% with no prophylaxis in patients undergoing knee or hip arthroplasty (Falck-Ytter et al.…”

Recommendations from the ICM-VTE: General

“…Jørgensen et al, studied 649 patients on vitamin K antagonist treatment undergoing THA and TKA 1956 . Of these, 430 patients were bridged, and 215 patients had their vitamin K antagonist paused.…”

A feasibility randomised controlled trial to evaluate the effectiveness of a novel neuromuscular electro-stimulation device in preventing the formation of oedema following total hip replacement surgery

“…Recent studies on fast-track (or Enhanced Recovery after Surgery) cohorts suggest that there may be an increased role for non-pharmalogical devices that can be used whilst walking ( Jorgensen and Kehlet, 2017 ). This is the first randomised controlled trial to evaluate the effectiveness of the geko™ device.…”