Venous Thromboembolism Prophylaxis in Thoracic Surgery

Abstract

Venous thromboembolism (VTE) is a dreaded post-operative complication in nearly all surgical specialties. There has been a decades-long effort to identify patients with high risk for post-operative VTE and determine the most appropriate course of action to prevent VTE occurrence. The 9^th edition of the American College of Chest Physicians (ACCP) guidelines consider thoracic surgery patients to be at moderate risk for post-operative VTE. Despite recognition of post-operative VTE risk in thoracic surgery patients, there is a lack of consensus regarding the best practices to reduce VTE occurrence. VTE Risk Assessment Models (RAMs), including the Caprini RAM, have been developed outside of thoracic surgery to risk stratify patients for post-operative VTE and recommend appropriate prophylactic measures. Such interventions include early mobilization and inpatient mechanical compression devices, as well as chemoprophylaxis with unfractionated heparin and low-molecular-weight heparin, among other anticoagulants. Implementation of such interventions into general and vascular surgery have produced encouraging results with up to 84% reduction in VTE rates. Modification and application of existing RAMs in the thoracic surgery setting have shown promising preliminary results. Despite improvements achieved by implementing modified RAMs in thoracic surgery services at individual institutions, there are currently no field-specific guidelines to solidify practices nationwide. As a result, there remains considerable variability regarding patient screening, risk stratification, and VTE chemoprophylaxis practices. As most post-operative VTE occur after patient discharge, field-specific guidelines surrounding extended courses of chemoprophylaxis are needed. Large multicenter studies evaluating the implementation of specific VTE RAMs into thoracic surgery services are likely required before a standardized approach to VTE prevention can be achieved.