European Society of Thoracic Surgeons and The American.pptx
1. European Society of Thoracic
Surgeons and The American
Association for Thoracic Surgery
guidelines for the prevention of
cancer-associated venous
thromboembolism in thoracic
surgery
2. Background :
Venous thromboembolism (VTE), which includes
both deep vein thrombosis (DVT) and
pulmonary embolism (PE), is a potentially fatal
but preventable perioperative complication.
PE is the third most common cause of
cardiovascular death after myocardial infarction
and stroke, the most common preventable
cause of hospital death, and the risk of
occurrence can be significantly mitigated
through prophylaxis.
3. Despite thoracic oncology patients undergoing
surgical resection being considered amongst the
highest risk for VTE in the perioperative period,
specific VTE prophylaxis guidelines have not
been defined for this population.
4. *These joint evidence-based guidelines from
The American Association for Thoracic Surgery
(AATS) and the European Society of Thoracic
Surgeons (ESTS) were conducted with guidance
from the McMaster University GRADE Center.
*European Journal of Cardio-Thoracic Surgery
2022.
*Received 10 September 2021; received in
revised form 21 April 2022; accepted 9 May
2022
5. Description of the Health Problem
*VTE, comprising DVT and PE, is a potentially fatal
but largely preventable postoperative complication.
Without thromboprophylaxis, the incidence of
objectively confirmed DVT is 10% to 40% in general
medical and surgical patients.
*Thrombotic complications are the most common
cause of 30- day postoperative mortality
*Compared with the noncancer surgical
populations, cancer patients who have undergone
surgical resection have a 2- to 3- fold increased risk
for postoperative DVT, a 3-fold increased risk for
fatal PE.
6. Thoracic surgery patients undergoing cancer
resections are considered a uniquely high-risk
population based on risk assessment models. A PE
in particular is associated with a high mortality
rate in patients with an already compromised
pulmonary status .
8. • Parenteral Anticoagulation Versus No
Anticoagulation.
• LMWH Versus UFH.
• Mechanical Prophylaxis Versus No Prophylaxis.
• Combined Mechanical and Pharmacological
Prophylaxis Versus Pharmacological Prophylaxis
Alone.
• Extended Versus In-Hospital Prophylaxis
• Pre- Versus Postoperative Administration of
Prophylaxis.
• Routine Postoperative Screening for VTE.
9. Parenteral Anticoagulation Versus No
Anticoagulation
*We identified 52 randomized controlled trials that fulfilled our
inclusion criteria and measured outcomes relevant to this context.
• 20 of the trials included patients undergoing major general surgery,
• 13 of the trials included patients undergoing major abdominal
surgery,
• 7 of the trials included patients undergoing gynecological surgery,
• 5 of the trials included patients undergoing urological surgery,
• 3 of the trials included patients undergoing gastrointestinal or
colorectal surgery,
• 2 trials included patients undergoing laparoscopic cholecystectomy,
• 1 trial included patients undergoing liver resection, and
• 1 trial included patients undergoing lobectomy.
10. • 20 trials reported on the effect of parenteral
anticoagulants (LMWH or UFH given
subcutaneously) on mortality
• 37 on symptomatic PE
• 8 on proximal DVT , 13 on distal DVT
• 30 on major bleeding, 9 on reoperation, 15 on
wound hematoma, 4 on wound infection, and 6
on heparin-induced thrombocytopenia (HIT).
11. Benefits:
The panel considered these health benefits to
be moderate. At a lower baseline risk of VTE in
this patient population the anticipated desirable
effects with reductions in PE and DVT would
probably be considered small
12. Harms and burden:
• Parenteral anticoagulation as compared to not using
anticoagulation may increase major bleeding ,this
corresponds to 6 more major bleeds per 1000
patients.
• Use of anticoagulants may have no impact on
reoperation.
• The occurrence of wound hematoma may be
increased with use of anticoagulants.
• The use of parenteral anticoagulants was also found
to have no influence on HIT.
**(The guideline panel considered the size of these
adverse effects to be small.)
13. Conclusions:
• Based on the body of available evidence, it is likely
that parenteral anticoagulation reduces the risk of
mortality, PE and DVT.
• The certainty was low due to indirectness of the
research evidence coming from older studies
primarily on other surgery types.
• The panel noted that the use of parenteral
anticoagulants in this population is highly
acceptable but the magnitude of beneficial effects
may not be clear in patients with cancer
undergoing lung resection.
• The panel noted the uncertainty about risks of
outcomes due to cancer versus due to surgery
14. LMWH Versus UFH
We identified 17 randomized controlled trials that fulfilled
our inclusion criteria and measured outcomes relevant to
this context .
All the trials included a study population consisting of
patients with cancer undergoing major surgeries, including
abdominal, pelvic, gynecological, gastrointestinal or
colorectal surgery, with 2 trials including patients
undergoing thoracic surgery or lung surgery.
Eight trials reported on the effect of LMWH versus UFH on
mortality, 15 on symptomatic PE, 8 on symptomatic DVT,
10 on major bleeding, 4 on reoperation, 6 on wound
hematoma, 3 on wound infection, and 2 on HIT.
15. Benefits:
• LMWH compared with UFH probably reduces
mortality ,this corresponds to 2 fewer deaths per
1000 patients.
• LMWH probably reduces PE ,this corresponds to
1 fewer symptomatic PE per 1000 patients.
• %. LMWH probably reduces symptomatic DVT,
this corresponds to 4 fewer DVT per 1000
patients.
**The panel considered these health benefits to
be small.
16. Harms and burden.
• LMWH compared with UFH probably has little
influence on major bleeding, this corresponds to 1
more major bleed per 1000 patients.
• Use of LMWH may reduce reoperation.
• The rate of wound hematoma is probably reduced
with LMWH.
• The rate of wound infections is probably
increased with LMWH.
**The guideline panel considered the size of the
anticipated undesirable effects to be small.
17. Conclusions:
• The conditional recommendation for use of
LMWH as thromboprophylaxis in patients with
cancer undergoing lung resection is due to a
balance of effects that probably favors LMWH.
• The panel made a conditional recommendation
for use of LMWH rather than a strong
recommendation given varying costs of the
intervention and issues regarding access to the
specific anticoagulants in different settings, with
both options being acceptable.
• The panel did not identify any further research
priorities for this guideline question.
18. Combined Mechanical and
Pharmacological Prophylaxis Versus
Pharmacological Prophylaxis Alone
*We identified 15 randomized controlled trials
that fulfilled our inclusion criteria and measured
outcomes relevant to this context.
19. Benefits
*Use of combined prophylaxis compared with
pharmacological prophylaxis alone may reduce
mortality ,this corresponds to 9 fewer deaths per 1000
patients.
*Combined prophylaxis may reduce PE ,this
corresponds to 1 fewer symptomatic PE per 1000
patients .
*Use of combined prophylaxis probably reduces
proximal DVT (RR, 0.14; 95% CI, 0.01-2.63; very low
certainty in the evidence of effects); this corresponds
to 10 fewer proximal DVT per 1000 patients.
*The panel considered these health benefits to be
small.
20. Harms and burden.
• For the effect of using combined prophylaxis on
major bleeding there were very serious concerns
about imprecision due to a small number of
events in the included trials and we are uncertain
about this effect
21. Conclusions:
*The conditional recommendation for use of
combined mechanical and pharmacological
prophylaxis in patients with cancer undergoing lung
resection is due to a balance of effects that probably
favors combined prophylaxis based on very low
certainty in the evidence, negligible costs for the in-
patient setting, and the intervention being viewed as
acceptable and feasible.
*Despite the very low uncertainty in the evidence, the
panel did not identify the use of combined prophylaxis
as a research priority
22. Mechanical Prophylaxis Versus No
Prophylaxis
• We identified 20 randomized controlled trials that
fulfilled our inclusion criteria and measured
outcomes relevant to this context.
• Mechanical prophylaxis compared with no
prophylaxis may reduce PE,this corresponds to 4
fewer symptomatic PE per 1000 patients.
• Use of mechanical prophylaxis may reduce
proximal ,this corresponds to 2 fewer proximal
DVT per 1000 patients.
• The panel considered these health benefits to be
small
23. Harms and burden
• The panel judged that overall the undesirable
anticipated effects of using mechanical
prophylaxis would be trivial.
24. Conclusions:
• The conditional recommendation for use of
mechanical prophylaxis in patients undergoing
lung resection, who do not receive
pharmacological prophylaxis, is due to a small
benefit and overall balance of efficacy and
safety that probably favors the intervention in
the context of very low certainty of evidence,
likely acceptability and feasibility, as well as
negligible costs.
25. Extended Versus In-Hospital
Prophylaxis
• We identified 7 randomized controlled trials
that fulfilled our inclusion criteria and
measured outcomes relevant to this context.
• All of the trials addressed use of extended
prophylaxis with LMWH for a duration up to
28 to 35 days compared with LMWH for a
duration of 6 to 10 days.
26. Benefits:
• The effect of using extended prophylaxis compared
with in-hospital prophylaxis on mortality was
uncertain ,with 2 more (3 fewer to 9 more) deaths
per 1000 patient.
• Extended prophylaxis probably reduces PE ,this
corresponds to 11 fewer symptomatic PE per 1000
patients.
• Use of extended prophylaxis probably reduces
proximal DVT ,this corresponds to 9 fewer proximal
DVT per 1000 patients.
• The panel considered these health benefits to be
small.
27. Harms and burden.
• s extended prophylaxis may result in a
reduction in major bleeding ,this corresponds
to 5 fewer major bleeds per 1000 patients.
• No data was reported in the included trials on
wound infection, wound hematoma, or
reoperation.
28. Conclusion:
• The panel judged that within the
heterogenous population of patients
undergoing lung resection, for those at higher
risk of thrombosis the balance of effects
probably favors use of extended prophylaxis,
whereas for those at lower risk the balance
probably favors in-hospital prophylaxis only.
29. Pre- Versus Postoperative
Administration of Prophylaxis
• We identified 3 randomized controlled trials
that fulfilled our inclusion criteria and
measured outcomes relevant to this context
