Venous Thromboembolism following Microsurgical Breast Reconstruction: A Longitudinal Analysis of 12,778 Patients.
Journal
Plastic and reconstructive surgery
ISSN: 1529-4242
Titre abrégé: Plast Reconstr Surg
Pays: United States
ID NLM: 1306050
Informations de publication
Date de publication:
09 2020
09 2020
Historique:
pubmed:
27
5
2020
medline:
23
9
2020
entrez:
27
5
2020
Statut:
ppublish
Résumé
Venous thromboembolism is a dreaded complication following microsurgical breast reconstruction. Although the high-risk nature of the procedure is well known, a thorough analysis of modifiable risk factors has not been performed. The purpose of this study was to analyze the association of such factors with the postoperative occurrence of venous thromboembolism longitudinally. Using the Truven MarketScan Database, a retrospective cohort study of women who underwent microsurgical breast reconstruction from 2007 to 2015 and who developed postoperative venous thromboembolism within 90 days of reconstruction was performed. Predictor variables included age, timing of reconstruction, body mass index, history of radiation therapy, history of venous thromboembolism, Elixhauser Comorbidity Index, and length of stay. Univariate analyses were performed, in addition to logistic and zero-inflated Poisson regressions, to evaluate predictors of venous thromboembolism and changes in venous thromboembolism over the study period, respectively. Twelve thousand seven hundred seventy-eight women were identified, of which 167 (1.3 percent) developed venous thromboembolism. The majority of venous thromboembolisms (67.1 percent) occurred following discharge, with no significant change from 2007 to 2015. Significant predictors of venous thromboembolism included Elixhauser score (p < 0.01), history of venous thromboembolism (p < 0.03), and length of stay (p < 0.001). Compared to patients who developed a venous thromboembolism during the inpatient stay, patients who developed a postdischarge venous thromboembolism had a lower mean Elixhauser score (p < 0.001). Postoperative venous thromboembolism continues to be an inadequately addressed problem, as evidenced by a stable incidence over the study period. Identification of modifiable risk factors, such as length of stay, provides potential avenues for intervention. As the majority of venous thromboembolisms occur following discharge, future studies are warranted to investigate the role for an intervention in this period. Risk, III.
Sections du résumé
BACKGROUND
Venous thromboembolism is a dreaded complication following microsurgical breast reconstruction. Although the high-risk nature of the procedure is well known, a thorough analysis of modifiable risk factors has not been performed. The purpose of this study was to analyze the association of such factors with the postoperative occurrence of venous thromboembolism longitudinally.
METHODS
Using the Truven MarketScan Database, a retrospective cohort study of women who underwent microsurgical breast reconstruction from 2007 to 2015 and who developed postoperative venous thromboembolism within 90 days of reconstruction was performed. Predictor variables included age, timing of reconstruction, body mass index, history of radiation therapy, history of venous thromboembolism, Elixhauser Comorbidity Index, and length of stay. Univariate analyses were performed, in addition to logistic and zero-inflated Poisson regressions, to evaluate predictors of venous thromboembolism and changes in venous thromboembolism over the study period, respectively.
RESULTS
Twelve thousand seven hundred seventy-eight women were identified, of which 167 (1.3 percent) developed venous thromboembolism. The majority of venous thromboembolisms (67.1 percent) occurred following discharge, with no significant change from 2007 to 2015. Significant predictors of venous thromboembolism included Elixhauser score (p < 0.01), history of venous thromboembolism (p < 0.03), and length of stay (p < 0.001). Compared to patients who developed a venous thromboembolism during the inpatient stay, patients who developed a postdischarge venous thromboembolism had a lower mean Elixhauser score (p < 0.001).
CONCLUSIONS
Postoperative venous thromboembolism continues to be an inadequately addressed problem, as evidenced by a stable incidence over the study period. Identification of modifiable risk factors, such as length of stay, provides potential avenues for intervention. As the majority of venous thromboembolisms occur following discharge, future studies are warranted to investigate the role for an intervention in this period.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Risk, III.
Identifiants
pubmed: 32453267
doi: 10.1097/PRS.0000000000007051
pii: 00006534-202009000-00001
doi:
Types de publication
Journal Article
Multicenter Study
Langues
eng
Sous-ensembles de citation
IM
Pagination
465-473Références
Office of the Surgeon General (US), National Heart, Lung, and Blood Institute (US). The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. 2008. Rockville, Md: Office of the Surgeon General; Available at: http://www.ncbi.nlm.nih.gov/books/NBK44178/. Accessed March 14, 2019.
Grosse SD, Nelson RE, Nyarko KA, Richardson LC, Raskob GE. The economic burden of incident venous thromboembolism in the United States: A review of estimated attributable healthcare costs. Thromb Res. 2016;137:3–10.
Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(Suppl):338S–400S.
Pannucci CJ, MacDonald JK, Ariyan S, et al. Benefits and risks of prophylaxis for deep venous thrombosis and pulmonary embolus in plastic surgery: A systematic review and meta-analysis of controlled trials and consensus conference. Plast Reconstr Surg. 2016;137:709–730.
Murphy RX Jr, Alderman A, Gutowski K, et al. Evidence-based practices for thromboembolism prevention: Summary of the ASPS Venous Thromboembolism Task Force Report. Plast Reconstr Surg. 2012;130:168e–175e.
Pannucci CJ, Dreszer G, Wachtman CF, et al. Postoperative enoxaparin prevents symptomatic venous thromboembolism in high-risk plastic surgery patients. Plast Reconstr Surg. 2011;128:1093–1103.
Pannucci CJ, Bailey SH, Dreszer G, et al. Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients. J Am Coll Surg. 2011;212:105–112.
Pannucci CJ, Swistun L, MacDonald JK, Henke PK, Brooke BS. Individualized venous thromboembolism risk stratification using the 2005 Caprini Score to identify the benefits and harms of chemoprophylaxis in surgical patients: A meta-analysis. Ann Surg. 2017;265:1094–1103.
Wille-Jørgensen P, Rasmussen MS, Andersen BR, Borly L. Heparins and mechanical methods for thromboprophylaxis in colorectal surgery. Cochrane Database Syst Rev. 2003;4:CD001217.
Kakkos SK, Caprini JA, Geroulakos G, et al. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism. Cochrane Database Syst Rev. 2016;9:CD005258.
American Society of Plastic Surgeons. 2017 plastic surgery statistics report. Available at: https://www.plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-2017.pdf. Accessed March 13, 2019.
Enajat M, Damen TH, Geenen A, Timman R, van der Hulst RR, Mureau MA. Pulmonary embolism after abdominal flap breast reconstruction: Prediction and prevention. Plast Reconstr Surg. 2013;131:1213–1222.
Seruya M, Venturi ML, Iorio ML, Davison SP. Efficacy and safety of venous thromboembolism prophylaxis in highest risk plastic surgery patients. Plast Reconstr Surg. 2008;122:1701–1708.
Lee JS, Son BH, Choi HS, et al. Pulmonary thromboembolism following mastectomy with immediate TRAM in the patients with breast cancer: A prospective study. J Breast Cancer 2006;9:354–360.
Pannucci CJ, Chang EY, Wilkins EG. Venous thromboembolic disease in autogenous breast reconstruction. Ann Plast Surg. 2009;63:34–38.
Kim EK, Eom JS, Ahn SH, Son BH, Lee TJ. The efficacy of prophylactic low-molecular-weight heparin to prevent pulmonary thromboembolism in immediate breast reconstruction using the TRAM flap. Plast Reconstr Surg. 2009;123:9–12.
Hansen L. The Truven Health MarketScan Databases for life sciences researchers. Available at: https://truvenhealth.com/Portals/0/Assets/2017-MarketScan-Databases-Life-Sciences-Researchers-WP.pdf. Accessed March 20, 2019.
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care 1998;36:8–27.
Fischer JP, Wes AM, Tuggle CT, Wu LC. Venous thromboembolism risk in mastectomy and immediate breast reconstruction: Analysis of the 2005 to 2011 American College of Surgeons National Surgical Quality Improvement Program data sets. Plast Reconstr Surg. 2014;133:263e–273e.
Masoomi H, Paydar KZ, Wirth GA, Aly A, Kobayashi MR, Evans GR. Predictive risk factors of venous thromboembolism in autologous breast reconstruction surgery. Ann Plast Surg. 2014;72:30–33.
Butz DR, Lapin B, Yao K, et al. Advanced age is a predictor of 30-day complications after autologous but not implant-based postmastectomy breast reconstruction. Plast Reconstr Surg. 2015;135:253e–261e.
Kim JY, Khavanin N, Rambachan A, et al. Surgical duration and risk of venous thromboembolism. JAMA Surg. 2015;150:110–117.
Engelman RM, Rousou JA, Flack JE III, et al. Fast-track recovery of the coronary bypass patient. Ann Thorac Surg. 1994;58:1742–1746.
Zhuang CL, Ye XZ, Zhang XD, Chen BC, Yu Z. Enhanced recovery after surgery programs versus traditional care for colorectal surgery: A meta-analysis of randomized controlled trials. Dis Colon Rectum 2013;56:667–678.
Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: A meta-analysis of randomized controlled trials. Clin Nutr. 2010;29:434–440.
Ren L, Zhu D, Wei Y, et al. Enhanced recovery after surgery (ERAS) program attenuates stress and accelerates recovery in patients after radical resection for colorectal cancer: A prospective randomized controlled trial. World J Surg. 2012;36:407–414.
Temple-Oberle C, Shea-Budgell MA, Tan M, et al.; ERAS Society. Consensus review of optimal perioperative care in breast reconstruction: Enhanced Recovery after Surgery (ERAS) Society recommendations. Plast Reconstr Surg. 2017;139:1056e–1071e.
Batdorf NJ, Lemaine V, Lovely JK, et al. Enhanced recovery after surgery in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg. 2015;68:395–402.
Afonso A, Oskar S, Tan KS, et al. Is enhanced recovery the new standard of care in microsurgical breast reconstruction? Plast Reconstr Surg. 2017;139:1053–1061.
Bonde C, Khorasani H, Eriksen K, Wolthers M, Kehlet H, Elberg J. Introducing the fast track surgery principles can reduce length of stay after autologous breast reconstruction using free flaps: A case control study. J Plast Surg Hand Surg. 2015;49:367–371.
Bonde CT, Khorasani H, Elberg J, Kehlet H. Perioperative optimization of autologous breast reconstruction. Plast Reconstr Surg. 2016;137:411–414.
Rochlin DH, Leon DS, Yu C, Long C, Nazerali R, Lee GK. The power of patient norms: Postoperative pathway associated with shorter hospital stay after free autologous breast reconstruction. Ann Plast Surg. 2019;82(Suppl 4):S320–S324.
Momeni A, Fox JP. Venous thromboembolism after surgical treatment of breast cancer. Ann Plast Surg. 2018;80:188–192.
Sweetland S, Green J, Liu B, et al.; Million Women Study collaborators. Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: Prospective cohort study. BMJ 2009;339:b4583.
Pannucci CJ, Rockwell WB, Ghanem M, Fleming KI, Momeni A, Agarwal J. Inadequate enoxaparin dosing predicts 90-day venous thromboembolism risk among plastic surgery inpatients: An examination of enoxaparin pharmacodynamics. Plast Reconstr Surg. 2017;139:1009–1020.
Turpie AG. Oral, direct factor Xa inhibitors in development for the prevention and treatment of thromboembolic diseases. Arterioscler Thromb Vasc Biol. 2007;27:1238–1247.
Hermans C, Claeys D. Review of the rebound phenomenon in new anticoagulant treatments. Curr Med Res Opin. 2006;22:471–481.
Bijsterveld NR, Moons AH, Meijers JC, et al. Rebound thrombin generation after heparin therapy in unstable angina: A randomized comparison between unfractionated and low-molecular-weight heparin. J Am Coll Cardiol. 2002;39:811–817.
Lassen MR, Borris LC, Anderson BS, et al. Efficacy and safety of prolonged thromboprophylaxis with a low molecular weight heparin (dalteparin) after total hip arthroplasty: The Danish Prolonged Prophylaxis (DaPP) Study. Thromb Res. 1998;89:281–287.
Hull RD, Pineo GF, Francis C, et al. Low-molecular-weight heparin prophylaxis using dalteparin extended out-of-hospital vs in-hospital warfarin/out-of-hospital placebo in hip arthroplasty patients: A double-blind, randomized comparison. North American Fragmin Trial Investigators. Arch Intern Med. 2000;160:2208–2215.
Bergqvist D, Nilsson PE. Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N Engl J Med. 2002:346:975–980.
Rasmussen MS. Preventing thromboembolic complications in cancer patients after surgery: A role for prolonged thromboprophylaxis. Cancer Treat Rev. 2002;28:141–144.
Rasmussen MS, Jorgensen LN, Wille-Jørgensen P, et al.; FAME Investigators. Prolonged prophylaxis with dalteparin to prevent late thromboembolic complications in patients undergoing major abdominal surgery: A multicenter randomized open-label study. J Thromb Haemost. 2006;4:2384–2390.
Pannucci CJ. Evidence-based recipes for venous thromboembolism prophylaxis: A practical safety guide. Plast Reconstr Surg. 2017;139:520e–532e.