A Review of Venous Thromboembolism Risk Assessment and Prophylaxis in Plastic Surgery

Nikhil A. Agrawal, M.D.; Kirsty Hillier, M.D.; Riten Kumar, M.D., M.Sc.; Shayan A. Izaddoost, M.D., Ph.D.; Rod J. Rohrich, M.D.

Disclosures

Plast Reconstr Surg. 2022;149(1):121e-129e. 

In This Article

Abstract and Introduction

Abstract

Background: Venous thromboembolism is a significant cause of postoperative death and morbidity. While prophylactic and treatment regimens exist, they usually come with some risk of clinically relevant bleeding and, thus, must be considered carefully for each individual patient.

Methods: This special topic article represents a review of current evidence regarding venous thromboembolism risk, biology, and prevention in plastic surgery patients. The specific types and duration of available prophylaxis are also reviewed. The balance of venous thromboembolism risk must be weighed against the risk of hemorrhage.

Results: Though alternatives exist, the most validated risk assessment tool is the 2005 modification of the Caprini Risk Assessment Model. Controversies remain regarding recommendations for outpatient and low risk cosmetic patients. The authors additionally make recommendations for high-risk patients regarding the use of tranexamic acid, estrogen therapy, anesthesia, and prophylaxis regimens.

Conclusion: Our profession has made great strides in understanding the science behind venous thromboembolism, risk stratification for patients, and prophylactic regimens; yet, continued studies and definitive data are needed.

Introduction

The term venous thromboembolism encompasses the diagnoses of both deep vein thrombosis and pulmonary embolism.[1] Venous thromboembolism is the leading cause of preventable hospital death in the United States and worldwide, and the American Heart Association has a call to action to reduce hospital-acquired venous thromboembolism.[2] Venous thromboembolism often occurs in the postoperative period and remains a leading cause of postoperative mortality. While the exact incidence in the plastic surgery population is unknown, a recent multicenter cohort study estimated it to be 0.2 percent, with a venous thromboembolism-associated mortality rate of 8 percent.[3] Thus, preventing venous thromboembolism can reduce postoperative mortality.[4] In one series, although the overall mortality rate was low at 0.001 percent, pulmonary embolus was implicated in more than 50 percent of the mortality among outpatient cosmetic plastic surgery patients. Most thrombotic events occurred after abdominoplasty procedures.[5] Besides the risk of death, long-term consequences of venous thromboembolism include right heart strain, pulmonary hypertension, postthrombotic syndrome, and recurrent venous thromboembolism.

These potentially serious outcomes are weighed against the risk of bleeding from pharmacologic prophylaxis.[5,6] Risk stratification models help identify patients at higher risk for venous thromboembolism who may benefit from prophylaxis. The Caprini score was developed in 1991, initially for surgical patients only, and has been studied extensively with subsequent modifications and now includes medical patients.[6] The 2005 Caprini modification took 15 years to achieve adequate validation and gain widespread use. Although the Caprini score is not a perfect model, it has been validated in plastic surgery patients.[7] The optimal pharmacologic regimen for prophylaxis is also under review.[8] This special topic article reviews mechanisms of venous thromboembolism, risk stratification, and venous thromboembolism prophylaxis.

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