Specific agents for risk reduction
- apixaban (oral factor Xa inhibitor)
- aspirin (see role of ASA for DVT prophylaxsis)
- low molecular wt glycosaminoglycan with potent anti factor Xa activity
- low molecular weight heparins
- may be more effective in total hip arthroplasty as compared to total knee arthroplasty
- typically LMWH are administered 12-24 hours following surgery and is continued for 14 days
- recombinant hirudin desirudin
- may offer up to 86% risk reduction of DVT
- direct inhibitor of thrombin
- rivaroxaban (Xarelto)
- highly selective direct factor Xa inhibitor with oral bioavailability and rapid onset of action
- availability – 10 mg, 15 mg, and 20 mg tablets
- indications (non-comprehensive)
- prophylaxis of deep vein thrombosis (DVT) in adults undergoing hip and knee replacement
- treatment of patients with DVT and pulmonary embolism (PE)
- long-term treatment to prevent recurrence of DVT and PE
- SQ heparin
- thrombolytic therapy
- difficulty in assessing the risk of bleeding complications among various agents depends mainly on dose of meds used and amount of monitoring
- i.e., to achieve the desired anticoagulation effect (and DVT prophylaxsis), how much bleeding are we willing to accept?
- published bleeding complications note 5% bleeding from LMWH, 3% bleeding from coumadin, and 2.5% from SQ heparin
- in contrast, the bleeding complications from ASA is approximately 0.4%
Mechanical methods for risk reduction
- note that there is a large venous plexus in the foot which is compressed when the foot is flattened with wt bearing
- wt bearing compresses about 30 ml out of the foot and flushes it into the deep venous system
- foot pump systems attempt to reproduce this effect
- TED hose (compression stockings) are recommended when using mechanical devices in order to help control venous capacitance
- compression stockings
- note that mechanical compression devices that wrap around the leg cannot be used in total knee patients
- in the study by Warwick, et al. (1998), DVT was noted in 18% of foot pump patients vs 13% of enoxaparin patients (no sig difference)
- patients in the enoxaparin group had significantly more bruising, thigh swelling, and wound oozing
- the authors used venography to evaluate DVT formation
- the authors concluded that foot pump devices had comprable efficacy to low molecular wt heparin
- reference - Comparison of the use of a foot pump with the use of low-molecular-weight heparin for the prevention of deep-vein thrombosis after total hip replacement. A prospective, randomized trial.
- foot movement
- sustained movement of the foot (30 cycles for one minute) will produce a sustained increase in the venous outflow (22 % greater than baseline) which gradually returns to the base line after 30 min
- reference - The effect of active movement of the foot on venous blood flow after after total hip replacement.
- epidural anesthesia has clearly been shown to reduce prevalence of DVT
- potential problem is that blood thinning agents cannot be used as long as the epidural catheter is in place (due to the risk of epidural hematoma and resulting neurologic deficit)
- reference: The prevalence of deep venous thrombosis after total hip arthroplasty with hypotensive epidural anesthesia
American Society of Regional Anesthesia and Pain Medicine
Comparison of enoxaparin and warfarin for the prevention of venous thromboembolic disease after total hip arthroplasty. Evaluation during hospitalization and three months after discharge.
Finding the right fit: effective thrombosis risk stratification in orthopedic patients.
Aspirin for Preventing Venous Thromboembolism
Potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty.
A non-interventional comparison of rivaroxaban with standard of care for thromboprophylaxis after major orthopaedic surgery in 17,701 patients with propensity score adjustment.
Antithrombotic prophylaxis in major orthopaedic surgery: an historical overview and update of current recommendations.
The use of novel oral anticoagulants for thromboprophylaxis after elective major orthopedic surgery.
Benefit-to-harm ratio of thromboprophylaxis for patients undergoing major orthopaedic surgery. A systematic review.
Novel oral anticoagulants for thromboprophylaxis after orthopaedic surgery.
Systematic review of randomized controlled trials of new anticoagulants for venous thromboembolism prophylaxis in major orthopedic surgeries, compared with enoxaparin.
Direct treatment comparison of DAbigatran and RIvaroxaban versus NAdroparin in the prevention of venous thromboembolism after total knee arthroplasty surgery: design of a randomised pilot study (DARINA).
Cost-effectiveness impact of rivaroxaban versus new and existing prophylaxis for the prevention of venous thromboembolism after total hip or knee replacement surgery in France, Italy and Spain.
Elective hip and knee arthroplasty and the effect of rivaroxaban and enoxaparin thromboprophylaxis on wound healing.
Efficacy and safety of rivaroxaban or fondaparinux thromboprophylaxis in major orthopedic surgery: findings from the ORTHO-TEP registry.
Oral rivaroxaban for the prevention of symptomatic venous thromboembolism after elective hip and knee replacement.
Cost and outcomes associated with rivaroxaban vs enoxaparin for the prevention of postsurgical venous thromboembolism from a US payer's perspective.
Cost-effectiveness of rivaroxaban in the prevention of venous thromboembolism: a Canadian analysis using the Ontario Ministry of Health Perspective.
Concomitant use of medication with antiplatelet effects in patients receiving either rivaroxaban or enoxaparin after total hip or knee arthroplasty.
The effects of rivaroxaban on the complications of surgery after total hip or knee replacement: results from the RECORD programme.
Risk factors for venous thromboembolism after total hip and total knee arthroplasty: a meta-analysis