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Deep Venous Thrombosis (DVT) – Risk Reduction

Procedure-specific risk reduction

Specific agents for risk reduction

  • apixaban (oral factor Xa inhibitor)
  • aspirin  (see role of ASA for DVT prophylaxsis)
  • danaparoid
    • low molecular wt glycosaminoglycan with potent anti factor Xa activity
  • fondaparinux
  • 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
    • references
  • SQ heparin
  • thrombolytic therapy
  • warfarin

Bleeding complications

  • 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

Epidural anesthesia

See also
      Coagulation Pathway
      Pulmonary Embolus
      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