The panel based this recommendation on the trivial incremental benefits and the small increased risk of major bleeding associated with pharmacological prophylaxis. Pharmacological prophylaxis probably reduces mortality slightly following major gynecological surgery (RR, 0.75; 95% CI, 0.61-0.93; low certainty in the evidence of effects). There is likely no difference in mortality between extended- and standard-course antithrombotic prophylaxis (RR, 0.94; 95% CI, 0.64-1.39; moderate certainty in the evidence of effects); this corresponds to 1 fewer death (6 fewer to 6 more) per 1000 patients. The 2011 AAOS guideline402  recommends some form of chemoprophylaxis (including ASA) along with intermittent pneumatic compression after total hip or knee arthroplasty. Controlled clinical trial in 632 patients using 125I-fibrinogen uptake test and lung perfusion scans in patients with deep venous thrombosis, Drug prevention of postoperative deep vein thrombosis. Six studies38,280,353-356  were conducted on patients undergoing urological surgery. The panel judged that the potential benefits of pharmacological prophylaxis were outweighed by the small increased risk of major bleeding in average-risk patients undergoing laparoscopic cholecystectomy. Supplement 2 provides the complete “Disclosure of Interests” forms of all panel members. Ten studies reported the effect of mechanical prophylaxis compared with no prophylaxis on risk of mortality.49,77,78,81,83-85,88,90,94  Nine studies reported the effect on the development of symptomatic PEs,37,76,78,81,83,84,86,88,92  and 5 studies reported the effect on any PE.53,77,85,86,93  No study reported data on symptomatic proximal or distal DVT, but 8 studies reported on any proximal DVT,37,78,79,82,84,85,92,93  and 7 studies reported on any distal DVT.37,77,79,82,85,92,93. This corresponds to 1 more (1 fewer to 6 more) per 1000 patients. will be notified by email within five working days should your response be This document follows the previous ESC Guidelines focusing on the clinical management of pulmonary embolism (PE), published in 2000, 2008, and 2014. The guideline panel judged that, for patients undergoing radical prostatectomy requiring pharmacological prophylaxis, based upon very low certainty in the evidence, LMWH or UFH can be used. Based on RCT evidence, pharmacological prophylaxis may result in little or no difference in symptomatic PEs (RR, 0.84; 95% CI, 0.03-27.42; very low certainty in the evidence of effects), but we are very uncertain of this finding. Framing the question and deciding on important outcomes, McMaster University (developed by Evidence Prime, Inc.), Mechanical compression versus subcutaneous heparin therapy in postoperative and posttrauma patients: a systematic review and meta-analysis, Efficacy of intermittent pneumatic compression for venous thromboembolism prophylaxis in patients undergoing gynecologic surgery: A systematic review and meta-analysis, Stratified meta-analysis of intermittent pneumatic compression of the lower limbs to prevent venous thromboembolism in hospitalized patients, Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism, Intermittent pneumatic compression or graduated compression stockings for deep vein thrombosis prophylaxis? Thirty studies reported the effect of LMWH vs UFH on risk of mortality.305,307,308,310-312,314,317-319,321,322,325-327,329-339,341,342,346,347  Thirty-one studies reported the effect of LMWH vs UFH on development of symptomatic PEs,295,305-306,310-312,314-319,321,322,324,326-335,337,339,344-346  5 studies reported the effect on symptomatic proximal DVTs,306,316,326,334,336  and 7 reported the effect on symptomatic distal DVTs.306,316,326,329,334,336,341  Thirty-four studies reported the effect of LMWH vs UFH on risk of major bleeding,295,305-307,311,313,315-319,321-339,341,344-346  and 16 studies reported the effect on risk of reoperation.305,307,309,317,319,322,323,326,329,330,333-337,341. Members of the guideline panel received travel reimbursement for attendance at in-person meetings. There may be no difference in mortality between pharmacological prophylaxis combined with mechanical prophylaxis and pharmacological prophylaxis alone (RR, 0.29; 95% CI, 0.06-1.38; low certainty in the evidence of effects); this corresponds to 5 fewer (7 fewer to 3 more) deaths per 1000 patients. Question: Should pharmacological prophylaxis vs no pharmacological prophylaxis be used for patients undergoing major neurosurgical procedures? Part C summarizes ASH decisions about which interests were judged to be conflicts. LMWH results in little or no difference in mortality compared with UFH (RR, 0.26; 95% CI, 0.03-2.36; high certainty in the evidence of effects), which corresponded to 3 fewer (4 fewer to 5 more) deaths per 1000 patients. For radical prostatectomy, the guideline provides a more nuanced set of recommendations that differ by surgical approach (open, laparoscopic, or robotically assisted laparoscopic) and extent of the node dissection (without, standard, or extended). They further judged that the balance between desirable and undesirable effects probably favors combined pharmacological and mechanical prophylaxis over pharmacological prophylaxis alone. LMWH may result in a small increase in major bleeding (RR, 2.4; 95% CI, 0.53-10.78; low certainty in the evidence of effects). We identified 1 systematic review of RCTs addressing this research question.30  We identified 2 studies118,349  in that review that fulfilled our inclusion criteria and measured outcomes relevant to this context. The panel determined that there was possibly important uncertainty or variability in how much affected individuals valued the main outcomes. Pharmacological prophylaxis probably results in no difference in reoperations (RR, 2.01; 95% CI, 0.29-14.05; low certainty in the evidence of effects), corresponding to 1 more (1 fewer to 19 more) per 1000 patients. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. In addition, pharmacological prophylaxis could be considered for patients undergoing major neurosurgical procedures that carried a lower risk for major bleeding and in those patients with persistent mobility restrictions after the bleeding risk declines following surgery. It further suggests against placement of an IVC filter for primary VTE prevention, as well as against periodic surveillance with venous compression ultrasound. The guideline panel suggests against pharmacological prophylaxis for patients undergoing TURP. Pharmacological prophylaxis combined with mechanical prophylaxis vs pharmacological prophylaxis alone, 5. The guideline panel reviewed draft EtD tables before, during, or after the guideline panel meeting and made suggestions for corrections and identified missing evidence. Pharmacological prophylaxis would also incur moderate costs and not be cost-effective. Finally, the panel acknowledges that, for some questions, limited direct data were available (eg, VTE prophylaxis following urological and gynecological procedures and for major trauma). This corresponds to 20 more (7 fewer to 138 more) major bleeding events per 1000 patients receiving LMWH vs UFH. The results did not change appreciably. They further judged that the balance between desirable and undesirable effects probably favors pneumatic compression prophylaxis over graduated compression stockings prophylaxis. The EtD framework is available online at https://guidelines.gradepro.org/profile/05201A35-BCDA-9EFA-98CB-892C0AB72944. To diagnose deep vein thrombosis, your doctor will ask you about your symptoms. The panel recognized that this particular comparison applied only to select patients undergoing radical prostatectomy considered at high risk for VTEs (eg, patients with prior VTEs). A randomized, multicenter, open-label, parallel-group comparison of enoxaparin and warfarin, A comparison of subcutaneous low-molecular-weight heparin with warfarin sodium for prophylaxis against deep-vein thrombosis after hip or knee implantation, The North American Fragmin Trial Investigators, Low-molecular-weight heparin prophylaxis using dalteparin in close proximity to surgery vs warfarin in hip arthroplasty patients: a double-blind, randomized comparison, Prevention of venous thromboembolism after knee arthroplasty. This 10th-edition guideline update is referred to as AT10.1One of the most notable changes in the updated guideline is the recommended choice of anticoagulant in patients with acute DVT or PE without c… We tested potential differences in the effects with specific drugs and between classes (anti–factor IIa vs anti–factor Xa). Because of the relative paucity of studies on patients undergoing laparoscopic cholecystectomy, data across major general, major gynecological, and major urological procedures were pooled, and laparoscopic cholecystectomy-specific baseline risk estimates were applied.350  Five studies66,294,301,351,352  were conducted on patients undergoing major gynecological surgery. For patients undergoing major surgery and at risk for VTE, the ASH guideline panel suggests using mechanical prophylaxis over no mechanical prophylaxis, recognizing that the certainty in the evidence is very low for this recommendation. The EtD framework is available online at https://guidelines.gradepro.org/profile/A10CDC06-B411-D572-959A-A8405E1373A1. The risks of mortality may be similar for patients treated with LMWH and UFH (RR, 1.03; 95% CI, 0.89-1.18; very low certainty in the evidence of effects), but we are very uncertain of this finding. This corresponds to 6 more (3 fewer to 20 more) major bleeding events per 1000 patients receiving pharmacological prophylaxis. Is routine chemical thromboprophylaxis after total hip replacement really necessary in a Japanese population? Eur Heart J 2019;Aug 31:[Epub ahead of print]. Other purposes are to inform policy, education, and advocacy and to state future research needs. A comparative randomized trial, Fraxiparine: Second International Symposium Recent Pharmacologic and Clinical Data, The European Fraxiparin Study (EFS) Group, Comparison of a low molecular weight heparin and unfractionated heparin for the prevention of deep vein thrombosis in patients undergoing abdominal surgery, Efficacy and tolerance of Fraxiparine in the prevention of deep vein thrombosis in general surgery performed with medullar conduction anesthesia [in French], Low dose heparin versus low molecular weight heparin (Kabi 2165, Fragmin) in the prophylaxis of thromboembolic complications of abdominal oncological surgery, Orgaran (Org 10172) or heparin for preventing venous thrombosis after elective surgery for malignant disease? This corresponds to 10 fewer (0-14 fewer) symptomatic proximal DVTs per 1000 patients based on a baseline risk of 1.6% from observational data.73  It may reduce symptomatic distal DVTs (RR, 0.57; 95% CI, 0.36-0.90; low certainty in the evidence of effects), which corresponds to 1 fewer (0-1 fewer) symptomatic distal DVT per 1000 patients undergoing major general surgery based on a baseline risk of 1.6% from observational data.73. [in German], Deep venous thrombosis prophylaxis with low molecular weight heparin and elastic compression in patients having total hip replacement. In contrast, for patients at high risk for major bleeding, the large undesirable consequences of major bleeding led to a balance that favors no pharmacological prophylaxis. The evidence base to inform the relative effectiveness of LMWH prophylaxis vs UFH prophylaxis was comparable to that used to inform this question for patients undergoing TURP (see Recommendation 22). Pharmacological prophylaxis does not appear to increase the risk of reoperation (RR, 0.93; 95% CI, 0.35-2.50; very low certainty in the evidence of effects) following major gynecological procedures. There probably would be no impact on health equity; both agents appear acceptable to stakeholders and are feasible to implement. For policy makers: the recommendation can be adopted as policy in most situations. Determinants and time course of the postthrombotic syndrome after acute deep venous thrombosis. A placebo-controlled study, Deep vein thrombosis in elderly Hong Kong Chinese with hip fractures detected with compression ultrasound and Doppler imaging: incidence and effect of low molecular weight heparin, Prevention of thromboembolism in hip-fracture patients. Question: Should mechanical prophylaxis vs no prophylaxis be used for patients undergoing major surgery? LMWH prophylaxis appears to result in little or no difference in mortality compared with UFH prophylaxis (RR, 1.03; 95% CI, 0.89-1.18; low certainty in the evidence of effects), corresponding to 1 more (2 fewer to 3 more) deaths per 1000 patients. This would correspond to 6 fewer (2-8 fewer) symptomatic proximal DVTs and 0 fewer (0-1 fewer) symptomatic distal DVTs per 1000 patients undergoing major neurosurgical procedures, based on baseline risks from observational data of 1.2% and 0.1%, respectively.364. AHRQ Publication No. A guidance document from the American College of Gynecology dates back to 2007415 ; as a result, the 2012 ACCP guidelines provide the timeliest guidance for gynecological surgery. For patients undergoing total hip arthroplasty or total knee arthroplasty, the ASH guideline panel suggests using ASA or anticoagulants (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). The EtD framework is available online at https://guidelines.gradepro.org/profile/E753AE97-D04A-D35F-ABE1-F9CAB9461DD1. Also, the need for reoperation may be increased (RR, 1.84; 95% CI, 0.89-3.80; very low certainty in the evidence of effects) corresponding to 2 more reoperations (0 fewer to 6 more) per 1000 patients. The panel judged that the research priorities in major trauma related to establishing the effectiveness and the timing of intervention with pharmacological prophylaxis for patients receiving mechanical prophylaxis following major trauma, rather than comparative studies of LMWH vs UFH. For patients who receive pharmacologic prophylaxis, using combined prophylaxis with mechanical and pharmacological methods over prophylaxis with pharmacological agents alone (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). Prevention of thromboembolism in hysterectomies with low molecular weight heparin Fragmin [in German]. Patients with low-risk PE may be safely discharged early from hospital or receive only outpatient treatment with LMWH, followed by vitamin K antagonists, although nonvitamin K-dependent oral anticoagulants may be as eff… Overall, the balance of effects did not favor LMWH or UFH, nor did cost-effectiveness or issues surrounding equity, acceptability, and feasibility, at least for inpatient prophylaxis. In absolute terms, this corresponds to 1 fewer (1 fewer to 7 more) symptomatic distal DVT per 1000 patients, based on a baseline risk of 0.2% from observational data.364. A prospective trial, Low molecular weight heparin and compression stockings in the prevention of venous thromboembolism in neurosurgery, Optimal prophylactic method of venous thromboembolism for gastrectomy in Korean patients: an interim analysis of prospective randomized trial, Medicamentous prophylaxis of deep vein thrombosis in emergency surgical patients, Pharmacological prophylaxis for deep vein thrombosis in acute spinal cord injury: an Indian perspective, Venous thromboembolism incidence and prophylaxis use after gastrectomy among Korean patients with gastric adenocarcinoma: the PROTECTOR randomized clinical trial, Incidence of venous thromboembolic complications in instrumental spinal surgeries with preoperative chemoprophylaxis, Prophylactic use of low molecular weight heparin in combination with graduated compression stockings in post-operative patients with gynecologic cancer [in Chinese], The effectiveness of prophylactic inferior vena cava filters in trauma patients: a systematic review and meta-analysis, Inferior vena cava filters and postoperative outcomes in patients undergoing bariatric surgery: a meta-analysis, Risks and benefits of prophylactic inferior vena cava filters in patients undergoing bariatric surgery, Experience with inferior vena cava filter placement in patients undergoing open gastric bypass procedures, Prophylactic inferior vena cava (IVC) filter placement may increase the relative risk of deep venous thrombosis after acute spinal cord injury, Efficacy of prophylactic vena cava filters in high-risk trauma patients, Preoperative placement of retreivable inferior vena cava filters in bariatric surgery, Prophylactic inferior vena cava filter placement does not result in a survival benefit for trauma patients, Prophylactic Greenfield filter placement in selected high-risk trauma patients, Concurrent prophylactic placement of inferior vena cava filter in gastric bypass and adjustable banding operations in the Bariatric Outcomes Longitudinal Database, Efficacy of prophylactic inferior vena cava filter placement in bariatric surgery, Risk-group targeted inferior vena cava filter placement in gastric bypass patients, Efficacy of prophylactic placement of inferior vena cava filter in patients undergoing spinal surgery, A pilot study on the randomization of inferior vena cava filter placement for venous thromboembolism prophylaxis in high-risk trauma patients, Early placement of prophylactic vena caval filters in injured patients at high risk for pulmonary embolism, Prophylactic vena cava filter insertion in selected high-risk orthopaedic trauma patients, Inferior vena cava filters prevent pulmonary emboli in patients with metastatic pathologic fractures of the lower extremity, Inferior vena cava filters to prevent pulmonary embolism: systematic review and meta-analysis, A multicenter trial of vena cava filters in severely injured patients, Agency for Healthcare Research and Quality, Pharmacologic and Mechanical Prophylaxis of Venous Thromboembolism Among Special Populations. Pharmacological prophylaxis results in little or no difference in reoperation (RR, 0.75; 95% CI, 0.21-2.77; low certainty in the evidence of effects). An update of NICE guidelines published in 2018 offers guidelines regarding VTE prophylaxis for patients undergoing cardiac or major vascular surgery.401  This guideline recommends considering mechanical VTE prophylaxis on admission for patients who are undergoing cardiac surgery and are at increased risk for VTE and continuing this until the patient no longer has significantly reduced mobility relative to their normal or anticipated mobility. Remark: Patients with other risk factors for VTEs (eg, history of VTE, thrombophilia, or malignancy) may benefit from pharmacological prophylaxis. Further high-quality research studies using clinically important outcomes comparing combination pharmacological and mechanical methods with pharmacological methods alone are required to provide greater certainty about this recommendation. For patients undergoing radical prostatectomy, the ASH guideline panel suggests against using pharmacological prophylaxis (conditional recommendation based on very low certainty in the evidence of effects ⊕◯◯◯). Available at: AUA Best Practice Statement for the prevention of deep vein thrombosis in patients undergoing urologic surgery. For patients at low risk for VTE, mechanical prophylaxis was suggested over no prophylaxis, preferably with intermittent pneumatic compression. In most circumstances, these innovations would be expected to reduce the overall risk of postoperative VTEs. The guideline panel determined that there is moderate certainty evidence for a net health benefit/harm from using LMWH over UFH. The panel recognized during its deliberations that the practice of radical prostatectomy varies greatly, ranging from robotically assisted laparoscopic radical prostatectomy with no or a limited pelvic lymph node dissection to open radical prostatectomy with extended pelvic lymph node dissection. Our update of the systematic review did not identify any additional studies that fulfilled the inclusion criteria. The panel judged the costs associated with mechanical prophylaxis to be moderate based on very low certainty in the evidence about resource requirements, with no available studies explicitly addressing this question. Vena cava filters are used when you cannot take medications to thin your blood or if you have blood clots while taking this type of medication. Decision aids may be useful in helping individuals to make decisions consistent with their individual risks, values, and preferences. The guideline panel determined that there was very low certainty evidence for a net health benefit/harm from using LMWH rather than warfarin. The EtD framework is available online at https://guidelines.gradepro.org/profile/96D5A309-8606-4469-B732-E1844465CC75. There were no relevant adverse events deemed critical for this comparison. Furthermore, a recently published high-quality RCT of IVC filters, following major trauma for patients in whom pharmacological prophylaxis was considered contraindicated, did not find that IVC filters reduced symptomatic PE or death.155  Given there are serious nonthrombotic risks associated with IVC filters (eg, IVC perforation and IVC filter embolization) that were not considered in our analysis, this would further strengthen our recommendation against IVC filter use.156. We are very uncertain whether pharmacological prophylaxis results in little or no difference in reoperation (RR, 0.93; 95% CI, 0.35-2.50; very low certainty in the evidence of effects); this corresponds to 1 fewer (8 fewer to 18 more) reoperation per 1000 patients. The risks of mortality may be similar for patients treated with LMWH and UFH (RR, 1.03; 95% CI, 0.89-1.18; low certainty in the evidence of effects); this corresponds to 0 fewer deaths per 1000 men. accepted. The panel judged from our analysis of data, largely from observational studies, that the high rates of DVT and the trend for higher mortality associated with the use of IVC filters outweighed the potential reduction in PEs. Further high-quality research studies using clinically important outcomes to identify patients with high baseline risk for VTE in whom combined pharmacological and mechanical prophylaxis would be of value, particularly outside the orthopedic setting, are needed. All studies included surgical patients. Adaptation of these guidelines will be necessary in many circumstances. The 2013 International Angiology guideline favors LMWH, fondaparinux, VKAs, rivaroxaban, apixaban, or dabigatran, along with use of intermittent pneumatic compression after total hip arthroplasty.403  The most current NICE guideline recommends LMWH or rivaroxaban after total hip arthroplasty and the same after total knee arthroplasty, with the additional option of ASA.401, For VTE prophylaxis after surgery for hip fractures, the 2012 ACCP guideline recommends LMWH for VTE prophylaxis vs fondaparinux and low-dose UFH over adjusted-dose VKAs or ASA.407  Concurrent use of an intermittent pneumatic compression device was also recommended. For patients undergoing major general surgery, the ASH guideline panel suggests using pharmacological prophylaxis over no pharmacological prophylaxis (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯). The panel determined that there was probably important uncertainty or variability in how much affected individuals value the main outcomes. The panel determined that there was probably important uncertainty or variability in how much affected individuals value the main outcomes. Comparison of low-dose heparin and low-molecular-weight heparin combined with dihydroergotamine, Low-dose heparin for prevention of venous thromboembolism in total hip arthroplasty and surgical repair of hip fractures, A randomised, double-blind, placebo-controlled trial of dermatan sulphate for prevention of deep vein thrombosis in hip fracture, Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial, Low-dosage ancrod for prevention of thrombotic complications after surgery for fractured neck of femur, Venous thrombosis in patients with fracture of the upper end of the femur. • Patients with established deep vein thrombosis (DVT). The benefit of pharmacological prophylaxis should be considered for patients at high risk or very high risk for VTE, but the overall risk/benefit profile is questionable, given an increase in bleeding events, particularly because neurosurgical bleeding events can be more serious. The guideline panel suggests using ASA or anticoagulants for patients undergoing total hip arthroplasty or total knee arthroplasty (conditional recommendation based on very low certainty in the evidence of effects). Similarly, pharmacological prophylaxis may not reduce symptomatic proximal DVTs (RR, 0.38; 95% CI, 0.14-1.00; very low certainty in the evidence of effects) or symptomatic distal DVTs (RR, 0.52; 95% CI, 0.31-0.87; very low certainty in the evidence of effects). Perioperative thromboembolic prophylaxis with low molecular weight heparin and postoperative bleeding complications [in German]. When DVT is confirmed, anticoagulation is indicated to control symptoms, prevent progression and reduce the risk of post‐thrombotic syndrome and pulmonary embolism. For patients considered at very high risk of postoperative VTE and at low bleeding risk, high-quality comparative studies of LMWH vs UFH using clinically important outcome measures would be of value. Baseline risk estimates specific to gynecological procedures396,397  were applied to determine the desirable and undesirable effects of prophylaxis in absolute terms. There was possibly important uncertainty or variability about how patients may value these outcomes. The panel judged the costs associated with extended-duration prophylaxis to be moderate based on very low certainty in the evidence. Supplement 3 provides the complete “Disclosure of Interest” forms of researchers who contributed to these guidelines. We rated the overall certainty in the evidence of effects as very low based on the lowest certainty in the evidence for the critical outcomes, downgrading for study limitations, imprecision, and inconsistency. Access the full guidelines on the Blood Advances website: American Society of Hematology 2018 Guidelines for Management of Venous Thromboembolism: Optimal Management of Anticoagulation Therapy The 2012 ACCP guideline for orthopedic surgery patients407  recommended LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose UFH, adjusted-dose vitamin K antagonists (VKAs), ASA, and/or intermittent pneumatic compression, with the proviso that they are portable, out of concerns regarding compliance. Question: Should extended antithrombotic prophylaxis vs short-term antithrombotic prophylaxis be used for patients undergoing major surgery? Policy makers interested in these guidelines include those involved in developing local, national, or international programs aiming to safely reduce the incidence of VTE and/or to evaluate direct and indirect harms and costs related to VTE and its prevention. Search for other works by this author on: Guidelines 2.0: systematic development of a comprehensive checklist for a successful guideline enterprise, Clinical Practice Guidelines We Can Trust, Board of Trustees of the Guidelines International Network, Guidelines International Network: toward international standards for clinical practice guidelines, Guidelines International Network: Principles for disclosure of interests and management of conflicts in guidelines, GRADE: an emerging consensus on rating quality of evidence and strength of recommendations, GRADE guidelines: 1. 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