In-hospital and postdischarge venous thromboembolism after vascular surgery

Objective: Recent single-center reports demonstrate a high (up to 10%) incidence of postoperative venous thromboembolism (VTE) after major vascular surgery. Moreover, vascular patients rarely receive prolonged prophylaxis despite evidence that it reduces thromboembolic events after discharge. This study used a national, prospective, multicenter database to define the incidence of overall and postdischarge VTE after major vascular operations and assess risk factors associated with VTE development.

Methods: Patients with VTE who underwent elective vascular procedures (n = 45,548) were identified from the 2007-2009 National Surgical Quality Improvement Program (NSQIP) database. The vascular procedures included carotid endarterectomy (CEA; n = 20,785), open thoracoabdominal aortic aneurysm (TAAA) repair (n = 361), thoracic endovascular aortic repair (TEVAR; n = 732), open abdominal aortic (OAA) surgery (n = 6195), endovascular aneurysm repair (EVAR; n = 7361), and infrainguinal bypass graft (BPG; n = 10,114). Univariable and multivariable analyses were performed to ascertain risk factors associated with VTE.

Results: VTE was diagnosed in 187 patients (1.3 %) who underwent aortic surgery, with TAAA repair having the highest rate of VTE (4.2%), followed by TEVAR (2.2%), OAA surgery (1.7%), and EVAR (0.7%). In this subgroup, pulmonary embolisms (PE) were diagnosed in 52 (0.4%) and deep venous thrombosis (DVT) in 144 (1%). VTE rates were 1.0% and 0.2% for patients who underwent a BPG or CEA, respectively. Forty-one percent of all VTEs were diagnosed after discharge. The median (interquartile range) number of days from surgery to PE and DVT were 10 (5-15) and 10 (4-18), respectively. On multivariable analyses, type of surgical procedure, totally dependent functional status, disseminated cancer, postoperative organ space infection, postoperative cerebrovascular accident, failure to wean from ventilator ≤48 hours, and return to the operating room were significantly associated with development of VTE. In those experiencing a DVT or PE, overall mortality increased from 1.5% to 6.2% and from 1.5% to 5.7% respectively (P < .05 for both).

Conclusions: Postoperative VTE is associated with the type of vascular procedure and is highest after operations in the chest and abdomen/pelvis. About 40% of VTE events in elective vascular surgery patients were diagnosed after discharge, and the presence of VTE was associated with a quadrupled mortality rate. Future studies should evaluate the benefit of DVT screening and postdischarge VTE prophylaxis in high-risk patients.