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Routine vena cava filters inappropriate for VTE prophylaxis in bariatric surgery patients
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There is no conclusive evidence to support the use of measures to prevent venous thromboembolism among patients undergoing bariatric surgery, according to results of a recent analysis.
Strategies to prevent VTE in patients undergoing bariatric surgery can include augmented dosing of pharmacotherapy (ie, enoxaparin sodium administered >40 mg daily or 30 mg twice daily) and the placement of inferior vena cava filters before surgery.
Daniel J. Brotman
Daniel J. Brotman, MD, associate professor of medicine and director of the hospitalist program at The Johns Hopkins Hospital, and colleagues conducted a systematic review and meta-analysis to assess the efficacy and safety of these methods. The analysis included 13 articles: five involved patients with and without filters and eight included patients who received different pharmacologic therapies.
None of the selected studies randomly assigned patients to receive various interventions. However, one study reported low–molecular-weight heparin was superior to unfractionated heparin in the prevention of VTE (0.25% vs. 0.68%, P<.001), according to researchers. This particular study also noted no significant differences in bleeding, they added.
Another study suggested that continued postoperative enoxaparin sodium therapy might be more effective in preventing VTE compared with inpatient treatment.
Additional data indicate a lack of evidence to support the hypothesis that vena cava filters reduced the risk for pulmonary embolism. Further, they suggested increased rates with filters (RR=1.21; 95% CI, 0.57-2.56), researchers wrote.
Low-grade evidence suggested filters were linked to a greater risk for mortality (RR=4.30; 95% CI, 1.60-11.54), as well as an increased risk for deep vein thrombosis (RR=2.94; 95% CI, 1.35-6.38), Brotman and colleagues wrote.
“We found no evidence to support filter placement as prophylaxis in patients undergoing bariatric surgery, with a trend toward higher [DVT] rates and higher mortality in patients receiving filters,” the researchers wrote. “We note that, despite the patient population — which might be assumed to be at particularly high risk of postoperative VTE because of their body habitus — rates of thrombosis and mortality were reassuringly low.”
Reference:
Brotman DJ. JAMA Surg. 2013;doi:10.1001/jamasurg.2013.72.
Perspective
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Harry S. Jacob, MD, FRCPath(Hon)
Note that these results should not imply that pharmacologic DVT prophylaxis is not crucial in this high-risk group. Malpractice lawyers are watching.
Perspective
Back to TopBruce M. Wolfe, MD
From a research standpoint, the incidence or frequency of venous thromboembolism — particularly fatal pulmonary embolism — is so low that it is exceedingly difficult to study. To do a randomized trial that is adequately powered to give definitive answers about how to prevent VTE is very difficult. The study has to be large due to the low incidence.
Pulmonary embolism is generally No. 2 on the list of causes when uncommon deaths occur as a result of bariatric surgery. It’s a frightening potential risk and deserves the attention it gets. However, there is no more than one death out of 1,000 surgeries due to pulmonary embolism.
The researchers found that one study suggested low-molecular–weight heparin is more efficacious than unfractionated heparin in preventing VTE. However, I’m not convinced that it’s a matter of which drug rather than dose.
Another paper found that if you continue the prophylaxis beyond the hospitalization, this may be a way to prevent VTE better compared with inpatient treatment alone. That’s an interesting and challenging observation because of the logistics involved with continuing an injectable treatment for people who have left the hospital. However, there is evidence that the risk of VTE lasts for as long as 90 days, so that’s one of the findings that did seem impressive.
Otherwise, the researchers weren’t able definitively prove much about the effectiveness and safety of strategies to prevent VTE in patients undergoing bariatric surgery.
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