Race identified as risk factor for VTE after pulmonary resection for lung cancer
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Key takeaways:
- High-risk cohorts include Black patients and those with interstitial fibrosis or advanced-stage disease.
- Performing a minimally invasive resection associated with lower risk for postoperative VTE.
Black patients and those with interstitial fibrosis or advanced-stage disease had a higher risk for developing clinically detectable postoperative venous thromboembolism after pulmonary resection for lung cancer, study results showed.
The findings, presented at Society of Thoracic Surgeons’ Annual Meeting and published in The Annals of Thoracic Surgery, suggest a need for increased awareness efforts when treating patients with these high-risk factors, according to researchers.
“Because nonmodifiable risk factors (Black race, interstitial fibrosis and advanced-stage disease) predominate in postoperative [pulmonary embolism] and VTE-associated mortality is increased, enhanced awareness and targeted perioperative prophylactic measures should be considered in these high-risk cohorts,” Andrea L. Axtell, MD, MPH, assistant professor of surgery in the division of cardiothoracic surgery at University of Wisconsin School of Medicine and Public Health, told Healio.
Background and methodology
For patients undergoing oncologic surgery, VTE is a potentially major cause of both morbidity and mortality, according to background information provided by study investigators.
Axtell and colleagues conducted a retrospective national cohort analysis to identify potential risk factors for postoperative VTE and VTE-associated mortality to improve the safety of lung cancer resection among such patients, while also attempting to identify high-risk cohorts that would potentially benefit from enhanced perioperative prophylactic measures.
Researchers utilized data from Society of Thoracic Surgeon’s General Thoracic Surgery Database to develop a study cohort of 57,531 adults who had previously underwent a pulmonary resection for lung cancer between January 2009 and June 2021, excluding patients who underwent an extrapleural pneumonectomy or emergency resection.
They compared baseline clinical, operative, pathologic characteristics and postoperative outcomes between patients who either did or did not develop a clinically detectable postoperative pulmonary embolism or deep venous thrombosis.
Results
Of the 57,531 patients who underwent pulmonary resection for lung cancer, 758 patients (1.3%) developed a postoperative pulmonary embolism.
The analysis showed Black patients (12% vs. 7%), those with interstitial fibrosis (3% vs. 2%) or a history of VTE (12% vs. 6%) more frequently developed a postsurgical pulmonary embolism.
Additionally, patients who underwent bilobectomy (6% vs. 4%) or pneumonectomy (8% vs. 5%) had a higher risk for developing postoperative pulmonary embolism; researchers noted no difference in the proportion of postoperative pulmonary embolism due to preoperative pulmonary function, histology or neoadjuvant therapy.
Additionally, patients with postoperative pulmonary embolism had higher 30-day mortality (14% vs. 3%), reintubation (25% vs. 8%) and readmission (49% vs. 15%) rates.
Multivariable analysis revealed that Black race (OR = 1.74; 95% CI, 1.39–2.16), having interstitial fibrosis (OR = 1.77; 95% CI, 1.15-2.72), extent of resection (OR for pneumonectomy relative to wedge = 1.92; 95% CI, 1.3-2.78), and increased operative duration (OR = 1.06; 95% CI, 1.04-1.08) as independent predictors of postoperative pulmonary embolism.
Next steps
According to researchers, enhanced perioperative prophylactic measures should be considered in high-risk cohorts, with lower extremity Doppler ultrasonography being a potential option.
“In this contemporary analysis of the STS General Thoracic Surgery Database, we identified a 2.5% occurrence of postoperative VTE and 1.3% occurrence of postoperative [pulmonary embolism] in patients undergoing a first-time pulmonary resection for lung cancer,” Axtell told Healio.
“Temporal trends demonstrate the incidence of postoperative VTE to be largely unchanged over the 12-year study period; however, the associated mortality slowly decreased from 20% in 2009 to 8% in 2018,” she added. “I think it will be important to study the safety and efficacy of extended-duration pharmacologic thromboprophylaxis in the outpatient setting for high-risk patients undergoing pulmonary resection.”
References:
- Axtell AL, et al. Ann Thorac Surg. 2024;doi:10.1016/j.athoracsur.2024.01.005.
- Axtell AL, et al. Predictors of venous thromboembolism after pulmonary resection for lung cancer — an analysis of the STS General Thoracic Surgery Database. Presented at: Society of Thoracic Surgeons Annual Meeting; Jan. 27-29, 2024; San Antonio.
Perspective
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Sudish C. Murthy, MD, PhD, FACS, FCCP
Axtell and colleagues provide important insights into the risks for postoperative VTE following pulmonary resection for cancer.They conclude that race, pre-existing interstitial lung disease (ILD) and extent of resection are important variables that might help clinicians risk stratify patients.
VTE can be a devastating complication following surgery of any kind, and perhaps even more so when associated with lung surgery. The study by Axtell and colleagues just begins to scratch the surface of this issue and is an important step forward.
Development of VTE is unfortunately very complicated to study and, because the database used by the investigators only extends out to 30 days, it only captures symptomatic VTE that occurred during that limited window of follow-up. Moreover, because there is no routine screening done for any of these patients, the preoperative prevalence of the entire at-risk cohort is unknown.
Finally, though race and extent of resection are very straightforward variables to capture, ILD is surprisingly subjective and its presence as a risk provides fairly nominal guidance.
Perhaps more continuous variables as a surrogate for ILD might be more informative for treating physicians and surgeons. Forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and the ratio of FEV1/FVC might be easier to use and easier to interpret.
Nonetheless, Axtell and colleagues should be congratulated on beginning to unwrap what I suspect is a very complicated process.
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