Efficacy and safety of aspirin for venous thromboembolism after total knee arthroplasty

doi:10.3969/j.issn.2095-4344.0730

Abstract

Abstract:

BACKGROUND: The best prevention strategy for venous thrombosis (VTE) is currently controversial, especially for patients with high risk of total knee arthroplasty. There are no fully safe, effective and inexpensive thrombus prevention drugs.

OBJECTIVE: To study the efficacy and safety of aspirin in preventing venous thrombosis after total knee arthroplasty.

METHODS: 300 patients undergoing primary unilateral total knee arthroplasty from September 2014 to December 2016 were randomly divided into two groups: conventional anticoagulation group and risk stratification group (n=150 per group), including 88 males and 212 females at the age of 49-85 years old. The conventional anticoagulation group received low molecular weight heparin for prevention and treatment. Risk stratification group was stratified according to the risk of venous thrombosis. 64 patients with low risk were treated with aspirin and 86 patients with high risk were treated with low molecular weight heparin. Complications were analyzed within 90 days after surgery, including deep venous thrombosis, pulmonary embolism, wound infection, bleeding and death.

RESULTS AND CONCLUSION: (1) Complications occurred in 39 cases (13%) within 90 days after follow-up. The total incidence of symptomatic deep vein thrombosis complications was 2% in 6 cases, and 19 cases (6.33%) had wound complications. There were 3 cases (2%) of symptomatic deep vein thrombosis in conventional anticoagulation group and 3 cases (2%) in risk stratification group. (2) The incidence of symptomatic deep vein thrombosis, proximal deep vein thrombosis and distal deep vein thrombosis and pulmonary embolism were 1.56% (1 case), 1.56% (1 case), 4.68% (3 cases), and 0% respectively in patients treated with aspirin. The incidence of symptomatic deep vein thrombosis, proximal deep vein thrombosis and distal deep vein thrombosis and pulmonary embolism in patients receiving low molecular weight heparin were 2.12% (5 cases), 0.85% (2 cases), 5.08% (12 cases) and 0.42% (1 case), respectively. There was no significant difference between the two groups (P > 0.05). (3) There were 11 cases of wound complications in the conventional anticoagulation group and 8 cases in the risk stratification group (χ² = 506, P = 0.318). (4) The incidences of wound-related complications (wound delayed healing, superficial wound infection and deep wound infection) were 1.56% (1 case), 0% and 1.56% (1 case) respectively in patients receiving aspirin, and 5.51% (13 cases), 1.27% (3 cases) and 0.42% (1 case) in patients receiving low molecular weight heparin. (5) Results suggested that aspirin and low molecular weight heparin can effectively prevent the occurrence of deep vein thrombosis. For low-risk patients, aspirin multi-mode thrombosis prevention is safe and effective.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Arthroplasty, Replacement, Knee, Venous Thrombosis, Aspirin, Heparin, Low-Molecular-Weight, Tissue Engineering

CLC Number:

R318

Zhang Hang, Zhang Zhi-qiang, He Qiang, He Yun-li, Zhang Qian, Feng Zhe, Li Yan, He Sen. Efficacy and safety of aspirin for venous thromboembolism after total knee arthroplasty [J]. Chinese Journal of Tissue Engineering Research, 2018, 22(15): 2321-2326.

Figures/Tables 2

随访术后90 d内共有39例(13%)出现并发症。其中症状性下肢深静脉血栓并发症的总发生率为2%(6/300)，伤口并发症的发生率为6.3%(19/300)。常规抗凝组和风险分层组各有3例(2%，3/150)发生症状性下肢深静脉血栓。接受低分子量肝素与阿司匹林作为药物血栓预防的患者具有相似的静脉血栓栓塞发生率(5.93%∶6.25%)。常规抗凝组患者发生VTE(包括深静脉血栓和肺栓塞)10例，其中3例症状性下肢深静脉血栓(2%，3/150)，1例近端深静脉血栓(0.66%，1/150)，8例远端及肌间深静脉血栓(5.33%，8/150)；1例肺栓塞(0.66%，1/150)。风险分层低风险组患者发生VTE(包括深静脉血栓和肺栓塞)4例，其中1例症状性下肢深静脉血栓(1.56%，1/64)，1例近端深静脉血栓(1.56%，1/64)，3例远端及肌间深静脉血栓(4.23%，3/64)；没有发生肺栓塞。风险分层高风险组患者发生VTE(包括深静脉血栓和肺栓塞)4例，其中2例症状性下肢深静脉血栓(2.33%，2/86)，1例近端深静脉血栓(1.16%，1/86)，3例远端及肌间深静脉血栓(3.48%，3/86)；没有发生肺栓塞。常规抗凝组与风险分层低风险组两组总体下肢深静脉血栓发生率、远端深静脉血栓发生率和肌间深静脉血栓发生率差异无显著性意义(P > 0.05)。常规抗凝组共计1例死亡，膝关节置换后突发心肌梗死。1例疑似肺栓塞病例，经查肺血管CTA为阴性，转入ICU后好转出院。常规抗凝组伤口并发症11例(发生率7.33%)，而风险分层组8例(发生率5.33%)，差异无显著性意义(χ2=506，P=0.318)。风险分层低风险组患者伤口延迟愈合、表浅伤口感染和深部伤口感染发生率分别为1.56%(1/64)，0%(0/64)，1.56%(1/64)，风险分层高风险组分别为5.81%(5/86)，1.16%(1/86)，0%(0/86)，而常规抗凝组分别为5.33%(8 /150)，1.33%(2/150)和0.67%(1/150)。按照药物分组接受阿司匹林治疗的患者伤口延迟愈合、表浅伤口感染和深部伤口感染发生率分别为1.56%(1例)，0%，1.56%(1例)，接受低分子量肝素治疗的患者分别为5.51%(13例)，1.27%(3例)和0.42%(1例)。 3例伤口表浅感染患者经过手术室清创、伤口换药痊愈，2例伤口深部感染患者均通过一期骨水泥假体植入，二期行膝关节假体翻修术。 "

References

[1] 杨庆铭,王鸿利.骨科大手术后静脉血栓栓塞症预防的临床趋势[J].中华骨科杂志, 2015,35(11):1121-1128.

[2] Dorr LD, Gendelman V, Maheshwari AV, et al. Multimodal thromboprophylaxis for total hip and knee arthroplasty based on risk assessment. J Bone Joint Surg Am. 2007;89(12):2648-2657.

[3] 彭慧明,翁习生,翟吉良,等.初次全膝关节成形术后常规抗凝患者症状性静脉血栓症发生率的调查研究[J].中华骨与关节外科, 2014, 7(2):101-104.

[4] Suen K, Westh RN, Churilov L, et al. Low-molecular-weight heparin and the relative risk of surgical site bleeding complications: results of a systematic review and meta-analysis of randomized controlled trials of venous thromboprophylaxis in patients after total joint arthroplasty. J Arthroplasty. 2017;32(9): 2911-2919.e6.

[5] Patel VP, Walsh M, Sehgal B, et al. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am. 2007;89(1):33-38.

[6] Huang RC, Parvizi J, Hozack WJ, et al. Aspirin is as effective as and safer than warfarin for patients at higher risk of venous thromboembolism undergoing total joint arthroplasty. J Arthroplasty. 2016;31(9 Suppl):83-86.

[7] Drescher FS, Sirovich BE, Lee A, et al. Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis. J Hosp Med. 2014;9(9):579-585.

[8] Lieberman JR, Pensak MJ. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am. 2013;95(19):1801-1811.

[9] Chu JN, Maselli J, Auerbach AD, et al. The risk of venous thromboembolism with aspirin compared to anticoagulants after hip and knee arthroplasty. Thromb Res. 2017;155:65-71.

[10] Deirmengian GK, Heller S, Smith EB, et al. Aspirin can be used as prophylaxis for prevention of venous thromboembolism after revision hip and knee arthroplasty. J Arthroplasty. 2016;31(10): 2237-2240.

[11] Raphael IJ, Tischler EH, Huang R, et al. Aspirin: an alternative for pulmonary embolism prophylaxis after arthroplasty. Clin Orthop Relat Res. 2014;472(2):482-488.

[12] Jameson SS, Charman SC, Gregg PJ, et al. The effect of aspirin and low-molecular-weight heparin on venous thromboembolism after hip replacement: a non-randomised comparison from information in the National Joint Registry. J Bone Joint Surg Br. 2011;93(11):1465-1470.

[13] Cafri G, Paxton EW, Chen Y, et al. Comparative effectiveness and safety of drug prophylaxis for prevention of venous thromboembolism after total knee arthroplasty. J Arthroplasty. 2017;32(11):3524-3528.e1.

[14] Bala A, Huddleston JI 3rd, Goodman SB, et al. Venous thromboembolism prophylaxis after TKA: aspirin, warfarin, enoxaparin, or factor Xa inhibitors. Clin Orthop Relat Res. 2017; 475(9):2205-2213.

[15] Nielen JT, Dagnelie PC, Emans PJ, et al. Safety and efficacy of new oral anticoagulants and low-molecular-weight heparins compared with aspirin in patients undergoing total knee and hip replacements. Pharmacoepidemiol Drug Saf. 2016;25(11): 1245-1252.

[16] Odeh K, Doran J, Yu S, et al. Risk-stratified venous thromboembolism prophylaxis after total joint arthroplasty: aspirin and sequential pneumatic compression devices vs aggressive chemoprophylaxis. J Arthroplasty. 2016;31(9 Suppl):78-82.

[17] 中华医学会骨科学分会.骨关节炎诊治指南(2007年版)[J].中华关节外科杂志:电子版,2007,1(4):280-283.

[18] González Della Valle A, Serota A, Go G, et al. Venous thromboembolism is rare with a multimodal prophylaxis protocol after total hip arthroplasty. Clin Orthop Relat Res. 2006;444: 146-153.

[19] Dorr LD, Gendelman V, Maheshwari AV, et al. Multimodal thromboprophylaxis for total hip and knee arthroplasty based on risk assessment. J Bone Joint Surg Am. 2007;89(12):2648-2657.

[20] Parvizi J, Smith EB, Pulido L, et al. The rise in the incidence of pulmonary embolus after joint arthroplasty: is modern imaging to blame. Clin Orthop Relat Res. 2007;463:107-113.

[21] Parvizi J, Huang R, Rezapoor M, et al. Individualized risk model for venous thromboembolism after total joint arthroplasty. J Arthroplasty. 2016;31(9 Suppl):180-186.

[22] Ogonda L, Hill J, Doran E, et al. Aspirin for thromboprophylaxis after primary lower limb arthroplasty: early thromboembolic events and 90 day mortality in 11,459 patients. Bone Joint J.2016; 98-B (3):341-348.

[23] 钱文伟,翁习生,常晓,等.人工髋关节置换后深静脉血栓形成影响因素的回顾分析[J].中国组织工程研究,2012,16(4):622-625.

[24] Sharrock NE, Gonzalez Della Valle A, Go G, et al. Potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty. Clin Orthop Relat Res. 2008; 466(3):714-721.

[25] Huang R, Buckley PS, Scott B, et al. Administration of aspirin as a prophylaxis agent against venous thromboembolism results in lower incidence of periprosthetic joint infection. J Arthroplasty. 2015;30(9 Suppl):39-41.

[26] Markel DC, York S, Liston MJ Jr, et al. Venous thromboembolism: management by American Association of Hip and Knee Surgeons. J Arthroplasty. 2010;25(1):3-9.e1-2.

[27] Devereaux PJ, Mrkobrada M, Sessler DI, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16): 1494-1503.

[28] Ozbudak O, Ero?ullari I, O?ü? C, et al. Doppler ultrasonography versus venography in the detection of deep vein thrombosis in patients with pulmonary embolism. J Thromb Thrombolysis. 2006;21(2):159-162.

[29] Colwell CW Jr, Froimson MI, Mont MA, et al. Thrombosis prevention after total hip arthroplasty: a prospective, randomized trial comparing a mobile compression device with low-molecular- weight heparin. J Bone Joint Surg Am. 2010;92(3):527-535.

[30] Jiang Y, Du H, Liu J, et al. Aspirin combined with mechanical measures to prevent venous thromboembolism after total knee arthroplasty: a randomized controlled trial. Chin Med J (Engl). 2014;127(12):2201-2205.

[31] Parvizi J, Huang R, Restrepo C, et al. Low-dose aspirin is effective chemoprophylaxis against clinically important venous thromboembolism following total joint arthroplasty: a preliminary analysis. J Bone Joint Surg Am. 2017;99(2):91-98.

[32] Khatod M, Inacio MC, Bini SA, et al. Pulmonary embolism prophylaxis in more than 30,000 total knee arthroplasty patients: is there a best choice. J Arthroplasty. 2012;27(2):167-172.