Updated guidelines on DVT prevention

This month, an expert group of physicians and surgeons has published their latest guidelines on preventing, diagnosing and treating blood clots - DVT's and pulmonary emboli.  It's a massive report, known as AT9 - even the executive summary runs 39 pages.  It can be found here.

Why do we, as plastic surgeons, need to know this stuff?  Because DVT's and PE's are serious, even lethal, problems that can happen after any long surgery.  So we take this stuff very seriously.  Patient safety, to steal a line from Ford Motor company, is job one.

Here are the latest recommendations for healthy plastic surgery patients:
1.  Pretty much everyone who goes to the operating room needs to be wearing sequential compression stockings (SCD's), unless they are less than 40 years old, and having a operation less than 45 minutes long.  We already do this.

2.  Most of the bigger cases (tummy tuck, lower body lift, etc.) should receive low molecular weight heparin - also known as "Lovenox".  We already do this too.

3.  People that are at very high risk should get both the SCD's and the Lovenox.  The way this" high risk" label is sorted out is based on a scale called the Caprini score.  My friends from the University of Michigan have done a lot of work, researching the use of this scale in plastic surgery patients (link to study).  You can see the details of the Caprini score there - it's a one page, easy to use system.

What's not totally settled in this latest report is the best timing for administering the Lovenox - 12 hours before surgery, at surgery, or sometime after surgery.  Currently, we follow the recommendations initially developed in by Orthopedic surgeons - who get a lot of DVT issues after hip and knee replacement surgery - and give it 10-12 hours post-op.  I'll be digging through the full report to see if I can find out more about this important detail.

This is one of those basic issues in plastic surgery that, although not as exciting as discussing celebrity surgery or the latest gee-whiz gadget, makes things safer for everybody.  If you are planning a big surgery, ask your surgeon about the methods he or she is going to use to prevent you from getting a DVT.

FDA approves Xarelto - a tablet to prevent DVT

Blood clots in the legs and lungs are a common and potentially deadly problem, especially after trauma, and hip or knee replacement surgery. Typically, we've used heparin, or more recently lovenox, injections to reduce the chance of these problems. But now, there's a tablet that does the same thing: Xarelto. You'll want to remember this name.

It was approved just this week, by the FDA, as a preventative measure against deep vein thrombosis (DVT), and pulmonary embolism (PE) following knee or hip replacement surgery. It's been approved in Europe and Canada for several years.

Xarelto is a pill taken once daily - how easy is that?! No blood tests are required. Patients having a knee replacement should take the medication for 12 days and patients undergoing a hip replacement procedure should take Xarelto for 35 days after surgery.

According to the studies, Xarelto was more effective than injections of Lovenox - our current standard treatment - in preventing DVT. In a study of more than 6,000 orthopedic patients, 9.7 percent of knee-replacement patients treated with Xarelto had a clot problem, compared with 18.8 percent of knee-replacement patients who received Lovenox. In a study involving hip replacement surgery, 1.1 percent of patients who received Xarelto had clots compared with 3.9 percent of those who received Lovenox.

So far, no one has done a study in plastic surgery patients, especially abdominoplasty. Under the current FDA labelling, that would be considered an "off-label" use. But if you had a family history of DVT, or you personally have had a DVT or PE in the past - this might be a new method to reduce your risk of having a blood clot after surgery. Interesting stuff!!

Thromboembolism risk and tummy tucks

There's a good review article on the risk of blood clotting problems known as "VTE's" and their relationship to abdominoplasty surgery in this months issue of Plastic and Reconstructive Surgery. VTE is the abbreviation for venous thrombo-embolism, and it includes such problems as deep vein thrombosis of the leg and pulmonary embolism.

Although this topic may sound obscure, pulmonary embolism can be fatal, and it can sneak up and strike suddenly after major surgery, without warning symptoms. My friend, Dr. Paul Vanek, once described VTE's as a "scud missile striking randomly in the middle of the night" - and that's a good way to think about it. So, anything we can learn to understand and prevent this problem better is really very important.

The authors reviewed the plastic surgery literature on VTE's, and their analysis revealed some findings that should make surgeons sit up and take notice.

In particular:

Risk of VTE with standard tummy tuck: 0.34% (= 1 / 300)

Risk of VTE when tummy tuck is combined with an intra-abdominal procedure (e.g. hysterectomy) 2.17% = 6 x risk

Risk of VTE when tummy tuck is combined with lower body lift (circumferential tummy tuck) 3.40% = 10 x risk.


Both of these findings were highly statistically significant.

Of course, wise surgeons do everything possible to prevent this problem. Using pneumatic compression leggings, which massage the calf area, keeping blood moving during surgery helps. Giving Lovenox, the medication which treats blood clots, helps significantly. And getting people moving as soon as possible after surgery helps too. But the risk of developing a VTE is still not eliminated.

So, what can we learn from this paper?

Personally, I think surgeons should give up doing the procedures that are high risk for these complications, until a proven strategy to prevent these potentially life-threatening problems can be developed and tested.

That mean no "circumferential" tummy tucks, and not doing tummy tucks at the same time as other operations inside the abdomen.

Just my two cents.