Advertisement

Annals of Surgical Oncology

, Volume 25, Issue 12, pp 3548–3555 | Cite as

Implementation of a Venous Thromboembolism Prophylaxis Protocol Using the Caprini Risk Assessment Model in Patients Undergoing Mastectomy

  • Alison Laws
  • Kathryn Anderson
  • Jiani Hu
  • Kathleen McLean
  • Lara Novak
  • Laura S. Dominici
  • Faina Nakhlis
  • Matthew Carty
  • Stephanie Caterson
  • Yoon Chun
  • Margaret Duggan
  • William Barry
  • Nathan Connell
  • Mehra Golshan
  • Tari A. King
Breast Oncology
  • 298 Downloads

Abstract

Background

Guidelines for venous thromboembolism (VTE) prophylaxis are not well-established for breast surgery patients. An individualized VTE prophylaxis protocol using the Caprini score was adopted at our institution for patients undergoing mastectomy ± implant-based reconstruction. In this study, we report our experience during the first year of implementation.

Methods

In August 2016, we adopted a VTE prophylaxis protocol for patients undergoing mastectomy ± implant-based reconstruction. We used the Caprini score, a validated risk assessment tool for VTE, to determine each patient’s perioperative prophylaxis regimen. Detailed chart review was performed to record patient and treatment details, the Caprini score, pharmacologic VTE prophylaxis administration, and 30-day incidence of VTE and bleeding complications. We performed univariate analysis to identify factors associated with protocol compliance.

Results

Overall, 522 patients met the inclusion criteria. Median age was 51 years, 486 (93.1%) patients had malignancy, 234 (44.8%) underwent bilateral mastectomy, and 350 (67.0%) underwent reconstruction. Caprini scores ranged from 2 to 11, with 431 (82.6%) patients having a score from 5 to 7. Overall protocol compliance was 60.5%, and was associated with bilateral mastectomy (p = 0.02), reconstruction (p = 0.03), and longer procedures (p < 0.001). The rate of VTE was 0.2% (95% confidence interval [CI] 0.03–1.1%), rate of reoperation for hematoma was 2.7% (95% CI 1.6–4.5%), and rate of blood transfusion was 0.4% (95% CI 0.1–1.4%).

Conclusions

The implementation of an individualized VTE prophylaxis protocol for patients undergoing mastectomy ± implant-based reconstruction is safe and feasible. Despite a high-risk cohort, the incidence of VTE was very low and bleeding complications were consistent with reported rates for breast surgery. Continued evaluation of this strategy is warranted.

Notes

Disclosures

Alison Laws, Kathryn Anderson, Jiani Hu, Kathleen McLean, Lara Novak, Laura S. Dominici, Faina Nakhlis, Matthew Carty, Stephanie Caterson, Yoon Chun, Margaret Duggan, William Barry, Nathan Connell, Mehra Golshan, and Tari A. King have no disclosures to declare.

References

  1. 1.
    Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e227S–e77S.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Mismetti P, Laporte S, Darmon JY, Buchmuller A, Decousus H. Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery. Br J Surg. 2001;88:913–30.CrossRefGoogle Scholar
  3. 3.
    National Clinical Guideline Centre—Acute and Chronic Conditions (UK). Venous thromboembolism: reducing the risk of venous thromboemolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. London: Royal College of Physicians (UK); 2010.Google Scholar
  4. 4.
    Prevention of fatal postoperative pulmonary embolism by low doses of heparin. An international multicentre trial. Lancet. 1975;2:45–51.Google Scholar
  5. 5.
    Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med. 1988;318:1162–73.CrossRefGoogle Scholar
  6. 6.
    Nwaogu I, Yan Y, Margenthaler JA, Myckatyn TM. Venous thromboembolism after breast reconstruction in patients undergoing breast surgery: an American College of Surgeons NSQIP analysis. J Am Coll Surg. 2015;220:886–93.CrossRefGoogle Scholar
  7. 7.
    Fischer JP, Wes AM, Tuggle CT, Wu LC. Venous thromboembolism risk in mastectomy and immediate breast reconstruction: analysis of the 2005 to 2011 American College of Surgeons National Surgical Quality Improvement Program data sets. Plast Reconstr Surg. 2014;133:263e–73e.CrossRefGoogle Scholar
  8. 8.
    Tran BH, Nguyen TJ, Hwang BH, et al. Risk factors associated with venous thromboembolism in 49,028 mastectomy patients. Breast. 2013;22:444–8.CrossRefGoogle Scholar
  9. 9.
    Andtbacka RH, Babiera G, Singletary SE, et al. Incidence and prevention of venous thromboembolism in patients undergoing breast cancer surgery and treated according to clinical pathways. Ann Surg. 2006;243:96–101.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Lovely JK, Nehring SA, Boughey JC, Degnim AC, Donthi R, Harmsen WS, et al. Balancing venous thromboembolism and hematoma after breast surgery. Ann Surg Oncol. 2012;19:3230–5.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Caprini JA. Individual risk assessment is the best strategy for thromboembolic prophylaxis. Dis Mon. 2010;56:552–9.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Bahl V, Hu HM, Henke PK, Wakefield TW, Campbell DA Jr, Caprini JA. A validation study of a retrospective venous thromboembolism risk scoring method. Ann Surg. 2010;251:344–50.CrossRefGoogle Scholar
  13. 13.
    Pannucci CJ, Bailey SH, Dreszer G, et al. Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients. J Am Coll Surg. 2011;212:105–12.CrossRefGoogle Scholar
  14. 14.
    The American Society of Breast Surgeons. Consensus guideline of venous thromboembolism (VTE) prophylaxis for patients undergoing breast operations. v11.30.2016. 2016. Available at: https://www.breastsurgeons.org/new_layout/about/statements/PDF_Statements/VTE_Statement.pdf.
  15. 15.
    Pannucci CJ, Chang EY, Wilkins EG. Venous thromboembolic disease in autogenous breast reconstruction. Ann Plast Surg. 2009;63:34–8.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Enajat M, Damen TH, Geenen A, Timman R, van der Hulst RR, Mureau MA. Pulmonary embolism after abdominal flap breast reconstruction: prediction and prevention. Plast Reconstr Surg. 2013;131:1213–22.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Miller ME, Czechura T, Martz B, et al. Operative risks associated with contralateral prophylactic mastectomy: a single institution experience. Ann Surg Oncol. 2013;20:4113–20.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Chatterjee A, Pyfer B, Czerniecki B, Rosenkranz K, Tchou J, Fisher C. Early postoperative outcomes in lumpectomy versus simple mastectomy. J Surg Res. 2015;198:143–8.CrossRefGoogle Scholar
  19. 19.
    Winther Lietzen L, Cronin-Fenton D, Garne JP, Kroman N, Silliman R, Lash TL. Predictors of re-operation due to post-surgical bleeding in breast cancer patients: a Danish population-based cohort study. Eur J Surg Oncol. 2012;38:407–12.CrossRefGoogle Scholar
  20. 20.
    Seth AK, Hirsch EM, Kim JY, Dumanian GA, Mustoe TA, Galiano RD, et al. Hematoma after mastectomy with immediate reconstruction: an analysis of risk factors in 883 patients. Ann Plast Surg. 2013;71:20–3.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Eck DL, Perdikis G, Rawal B, Bagaria S, McLaughlin SA. Incremental risk associated with contralateral prophylactic mastectomy and the effect on adjuvant therapy. Ann Surg Oncol. 2014;21:3297–303.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Friis E, Horby J, Sorensen LT, Pilsgaard B, Wille-Jorgensen P, Johansen L, et al. Thromboembolic prophylaxis as a risk factor for postoperative complications after breast cancer surgery. World J Surg. 2004;28:540–3.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Society of Surgical Oncology 2018

Authors and Affiliations

  • Alison Laws
    • 1
    • 2
    • 6
  • Kathryn Anderson
    • 1
    • 2
  • Jiani Hu
    • 3
  • Kathleen McLean
    • 1
    • 2
  • Lara Novak
    • 1
    • 2
  • Laura S. Dominici
    • 1
    • 2
  • Faina Nakhlis
    • 1
    • 2
  • Matthew Carty
    • 4
  • Stephanie Caterson
    • 4
  • Yoon Chun
    • 4
  • Margaret Duggan
    • 1
    • 2
  • William Barry
    • 3
  • Nathan Connell
    • 5
  • Mehra Golshan
    • 1
    • 2
  • Tari A. King
    • 1
    • 2
  1. 1.Department of SurgeryBrigham and Women’s HospitalBostonUSA
  2. 2.Breast Oncology ProgramDana-Farber/Brigham and Women’s Cancer CenterBostonUSA
  3. 3.Department of Biostatistics and Computational BiologyDana-Farber Cancer InstituteBostonUSA
  4. 4.Division of Plastic SurgeryBrigham and Women’s HospitalBostonUSA
  5. 5.Division of HematologyBrigham and Women’s HospitalBostonUSA
  6. 6.Department of SurgeryUniversity of CalgaryCalgaryCanada

Personalised recommendations