SLR - November 2022 - Paul Marinos, DPM
Title: Aspirin May Be a Suitable Prophylaxis for Patients with a History of Venous Thromboembolism Undergoing Total Joint ArthroplastyReference: Ludwick L, Shohat N, Van Nest D, Paladino J, Ledesma J, Parvizi J. Aspirin May Be a Suitable Prophylaxis for Patients with a History of Venous Thromboembolism Undergoing Total Joint Arthroplasty. J Bone Joint Surg Am. 2022 Aug 17;104(16)
Level of Evidence: Therapeutic Level III
Reviewed By: Paul Marinos, DPM
Residency Program: Kaiser San Francisco Bay Area Podiatry Residency Program
Podiatric Relevance: Venous Thromboembolism(VTE) is a major complication and concern for surgeons, especially for patients undergoing total joint arthroplasty. Despite this major concern, there is no consensus in the literature regarding the prophylactic drug of choice for this patient population. Over the years, patients with a history of VTE were prescribed non-aspirin prophylaxis, but recent studies have shown that aspirin is also a safe and effective anticoagulation choice for patients undergoing total joint arthroplasty. The purpose of this study was to assess whether aspirin is an effective agent for VTE prophylaxis in patients with a history of VTE.
Methods: This is a retrospective cohort study of 1,087 patients with a documented history of VTE undergoing primary or revision total joint arthroplasty. Patients without a history of VTE or patients taking chronic non-aspirin were not included in the study. Patient demographic characteristics and comorbidities including age, sex, American Society of Anesthesiologists (ASA) classification, and Charlson Comorbidity Index where collected. Symptomatic VTE such as deep vein thrombosis (DVT) and pulmonary embolism (PE) identified using ultrasound or CT scan and occurring within 90 days was documented. Finally, propensity score matching was performed to account for any confounding variables between the two groups.
Results: Of the 1,087 patients, 262 (24.1%) received aspirin and 825 (75.9%) received a more aggressive prophylactic agent such as warfarin, low-molecular weight heparin, factor Xa inhibitors, unfractionated heparin or fondaparinux. Prior to the match, there was no statistically significant difference in sex, age and obesity class between the two cohorts. Patients taking aspirin compared to those taking non-aspirin agents had a lower mean ASA classification and lower mean BMI. Patients in the non-aspirin group also had significantly longer operative times. Patients taking aspirin had a lower incidence of VTE at 0.4% compared to the patients taking a non-aspirin agent 1.5% but this was not statistically significant. Also, aspirin was not associated with an increased risk for subsequent VTE in patients with a history of VTE.
Conclusions: Overall, there was no statistically significant difference in the rate of PE or DVT between the two cohorts. This is an interesting finding and this is the first study to demonstrate the safety and efficacy of aspirin as a VTE prophylactic agent in patients with a documented history of VTE. A limitation is the retrospective nature of the study, especially considering the variability in the retrieval of data during the review of the clinical records. The potential use of aspirin as an alternative agent for VTE prophylaxis is intriguing and should be considered by surgeons. Further research such as a randomized control study could be the next step to further investigate the efficacy and safety of aspirin. Also, considering the patients included in this study underwent a hip or knee arthroplasty, it would be great to investigate the use of aspirin as a VTE prophylactic agent for patients undergoing total ankle arthroplasty with a history of VTE.