Prevention of vte in orthopedic surgery patients: Antithrombotic therapy and prevention of thrombosis, 9th ed: american college of chest physicians evidence-based clinical practice guidelines

  • Falck-Ytter Y
  • Francis C
  • Johanson N
 et al. 
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Background:  VTE is a serious, but decreasing complication following major orthopedic surgery. This guideline focuses on optimal prophylaxis to reduce postoperative pulmonary embolism and DVT.Methods: The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.Results: In patients undergoing major orthopedic surgery, we recommend the use of one of the following rather than no antithrombotic prophylaxis: low-molecular-weight heparin; fondaparinux; dabigatran, apixaban, rivaroxaban (total hip arthroplasty or total knee arthroplasty but not hip fracture surgery); low-dose unfractionated heparin; adjusted-dose vitamin K antagonist; aspirin (all Grade 1B); or an intermittent pneumatic compression device (IPCD) (Grade 1C) for a minimum of 10 to 14 days. We suggest the use of low-molecular-weight heparin in preference to the other agents we have recommended as alternatives (Grade 2C/2B), and in patients receiving pharmacologic prophylaxis, we suggest adding an IPCD during the hospital stay (Grade 2C). We suggest extending thromboprophylaxis for up to 35 days (Grade 2B). In patients at increased bleeding risk, we suggest an IPCD or no prophylaxis (Grade 2C). In patients who decline injections, we recommend using apixaban or dabigatran (all Grade 1B). We suggest against using inferior vena cava filter placement for primary prevention in patients with contraindications to both pharmacologic and mechanical thromboprophylaxis (Grade 2C). We recommend against Doppler (or duplex) ultrasonography screening before hospital discharge (Grade 1B). For patients with isolated lower-extremity injuries requiring leg immobilization, we suggest no thromboprophylaxis (Grade 2B). For patients undergoing knee arthroscopy without a history of VTE, we suggest no thromboprophylaxis (Grade 2B).Conclusions: Optimal strategies for thromboprophylaxis after major orthopedic surgery include pharmacologic and mechanical approaches.From the Department of Medicine (Dr Falck-Ytter), School of Medicine, Case Western Reserve University, Cleveland, OH; Hematology/Oncology Unit (Dr Francis), University of Rochester Medical Center, Rochester, NY; Department of Orthopaedic Surgery (Dr Johanson), Drexel University College of Medicine, Philadelphia, PA; Division of Hospital Medicine (Dr Curley), MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH; Innlandet Hospitals (Dr Dahl), Brumunddal, Norway; Thrombosis Research Institute (Dr Dahl), Chelsea, London, England; Department of Medicine (Dr Schulman), Division of Hematology and Thromboembolism, McMaster University, Hamilton, ON, Canada; Hemostasis and Thrombosis Center (Dr Ortel), Duke University Health System, Durham, NC; Tufts Medical Center (Dr Pauker), Boston, MA; and Shiley Center for Orthopaedic Research and Education at Scripps Clinic (Dr Colwell), La Jolla, CA.Correspondence to: Yngve Falck-Ytter, MD, Department of Medicine, School of Medicine, Case Western Reserve University, Case and VA Medical Center, 10701 East Blvd, Cleveland, OH 44106; e-mail: Yngve.Falck-Ytter@case.eduAuthor contributions: As Topic Editor, Dr Falck-Ytter oversaw the development of this article, including the data analysis and subsequent development of the recommendations contained herein.Dr Falck-Ytter: served as Topic Editor.Dr Francis: served as Deputy Editor.Dr Johanson: served as a panelist.Dr Curley: served as frontline clinician.Dr Dahl: served as a panelist.Dr Schulman: served as a panelist.Dr Ortel: served as a panelist.Dr Pauker: served as a panelist.Dr Colwell: served as a panelist.Financial/nonfinancial disclosures: The authors of this guideline provided detailed conflict of interest information related to each individual recommendation made in this article. A grid of these disclosures is available online at In summary, the authors have reported to CHEST the following conflicts of interest: Dr Francis received research grant support from the National Heart, Lung, and Blood Institute and Eisai Co, Ltd, and served as a steering committee member for a clinical trial sponsored by Eisai Co, Ltd. Dr Dahl has participated in scientific and speaking activities directly and indirectly sponsored by Boehringer Ingelheim GmbH, GlaxoSmithKline plc, Sanofi-Aventis LLC, Bayer Healthcare Pharmaceuticals, and Pfizer Inc. Dr Ortel received research grant support from the National Heart, Lung, and Blood Institute; the Centers for Disease Control and Prevention; Eisai Co, LtD; GlaxoSmithKline plc; Pfizer Inc; and Daiichi Sankyo, and has been a consultant for Sanofi-Aventis LLC and Boehringer Ingelheim GmbH. Dr Ortel has also received grant funds and speaking fees from Instrumentation Laboratories, Inc. Dr Colwell has been a consultant and received research funds from Medical Compression Systems, Ltd, but recused himself in determination of use of compression devices for the Antithrombotic Therapy and Prevention of Thrombosis 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Drs Falck-Ytter, Johanson, Curley, Schulman, and Pauker have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.Role of sponsors: The sponsors played no role in the development of these guidelines. Sponsoring organizations cannot recommend panelists or topics, nor are they allowed prepublication access to the manuscripts and recommendations. Guideline panel members, including the chair, and members of the Health & Science Policy Committee are blinded to the funding sources. Further details on the Conflict of Interest Policy are available online at This guideline is endorsed by the American Association for Clinical Chemistry, the American College of Clinical Pharmacy, the American Society of Health-System Pharmacists, the American Society of Hematology, and the International Society of Thrombosis and Hematosis.Additional information: The supplement Figures and Tables can be found in the Online Data Supplement at The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educational grants was also provided by Bristol-Myers Squibb; Pfizer, Inc; Canyon Pharmaceuticals; and sanofi-aventis US.Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at of this article is prohibited without written permission from the American College of Chest Physicians (

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  • Yngve Falck-Ytter

  • Charles W. Francis

  • Norman a. Johanson

  • Catherine Curley

  • Ola E. Dahl

  • Sam Schulman

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