European Journal of Cardio-Thoracic Surgery 2024, 66(2), ezae257 GUIDELINES

https://doi.org/10.1093/ejcts/ezae257

Cite this article as: Ahmed A, Koster A, Lance M, Milojevic M. European guidelines on perioperative venous thromboembolism prophylaxis: Cardiovascular surgery.
Eur J Cardiothorac Surg 2024; doi:10.1093/ejcts/ezae257.

GUIDELINES
European guidelines on perioperative venous thromboembolism
prophylaxis: Cardiovascular surgery
Aamer Ahmeda,b,�, Andreas Kosterc, Marcus Lanced, and Milan Milojevice
a
Department of Anaesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, UK, ESAIC
b
Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, UK, ESAIC
c
Sana Heart Centre Cottbus, Ruhr University Bochum, Germany, EACTAIC

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d
Aga Khan University Hospital Nairobi, Kenya, EACTAIC
e
Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia, EACTS

� Address for Correspondence: Aamer Ahmed MD, Department of Anaesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust UK,
LE3 9QP, Leicester, UK. E-mail address: aamer.ahmed@uhl-tr.nhs.uk

Keywords: venous thromboembolism • deep venous thrombosis • pulmonary artery embolism • prophylaxis • cardiac surgery • vascular
surgery • clinical practice guideline • quality improvement

RATIONALE transcatheter aortic valve replacement (TAVI), as an antithrom­

botic drug to preserve graft/prosthesis patency and decrease
Venous thromboembolism (VTE), thus comprising deep venous thromboembolic complications, might be regarded as an effect­
thrombosis (DVT) and pulmonary artery embolism (PE), are ive medication to decrease VTE [7–9].
associated with high morbidity and mortality [1–4]. However, In cardiac surgery, the early administration of medical venous
particularly after major surgery, the risk of early institution of thrombosis prophylaxis reduces the risk of PE (RR, 0.45, 95% CI,
pharmacological thrombosis prophylaxis has to be balanced 0.28–0.71; p < 0.01) and symptomatic VTE (RR, 0.44, 95% CI
against the risk of postoperative bleeding events. 0.28–0.71, p < 0.01) and is not associated with clinically relevant
In a large analysis of the National Inpatient Sample (NIS) of increased bleeding risk, including cardiac tamponade or the
patients after coronary artery bypass grafting surgery, the inci­ need for re-exploration of bleeding [3].
dence of VTE was 1.3–1.75% and associated with an increased In vascular surgery, pharmacological prophylaxis has been
mortality of 6.8% vs 1.7% (adjusted odds ratio 1.92 [95% confi­ associated with a trend towards a reduction of VTE and PE [2; 4].
dence interval 1.40–2.65] p < 0.001) [5]. Current literature on patients following cardiac or vascular
According to a meta-analysis in cardiac surgery, risk factors surgery does not show a substantial difference in the efficacy of
for VTE are a history of VTE, obesity, heart failure, prolonged unfractionated heparin (UFH) or low molecular weight heparin
bed rest, and mechanical ventilation [3]. (LMWH) when used for thrombosis prophylaxis [1]. LMWH can
In vascular surgery, the reported incidence of VTE is 0.7%, be administered once daily by subcutaneous injection, usually
with an incidence of PE of 0.2% [6]. The highest VTE rate was without routine coagulation monitoring. However, renal impair­
observed in patients with thoraco-abdominal aortic aneurysm ment might impact plasma levels and the need for dose adjust­
[4.2%], followed by thoracic endovascular repair (TEVAR) [2.2%], ment and drug effect monitoring [10].
open abdominal aortic surgery [1.7%], abdominal endovascular The pharmacological profile of UFH renders it more amenable
aneurysm repair (AEVAR) [0.7], infra-inguinal bypass graft surgery to reversal, thus making it preferable in conditions of a higher
[1.0%], and carotid endarterectomy [0.2%]. bleeding risk as immediately postoperatively after major surgery.
Patient-related risk factors after open AAA repair are obesity, However, when using UFH, the increased risk of heparin-
postoperative pneumonia, and prolonged postoperative mech­ induced thrombocytopaenia complications and more challeng­
anical ventilation (>48) [1]. ing mobilization with i.v. use, particularly after major trauma/
Of note, according to current guidelines, early administration surgery, has to be considered [11].
of aspirin, which is recommended in a large percentage of The research questions used for the systematic literature re­
these patient populations, including the special condition of view and summary of findings are provided in Tables 1 and 2.

This article is part of the Updated European guidelines on perioperative venous thromboembolism prophylaxis. For details concerning background, methods,
classification of recommendations, and members of the ESA VTE Guidelines Task Force, please refer to:
Samama CM, for the ESAIC, EACTAIC, EACTS, ISTH, EURAPS and EKS VTE Guidelines Task Force. European guidelines on perioperative venous thromboembolism
prophylaxis. Eur J Anaesthesiol 2024; 41(8):547-626.
This article was reviewed by ESAIC members and approved by ESAIC Board and EACTS Council.

© 2024 European Society of Anaesthesiology and Intensive Care and European Association for Cardio-Thoracic Surgery. This article has been co-published with
agreement in the European Journal of Cardio-Thoracic Surgery published by Oxford University Press on behalf of the European Association for Cardio-Thoracic
Surgery, and European Journal of Anaesthesiology published by Wolters Kluwer on behalf of the European Society of Anaesthesiology and Intensive Care.
The articles are identical except for minor stylistic and spelling differences in keeping with each journal’s style. Either of the citations can be used when citing
this article.
2 A. Ahmed et al. / European Journal of Cardio-Thoracic Surgery

Table 1. PICOT Questions Utilized for Systematic Literature Review

A Risk Cardiac Surgery

P Adult cardiac surgery (>/¼ 18 yr. old)

I Perioperative venous thrombosis prophylaxis, venous thromboprophylaxis
C No prophylaxis, Caprini score, standard care
O DVT, VTE, PE, mortality incidence, prevalence, predictors, thrombosis risk
T In-hospital, 30-day

B Risk Cardiac Intervention (TAVI)

P Adult cardiac intervention (TAVI) (>/¼ 18 yr. old)

I Perioperative venous thrombosis prophylaxis, venous thromboprophylaxis
C No prophylaxis, Caprini score, standard care

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O DVT, VTE, PE, mortality incidence, prevalence, predictors, thrombosis risk
T In-hospital, 30-day

C Risk Vascular Surgery

P Adult vascular surgery (>/¼ 18 yr. old)

I Perioperative venous thrombosis prophylaxis, venous thromboprophylaxis
C No prophylaxis: Caprini score, standard care
O DVT, VTE, PE, mortality incidence, prevalence, predictors, thrombosis risk
T In-hospital, 30-day

D Risk Vascular Intervention (EVAR)

P Adult vascular intervention (>/¼ 18 yr. old)

I Perioperative venous thrombosis prophylaxis, venous thromboprophylaxis
C No prophylaxis, Caprini score, standard care
O DVT, VTE, PE, mortality incidence, prevalence, predictors, thrombosis risk
T In-hospital, 30-day

E Preventive Strategies Cardiac Surgery

P Adult cardiac surgery (>/¼ 18 yr. old)

I Perioperative venous thrombosis prophylaxis, venous thromboprophylaxis ASA/P2Y12, UFH, LMWH, Fondaparinux, DOAC, No mechanical prophylaxis
C No prophylaxis, mechanical prophylaxis with ASA/P2Y12, UFH, LMWH, Fondaparinux, DOAC
O VTE, DVT, PE, major bleeding, reoperation for bleeding, mortality
T In-hospital, 30-day, 1-year

F Preventive Strategies Cardiac Intervention (TAVI)

P Adult cardiac intervention (TAVI), transcatheter mitral valve replacement, transcatheter pulmonary valve replacement (>/¼ 18 yr. old)
I Perioperative venous thrombosis prophylaxis, venous thromboprophylaxis ASA/P2Y12, UFH, LMWH, Fondaparinux, DOAC, No mechanical prophylaxis
C No prophylaxis, mechanical prophylaxis with ASA/P2Y12, UFH, LMWH, Fondaparinux, DOAC
O VTE, DVT, PE, major bleeding, reoperation for bleeding, mortality
T In-hospital, 30-day, 1-year

G Preventive Strategies Vascular Surgery

P Adult vascular surgery (>/¼ 18 yr. old)

I Perioperative venous thrombosis prophylaxis, venous thromboprophylaxis ASA/P2Y12, UFH, LMWH, Fondaparinux, DOAC, No mechanical prophylaxis
C No prophylaxis, mechanical prophylaxis with ASA/P2Y12, UFH, LMWH, Fondaparinux, DOAC
O VTE, DVT, PE, major bleeding, reoperation for bleeding, mortality
T In-hospital, 30-day, 1-year

H Preventive Strategies Vascular Intervention (EVAR, TEVAR)

P Adult vascular intervention (EVAR, TEVAR) (>/¼ 18 yr. old)

I Perioperative venous thrombosis prophylaxis, venous thromboprophylaxis ASA/P2Y12, UFH, LMWH, Fondaparinux, DOAC, No mechanical prophylaxis
C No prophylaxis, mechanical prophylaxis with ASA/P2Y12, UFH, LMWH, Fondaparinux, DOAC
O VTE, DVT, PE, major bleeding, reoperation for bleeding, mortality
T In-hospital, 30-day, 1-year
ASA: acetylsalicylic acid; DOAC: direct oral anticoagulant; DVT: deep vein thrombosis; EVAR: endovascular treatment of abdominal aortic aneurysms; LMWH:
low molecular weight heparin; PE: pulmonary embolism; TAVI: transcatheter aortic valve implantation; TEVAR: thoracic endovascular aortic repair; UFH: unfrac­
tionated heparin; VTE: venous thromboembolism.
Table 2. The Summary of Findings and Risk of Bias Assessment

First Author Year Type Patients Size Intervention Findings Risk

of Bias

Kwok M 2015 Metanalysis Cardiac Surgery 16 Randomized con­ Thromboprophylaxis Early initiation of venous thrombosis prophy­ High
trolled trials and incidence and risk laxis in non-bleeding patients was associated
49 Observational studies factors for deep vein with a reduced risk of pulmonary embolism
3 Meta-analysis thrombosis and pul­ (relative risk 0.45, 95% confidence interval
monary embolism 0.28–0.72, p ¼ 0.0008) or symptomatic ven­
ous thromboembolism (relative risk 0.44, 95%
confidence interval 0.28–0.71, p ¼ 0.0006)
compared to control without significant
heterogeneity
Haykal T 2021 Metanalysis Vascular Surgery 8 Randomized con­ Thromboprophylaxis Trend towards the lesser incidence of deep ven­ High
trolled trials with unfractionated ous thrombosis (risk ratio 0.34,
3.130 patients or low molecu­ 95%confidence interval 0.11-1.05, p ¼ 0,06,
lar heparin l2 ¼ 68%) and pulmonary embolism (relative
risk 0.17, 95% confidence interval 0.002-1.22,
p ¼ 0.08, l2 ¼ 41%) when comparing patients
with thrombosis prophylaxis to those to those
with placebo
Panhawar MS 2019 Observational Coronary artery by­ 331.950 Patients of None Venous thrombosis after coronary artery bypass High
pass Surgery National graft surgery is rare (1.3%) but associated with
Inpatient Sample an increased morbidity and mortality com­
pared to patients without (6.8% vs1.7%,
adjusted odds ratio 1.92, 95% confidence
interval 1.40-2.65, p ¼ 0.001)
Toth S 2020 Metanalysis Vascular Surgery 2 prospective co­ None Lower incidence of venous thrombosis after High
hort studies prophylaxis when compared to patients with­
1 retrospective cohort out (relative risk 0.70, 95% confidence interval
study 0.26-1.87)
2 randomized controlled
studies
5.248 Patients included in
meta-analysis
Wilsey HA 2019 Retrospective Coronary artery by­ 850 Patients Unfractionated hep­ Venous thromboembolism (2.12% vs1.41 %, High
cohort study pass surgery arin versus low mo­ p ¼ 0.43) group and bleeding events (1.18%
A. Ahmed et al. / European Journal of Cardio-Thoracic Surgery

lecular vs 0.94%, p ¼ 1.00) in the unfractionated hep­

weight heparin arin group vs the low molecular weight hep­
arin were not significantly different
Ramanan B 2013 Observational Vascular Surgery 45.548 Patients of None Venous thrombosis and pulmonary embolism High
National Surgical frequent after chest and abdominal vascular
Quality Improvement surgery and are associated with 4- fold
Program (2007-2009) mortality
(deep vein thrombosis 1.5% vs 6.2%, p ¼ 0.05
and pulmonary embolism 1.5% vs
5.7%, p ¼ 0.05)
3

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4 A. Ahmed et al. / European Journal of Cardio-Thoracic Surgery

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