Saturday, October 24, 2020

Shoulder arthroplasty: should patients be placed on low-dose aspirin?

Low-Dose Aspirin and the Rate of Symptomatic Venous Thromboembolic Complications Following Primary Shoulder Arthroplasty

These authors conducted a review ofcomplications occurring within 90 days of 2,394 primary shoulder arthroplasties performed over a three-year period.

Patients were preoperatively risk stratified into medically high, moderate or low risk as part of a standardized navigated care pathway. 81 mg ASA (low-dose) was routinely used once daily for 6 weeks for chemoprophylaxis unless alternative medications were deemed necessary by the medical team. 

Symptomatic venous thromboembolism (VTE) occurred following 0.63% (15/2,394) of primary shoulder arthroplasties. 

There were 9 patients with deep vein thrombosis (DVT) and 6 with pulmonary emboli (PE). 

81 mg ASA was utilized in 2,141 (89.4%) of patients, which resulted in an overall VTE rate of 0.56%. 

Medically high-risk patients were significantly more likely to have a VTE (P = .018). Patients with a history of prior DVT, asthma and cardiac arrhythmias were significantly more likely to have a VTE (P < .05). 

A total of 5 bleeding related complications in the entire cohort. Among patients treated with low-dose ASA for VTE prophylaxis, 4/2,141 (0.19%) had a postoperative hematoma that underwent aspiration in the office. Two of these patients required more than one aspiration and two patients ultimately returned to the operating room for an additional intervention. One patient initially treated with RSA had a hematoma evacuation and polyethylene exchange. The other patient developed a superficial infection from repeated hematoma aspiration and required surgical irrigation and débridement. One patient with a history of atrial fibrillation who received a novel oral anticoagulant medication (dabigatran) postoperatively developed a bleeding esophageal ulcer that required surgical intervention to control. Of the patients who were diagnosed with a VTE, bleeding complications secondary to VTE treatment occurred in 1/15 (6.7%).

Comment: Both VTE and bleeding are potentially serious complications of shoulder arthroplasty. This study examined the effectiveness and risks of low dose ASA as a prophylactic strategy. The manuscript does not present the location of the venous thromboses observed (lower extremity, surgical upper extremity, contralateral upper extremity). This information may be helpful in understanding the role of non-pharmacologic approaches, such as sequential lower extremity compression, early ambulation, compressive stockings. 

The increase risk of patients with prior DVT or cardiac disease is understandable. The increased risk of patients with asthma is unexplained.

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