This randomized clinical trial demonstrated that preoperative administration of low-molecular-weight-heparin (LMWH) is safe and feasible for lung cancer patients preparing to receive minimally invasive surgery.

<h2>Key Takeaway</h2>
<ul>
 <li>Preoperative administration of LMWH resulted in no significant effects on coagulationrelated events compared with postoperative start of LMWH for minimally invasive lung , cancer surgery patients.</li>
 <li>This method was found to be safe and feasible with minimal invasive surgery.</li>
 <li>There were no venous thromboembolisms (VTEs) or blood transfusion or other major complications between preoperative LMWH-administration group (PRL) and the postoperative LMWH-administration group (POL) with no significant differences between two groups.</li>
 <li>The operation duration was significantly longer in the PRL vs POL group.</li>
</ul>

<h2>Why This Matters</h2>
<ul>
 <li>There is a strong relationship between lung cancer and VTE, indicated by significant evidence showing that VTE incidence in lung cancer patients increased 22 times more than non-cancer patients, while the risk in lung cancer patients was still sevenfold higher than that in other malignancies.</li>
 <li>American Society of Clinical Oncology Clinical Practice Guideline recommends thromboprophylaxis before surgery and continuing for at least 7–10 days for cancer patients undergoing major surgery.</li>
 <li>There are no clear guidelines, no academic organization’s definite instructions, and no dependable clinical experiments for conducting preoperative anticoagulation.</li>
 <li>This study was innovatively designed to testify whether preoperative administration of LMWH in lung cancer patients was safe and feasible.</li>
</ul>

<h2>Study Design</h2>
<ul>
 <li>This trial was a prospective study in West China Hospital from July 2017 to June 2018 (ChiCTR2000040547) where patients prepared to undergo lung cancer surgery were randomly divided into PRL and POL groups with 4000 IU per day dosage. All patients received thromboprophylaxis until discharge.</li>
 <li>Inclusion criteria: Patients aged 18–75 years without any preoperative VTEs (both VTE history and current screening); intended for video-assisted thoracoscopic major thoracic surgery (including lobectomy and sub lobar resection); diagnosed pathologically with primary lung cancer</li>
 <li>Exclusion criteria: Coagulation disorders (preoperative international normalized ratio [INR] &gt;1.5, or blood platelet count &lt;50 × 109/L); receiving any therapeutic anticoagulation preoperatively; undergoing preoperative planned or intraoperative converted open thoracic surgery; severe renal or liver dysfunction; suffered intraoperative bleeding (&gt;500 ml owing to vessels rupture); rejected to continue the study at any point of the study; on menstruation perioperatively</li>
 <li>Endpoints: Postoperative coagulation function parameters; postoperative drainage data; hematologic data; intraoperative bleeding volume; reoperation rates; surgical time</li>
</ul>

<h2>Key Results</h2>
<ul>
 <li>A total of 246 patients were recruited from July 2017 to June 2018 in this study; patients were randomly allocated (N = 230) to PRL (n = 108) and POL (n = 122) groups. 
 <ul>
 <li>Finally, 212 participants were included in the analysis (PRL group: n = 101; mean age, 55.88 ± 10.11 years; POL group: n = 111; mean age, 58.17 ± 9.99 years).</li>
 <li>146/212 cases were analyzed on postoperative day 3 for coagulation profile (POL [n = 85] and PRL [n = 61]).</li>
 </ul></li>
 <li>No significant differences were found in coagulation parameters between the POL and PRL groups on first postoperative day: Prothrombin time (PT) (P = 0.158); activated partial thromboplastin time (APTT) (P = 0.339); thrombin time (TT) (P = 0.402); fibrinogen (FIB) (P = 0.806); INR (P = 0.190)</li>
 <li>Drainage data were comparable between the groups: Drainage duration (P = 0.165); mean drainage volume (P = 0.795); total drainage volume (P = 0.445)</li>
 <li>No difference was noted on postoperative day 1 between the two groups regarding intraoperative bleeding volumes (P = 0.195), postoperative hemoglobin value (P = 0.735), and platelet count (P = 0.472).</li>
 <li>The reoperation rate was comparable between the two groups (P = 0.606).</li>
 <li>Surgical time/operation duration in the PRL group was significantly longer than that in the POL group (117.15 ± 41.63 vs 104.13 ± 29.07 minutes, P = 0.008).</li>
 <li>Coagulation function parameters on postoperative day 3 were not significantly different between POL vs PRL groups: PT (P = 0.173); APPT (P = 0.712); TT (P = 0.951); FIB (P = 0.633); INR (P = 0.492); PLT (P = 0.141); HGB (P = 0.247)</li>
</ul>

<h2>Key limitations</h2>
<ul>
 <li>Sample size was relatively small, thus minimizing evidence grade of results.</li>
 <li>Postoperative blood examination was conducted in the morning (around 7 o’clock) but not at a specific point after LMWH administration.</li>
 <li>Lack of VTE occurrence in both groups was less convincing for preoperative start of LMWH providing sufficient thromboprophylaxis.</li>
 <li>Participants included were assessed at the early stage of lung cancer.</li>
 <li>Result could not be expanded to cover other races as only Chinese patients were included.</li>
</ul>

Reference

Safety profile of preoperative administration of low-molecular-weight heparin for Lung Cancer population

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Advancing Therapy with iGlarLixi: Differentiation from complex insulin regimens

An educational video outlining key data from indirect comparisons of iGlarLixi versus IDegAsp.

VTE & Bleeding risk assessment in surgical patients

Watch Prof. Joseph A. Caprini, MD, MS, FACS, RVT, DFSVS, Creator of The Caprini Risk Score for DVT, Discussing patients’ cases and VTE risk assessment in surgical patients.

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Watch the short video summary of the VTE SZ 2022 program, with a little teaser for 2023 at the end and stay tuned for our upcoming communications to join world-renowned experts in VTE management.

VTE Safety Zone 2023 Program Highlights

Watch Prof. Ajay Kakkar Director of Thrombosis Research Institute, London, UK, Sheds the light on 2023 VTE Safety Zone Program and its importance which aims to provide a forum for discussion and exchange in the field of VTE.

Pre vs post operative initiation of Thromboprophylaxis in Liver surgeries

Watch Prof. Mario Serradilla HPB Surgeon at Miguel Servet University Hospital, Associate Professor at University of Zaragoza, FACS, shedding the light on how to reduce risk of VTE in Liver surgeries.

Standard duration1
<ul>
 <li>Up to 7-10 days 
 <ul>
 <li>VTE prophylaxis</li>
 </ul></li>
</ul>
Do you consider longer treatment duration for some patients?
Extended duration1
<ul>
 <li>4 weeks 
 <ul>
 <li>VTE prophylaxis</li>
 </ul></li>
</ul>

Multiple guidelines recommend extended duration prophylaxis (up to 4 weeks) with LMWH such as Clexane®for patients with cancer undergoing abdominal or pelvic surgery2-6

black

<h2>Benefit of Prophylaxis for your high-risk surgical patient</h2>
In high-risk surgical patients
<ul>
 <li>Without prophylaxis,&nbsp;40-80 %</li>
 <li>Experienced a DVT event</li>
 <li>Among high-risk surgical patients with multiple risk factors7
 <ul>
 <li>With standard duration*8,&nbsp;9.4 %</li>
 <li>Had a VTE event</li>
 <li>Among patients undergoing major colorectral surgery receiving standard duration prophylaxis(up to 7-10 days, 40 mg Clexane)8</li>
 </ul></li>
</ul>
In high-risk surgical patients&nbsp;with cancer
<ul>
 <li>With standard duration*9,&nbsp;12 %</li>
 <li>Experienced a VTE event</li>
 <li>Among surgical patients undergoing abdominal surgery9
 <ul>
 <li>With extended duration9</li>
 <li>Clexane®:&nbsp;60 %</li>
 <li>Fewer VTE events&nbsp;vs&nbsp;only standard duration9</li>
 </ul></li>
</ul>
<h2>Which of your surgical patients is at an increased risk of VTE?</h2>
Certain patient-specific risk factors increase the VTE risk of surgical patients (in addition to the type of surgery)2,10,11
<ul>
 <li>Cancer</li>
 <li>Previous VTE</li>
 <li>Older age</li>
 <li>Obesity</li>
</ul>
*Standard duration 6-10 days with 40 mg Clexane®.8,9 
 †Standard duration 6-10 days + extended duration 21 days of 40 mg Clexane®.9 
 ‡In high-risk surgical patients with cancer after receiving 40 mg Clexane®&nbsp;standard duration Prophylaxis of 6-10 days vs 40 mg Clexane®&nbsp;extended duration prophylaxis for additional 21 days, 
 12% of patients had a VTE event vs 4.8% with extended duration.3

References

Benefit of Prophylaxis for High-Risk Surgical Patients

<h2>Key Takeaway</h2>
<ul>
 <li>The 2019 European Society of Cardiology (ESC) guidelines for the diagnosis and management of acute pulmonary embolism (PE) developed in collaboration with the European Respiratory Society features important updates on diagnosis, risk assessment, acute and chronic phase management, prevention of recurrence, management in patients with cancer and pregnant women and post-PE care.</li>
</ul>
<h2>Key Highlights</h2>
<h3>Updated recommendations</h3>
<ul>
 <li>The recommendation for rescue thrombolytic therapy in the setting of haemodynamic deterioration has been upgraded to class I.</li>
 <li>The recommendation for use of surgical embolectomy or catheter-directed as alternatives to rescue thrombolytic therapy has been upgraded to class IIa.</li>
 <li>Use of D-dimer and clinical prediction rules to rule out PE during pregnancy or post-partum is now an IIa recommendation.</li>
 <li>Further assessment of asymptomatic PE survivors at increased risk for chronic thromboembolic pulmonary hypertension (CTEPH) is now an IIb recommendation.</li>
</ul>
<h3>New recommendations</h3>
Diagnosis
<ul>
 <li>D-dimer cut-offs adjusted to age and clinical probability should be considered instead of fixed values (IIa).</li>
 <li>A positive proximal compression ultrasonography result calls for a risk assessment to guide the management of PE (IIa).</li>
 <li>Ventilation/perfusion (V/Q) single-photon emission computed tomography may be considered for the diagnosis of PE (IIb).</li>
</ul>
Risk assessment
<ul>
 <li>Assessment of the right ventricular function using imaging or laboratory biomarkers should be considered, even if the Pulmonary Embolism Severity Index is low or Simplified Pulmonary Embolism Severity Index is 0 (IIa).</li>
 <li>The severity of PE may be further stratified using validated scoring systems combining clinical, imaging and laboratory prognostic factors (IIb).</li>
</ul>
Acute treatment
<ul>
 <li>Non-vitamin K antagonist oral anticoagulants (NOACs) are recommended as the primary choice for anticoagulant treatment when oral anticoagulation is to be initiated in a patient with PE eligible for a NOAC (I).</li>
 <li>Multidisciplinary teams should be established for the management of high-risk and selected cases of intermediate-risk PE (IIa).</li>
 <li>Extracorporeal membrane oxygenation may be considered, in addition to surgical embolectomy or catheter-directed treatment for patients with refractory circulatory collapse or cardiac arrest (IIb).</li>
</ul>
Chronic treatment and preventing recurrence
<ul>
 <li>The guidelines no longer support terminology such as “provoked” vs “unprovoked” PE/venous thromboembolism.</li>
 <li>Patients with antiphospholipid antibody syndrome should receive indefinite treatment with a vitamin K antagonist (I).</li>
 <li>Extended anticoagulation should be considered for patients without any identifiable risk factor for the index PE event, those with a persistent risk factor apart from antiphospholipid antibody syndrome and those with a minor transient/reversible risk factor for the index PE event (IIa).</li>
 <li>A low dose of apixaban or rivaroxaban for extended anticoagulation should be considered after the first 6 months of treatment (IIa).</li>
</ul>
Post-PE care
<ul>
 <li>Routine assessment using an integrated model of care is recommended 3-6 months after acute PE and symptomatic patients with mismatched perfusion defects (on V/Q scan) &gt;3 months post-PE should be referred to an expert CTEPH centre (I).</li>
</ul>

The guidelines provide an update on the 2014 guidelines.

2019 ESC Guidelines for Acute Pulmonary Embolism

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