Sanchez-Garcia Jorge, Lopez-Verdugo Fidel, LeCorchick Spencer, Tran Alexandria, Gilroy Richard K, Fujita Shiro, Zendejas Ivan, Gagnon Andrew, Dow Sean, Krong Jake, Rodriguez-Davalos Manuel I, Stevens Scott M, Woller Scott C, Alonso Diane
Transplant and Hepatobiliary Surgery, Abdominal Transplant Services, Intermountain Medical Center, Murray, UT.
Department of General Surgery, School of Medicine, University of Utah, Salt Lake City, UT.
Transplant Direct. 2023 Feb 8;9(3):e1453. doi: 10.1097/TXD.0000000000001453. eCollection 2023 Mar.
Venous thromboembolism (VTE) occurs in 0.4% to 15.5% and bleeding occurs in 20% to 35% of patients after liver transplantation (LT). Balancing the risk of bleeding from therapeutic anticoagulation and risk of thrombosis in the postoperative period is challenging. Little evidence exists regarding the best treatment strategy for these patients. We hypothesized that a subset of LT patients who develop postoperative deep vein thromboses (DVTs) could be managed without therapeutic anticoagulation. We implemented a quality improvement (QI) initiative using a standardized Doppler ultrasound-based VTE risk stratification algorithm to guide parsimonious implementation of therapeutic anticoagulation with heparin drip.
In a prospective management QI initiative for DVT management, we compared 87 LT historical patients (control group; January 2016-December 2017) to 182 LT patients (study group; January 2018-March 2021). We analyzed the rates of immediate therapeutic anticoagulation after DVT diagnosis within 14 d of LT, clinically significant bleeding, return to the operating room, readmission, pulmonary embolism, and death within 30 d of LT before and after the QI initiative.
Ten patients (11.5%) in the control group and 23 patients (12.6%; = 0.9) in the study group developed DVTs after LT. Immediate therapeutic anticoagulation was used in 7 of 10 and 5 of 23 patients in the control and study groups, respectively ( = 0.024). The study group had lower odds of receiving immediate therapeutic anticoagulation after VTE (21.7% versus 70%; odds ratio = 0.12; 95% confidence interval, 0.019-0.587; = 0.013) and a lower rate of postoperative bleeding (8.7% versus 40%; odds ratio = 0.14, 95% confidence interval, 0.02-0.91; = 0.048). All other outcomes were similar.
Implementing a risk-stratified VTE treatment algorithm for immediate post-LT patients appears to be safe and feasible. We observed a decrease in the use of therapeutic anticoagulation and a lower rate of postoperative bleeding without adverse impacts on early outcomes.
肝移植（LT）后，静脉血栓栓塞（VTE）的发生率为0.4%至15.5%，出血发生率为20%至35%。在术后平衡治疗性抗凝导致的出血风险和血栓形成风险具有挑战性。关于这些患者的最佳治疗策略，几乎没有证据。我们假设一部分发生术后深静脉血栓形成（DVT）的LT患者可以在不进行治疗性抗凝的情况下得到管理。我们实施了一项质量改进（QI）计划，使用基于标准化多普勒超声的VTE风险分层算法来指导谨慎地实施肝素滴注治疗性抗凝。
在一项针对DVT管理的前瞻性管理QI计划中，我们将87例LT历史患者（对照组；2016年1月至2017年12月）与182例LT患者（研究组；2018年1月至2021年3月）进行了比较。我们分析了QI计划前后LT后14天内DVT诊断后立即进行治疗性抗凝的比率、临床显著出血、返回手术室、再次入院、肺栓塞以及LT后30天内的死亡情况。
对照组有10例患者（11.5%），研究组有23例患者（12.6%；P = 0.9）在LT后发生DVT。对照组10例患者中有7例、研究组23例患者中有5例立即接受了治疗性抗凝（P = 0.024）。研究组在VTE后接受立即治疗性抗凝的几率较低（21.7%对70%；优势比 = 0.12；95%置信区间，0.019 - 0.587；P = 0.013），术后出血率也较低（8.7%对40%；优势比 = 0.14，95%置信区间，0.02 - 0.91；P = 0.048）。所有其他结果相似。
为LT术后即刻患者实施风险分层的VTE治疗算法似乎是安全可行的。我们观察到治疗性抗凝的使用减少，术后出血率降低，且对早期结果没有不利影响。
