Joint 2022 European Society of Thoracic Surgeons and The American Association for Thoracic Surgery guidelines for the prevention of cancer-associated venous thromboembolism in thoracic surgery
Joint 2022 European Society of Thoracic Surgeons and The American Association for Thoracic Surgery guidelines for the prevention of cancer-associated venous thromboembolism in thoracic surgery
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DOI：
10.1093/ejcts/ezac488
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发表时间：
2022-12-02
影响因子：
3.4
通讯作者：
Litle, Virginia R.
中科院分区：
文献类型：
--
作者：
Shargall, Yaron;Wiercioch, Wojtek;Litle, Virginia R.
胸外科手术中预防癌症相关性静脉血栓栓塞（VTE）的ESTS/AATS联合指南背景静脉血栓栓塞（VTE）包括深静脉血栓形成和肺栓塞，是一种潜在的致命但可预防的术后并发症。接受手术切除的胸部肿瘤患者（通常在多模态诱导治疗后）是术后VTE的最高风险人群。目前还没有专门针对这些胸外科患者的VTE预防指南。循证建议将帮助临床医生管理和减轻术后VTE的风险，并为最佳实践提供信息。目的美国胸外科协会和欧洲胸外科医师协会的这些联合循证指南旨在告知临床医生和患者有关预防的决策，以预防接受肺癌或食管癌手术切除术患者的VTE。方法美国胸外科协会和欧洲胸外科医师协会组成了一个多学科的指南小组，包括广泛的成员，以尽量减少潜在的偏见时，制定建议。麦克马斯特大学GRADE中心支持指南的制定过程，包括更新或进行系统性证据审查。专家组根据临床问题和结果对临床医生和患者的重要性对其进行优先排序。采用了建议评估、发展和评价分级方法，包括建议评估、发展和评价分级证据到决策框架，这些框架都要征求公众意见。结果专家组就24项建议达成一致，这些建议侧重于对接受肺叶切除术和肺段切除术、肺切除术和食管切除术以及肺癌扩大切除术的患者进行预防的药理学和机械方法。结论：大多数建议的支持性证据的确定性被判定为低或非常低，主要是由于缺乏胸外科手术的直接证据。专家组有条件地建议，对于接受解剖性肺切除术或食管切除术的癌症患者，与不预防相比，使用肠外抗凝剂联合机械方法预防VTE。其他主要建议包括：有条件建议使用肠外抗凝剂而非直接口服抗凝剂，仅在临床试验背景下建议使用直接口服抗凝剂;有条件建议仅对中度或高度血栓形成风险的患者使用延长预防28 - 35天而非住院预防;有条件建议对接受肺切除术和食管切除术的患者进行VTE筛查。未来的研究重点包括术前血栓预防的作用和危险分层的作用，以指导使用扩展预防。（《胸血管外科杂志》2022;：1-31）
ESTS/AATS joint guidelines for prevention of cancer-associated VTE in thoracic surgery.Background Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is a potentially fatal but preventable postoperative complication. Thoracic oncology patients undergoing surgical resection, often after multimodality induction therapy, represent among the highest risk groups for postoperative VTE. Currently there are no VTE prophylaxis guidelines specific to these thoracic surgery patients. Evidenced-based recommendations will help clinicians manage and mitigate risk of VTE in the postoperative period and inform best practice. Objective These joint evidence-based guidelines from The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons aim to inform clinicians and patients in decisions about prophylaxis to prevent VTE in patients undergoing surgical resection for lung or esophageal cancer. Methods The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons formed a multidisciplinary guideline panel that included broad membership to minimize potential bias when formulating recommendations. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to public comment. Results The panel agreed on 24 recommendations focused on pharmacological and mechanical methods for prophylaxis in patients undergoing lobectomy and segmentectomy, pneumonectomy, and esophagectomy, as well as extended resections for lung cancer. Conclusions The certainty of the supporting evidence for the majority of recommendations was judged as low or very low, largely due to a lack of direct evidence for thoracic surgery. The panel made conditional recommendations for use of parenteral anticoagulation for VTE prevention, in combination with mechanical methods, over no prophylaxis for cancer patients undergoing anatomic lung resection or esophagectomy. Other key recommendations include: conditional recommendations for using parenteral anticoagulants over direct oral anticoagulants, with use of direct oral anticoagulants suggested only in the context of clinical trials; conditional recommendation for using extended prophylaxis for 28 to 35 days over in-hospital prophylaxis only for patients at moderate or high risk of thrombosis; and conditional recommendations for VTE screening in patients undergoing pneumonectomy and esophagectomy. Future research priorities include the role of preoperative thromboprophylaxis and the role of risk stratification to guide use of extended prophylaxis. (J Thorac Cardiovasc Surg 2022;:1-31)