Deep venous thrombosis prophylaxis: better living through chemistry--in opposition

The best prophylactic regimens for thromboembolic disease continue to be debated despite years of investigation. The surgeon must balance the clinical risks and benefits. A decision depends on accurate data and our ability to balance the risks of fatal pulmonary embolism (PE) to the risk of bleeding. The current risk for fatal PE is 0.1% with most current prophylactic regimes. The risk of perioperative bleeding increases 1.8% to 5.2% with low molecular weight heparins or warfarin and generally is dose dependent. Most of the current prophylactic recommendations are based on the presence or absence of deep venous thrombosis (DVT). However, the correlation between the presence of a DVT and the risk of PE is low and inconsistent. Therefore, DVT may not be an accurate surrogate marker for the patient at risk after total joint surgery. Our experience with 2800 consecutive total knee arthroplasty patients, using aspirin as our principle agent, shows a fatal PE risk of 0.1% and a low risk of bleeding. Therefore, our current recommendation is aspirin.