[Perioperative venous thromboembolism prophylaxis]

The overall thromboembolic risk results from patient-related risk and surgical risk. The latter has been decreasing regularly over the last decades due to the advances in perioperative management. The benefits of perioperative venous thromboembolism prophylaxis have been firmly established. Mechanical prophylaxis should be considered as first-line therapy in patients with bleeding risk. The association with a drug therapy increases the antithrombotic efficiency. However, the effect of mechanical prophylaxis on pulmonary embolism and mortality has not been demonstrated. Assessing renal function is a prerequisite before prescribing low-molecular-weight heparin, fondaparinux, dabigatran or rivaroxaban. Age over 75 years and low weight (less than 50 kg) should also be taken into account. Patients undergoing surgery associated with a moderate or high overall risk should receive prophylaxis until full mobilization. In case of total hip replacement, surgery for femoral neck fracture or major abdominal surgery, the prophylaxis should be extended by approximately 5 weeks. The clinical significance of distal deep vein thromboses is greatly debated. Surrogate venographic endpoints should be gradually replaced by clinical criteria. The latest oral antithrombotic agents may modify prevention strategies in the next few years. So far, no antagonists or biological monitoring are available for these products.