根据卡普里尼风险评定模型对乳房
切除术患者实施静脉血栓栓塞预防
静脉血栓栓塞是住院患者发病和死亡的主要可预防原因。目前，针对乳腺外科手术患者的静脉血栓栓塞预防指南尚未制定。从2016年8月开始，哈佛大学医学院布列根妇女医院根据芝加哥大学约瑟夫·卡普里尼教授等制定的深静脉血栓形成风险评定模型，对乳房切除术±假体植入重建患者实施个体化静脉血栓栓塞预防方案。
2018年8月20日，美国乳腺外科医师学会和肿瘤外科学会《肿瘤外科年鉴》在线发表哈佛大学医学院布列根妇女医院、达纳法伯布列根妇女癌症中心、达纳法伯癌症研究所、加拿大卡尔加里大学的研究报告，分析了根据卡普里尼深静脉血栓形成风险评定模型对乳房切除术±假体植入重建患者实施个体化静脉血栓栓塞预防方案的首年结果。
该研究首先对哈佛大学医学院布列根妇女医院病案进行仔细回顾，记录患者和治疗的具体信息、卡普里尼评分、静脉血栓栓塞药物预防措施、术后30天内的静脉血栓栓塞和出血并发症发生率。随后进行单因素分析，确定方案执行相关因素。
结果发现，符合分析标准患者共计522例，中位年龄51岁，其中恶性肿瘤患者486例（93.1%）、双侧乳房切除234例（44.8%）、重建350例（67.0%）。卡普里尼评分范围2～11分，其中评分5～7分患者431例（82.6%）。术后30天内的静脉血栓栓塞率仅0.2%（95%置信区间：0.03%～1.1%）、血肿再次手术率仅2.7%（95%置信区间：1.6%～4.5%）、输血率仅0.4%（95%置信区间：0.1%～1.4%）。方案总执行率60.5%，与双侧乳房切除（P=0.02）、重建（P=0.03）、手术过程较长（P<0.001）显著相关。
因此，该研究结果表明，对于乳房切除术±假体植入重建患者，实施个体化静脉血栓栓塞预防方案安全可行。虽然高风险患者比例较高，但是静脉血栓栓塞率极低，出血并发症发生率与既往乳腺外科手术报告相似，故有必要对该策略进行继续评估。
Ann Surg Oncol. 2018 Aug 20. [Epub ahead of print]
Implementation of a Venous Thromboembolism Prophylaxis Protocol Using the Caprini Risk Assessment Model in Patients Undergoing Mastectomy.
Alison Laws, Kathryn Anderson, Jiani Hu, Kathleen McLean, Lara Novak, Laura S. Dominici, Faina Nakhlis, Matthew Carty, Stephanie Caterson, Yoon Chun, Margaret Duggan, William Barry, Nathan Connell, Mehra Golshan, Tari A. King.
Brigham and Women's Hospital, Boston, USA; Dana-Farber/Brigham and Women's Cancer Center, Boston, USA; Dana-Farber Cancer Institute, Boston, USA; University of Calgary, Calgary, Canada.
BACKGROUND: Guidelines for venous thromboembolism (VTE) prophylaxis are not well-established for breast surgery patients. An individualized VTE prophylaxis protocol using the Caprini score was adopted at our institution for patients undergoing mastectomy±implant-based reconstruction. In this study, we report our experience during the first year of implementation.
METHODS: In August 2016, we adopted a VTE prophylaxis protocol for patients undergoing mastectomy±implant-based reconstruction. We used the Caprini score, a validated risk assessment tool for VTE, to determine each patient's perioperative prophylaxis regimen. Detailed chart review was performed to record patient and treatment details, the Caprini score, pharmacologic VTE prophylaxis administration, and 30-day incidence of VTE and bleeding complications. We performed univariate analysis to identify factors associated with protocol compliance.
RESULTS: Overall, 522 patients met the inclusion criteria. Median age was 51 years, 486 (93.1%) patients had malignancy, 234 (44.8%) underwent bilateral mastectomy, and 350 (67.0%) underwent reconstruction. Caprini scores ranged from 2 to 11, with 431 (82.6%) patients having a score from 5 to 7. Overall protocol compliance was 60.5%, and was associated with bilateral mastectomy (p=0.02), reconstruction (p=0.03), and longer procedures (p<0.001). The rate of VTE was 0.2% (95% confidence interval [CI] 0.03-1.1%), rate of reoperation for hematoma was 2.7% (95% CI 1.6-4.5%), and rate of blood transfusion was 0.4% (95% CI 0.1-1.4%).
CONCLUSIONS: The implementation of an individualized VTE prophylaxis protocol for patients undergoing mastectomy±implant-based reconstruction is safe and feasible. Despite a high-risk cohort, the incidence of VTE was very low and bleeding complications were consistent with reported rates for breast surgery. Continued evaluation of this strategy is warranted.
DOI: 10.1245/s10434-018-6696-y
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