EBM SPECIAL TOPIC

Evidence-Based Practices for Thromboembolism

Prevention: Summary of the ASPS Venous
Thromboembolism Task Force Report
Robert X. Murphy, Jr., M.D.
Amy Alderman, M.D.
Karol Gutowski, M.D.
Carolyn Kerrigan, M.D.
Karie Rosolowski, M.P.H.
Loren Schechter, M.D.
DeLaine Schmitz, R.N.,
M.S.H.L.
Edwin Wilkins, M.D.
Arlington Heights, Ill.
Summary: In July of 2011, the American Society of Plastic Surgeons Executive
Committee approved the Venous Thromboembolism Task Force Report. The
report includes a summary of the scientific literature relevant to venous throm-
boembolism and plastic surgery along with five evidence-based recommenda-
tions. The recommendations are divided into two sections: risk stratification and
prevention. The risk stratification recommendations are based on the 2005
Caprini Risk Assessment Module, which has been validated in the scientific
literature as an effective tool for risk-stratifying plastic and reconstructive surgery
patients based on individual risk factors for 60-day venous thromboembolism.
The three prophylaxis recommendations are dependent on an individual pa-
tient’s 2005 Caprini Risk Assessment Module score. (Plast. Reconstr. Surg. 130:
168e, 2012.)

A
ccording to the 2008 article, “The Surgeon
General’s Call to Action to Prevent Deep
Vein Thrombosis and Pulmonary Embo-
lism,” best estimates indicate that 350,000 to
600,000 Americans each year suffer from deep
vein thrombosis and pulmonary embolism, and
that at least 100,000 deaths may be directly or
indirectly related to these diseases.1 Although the
exact incidence of venous thromboembolism in
the plastic surgery population is unknown, venous
thromboembolism prophylaxis has been a topic of
interest for some time. In response, the focus of
the 2009 American Society of Plastic Surgeons
(ASPS) Partners in Quality Leadership Summit
was on venous thromboembolism in plastic sur-
gery. The primary action item to emerge from the
Summit was the appointment of a venous throm-
boembolism task force charged with: (1) evaluat-
ing the literature as it relates to venous thrombo-
embolism risk assessment in plastic surgery cases;
(2) developing a modified Caprini Risk-Assess-
ment Module and recommendations specific to
plastic surgery cases; and (3) developing tools and
aids to assist plastic surgeons across the health
system to implement best practices for deep vein
thrombosis/pulmonary embolism prevention and
treatment.
DISCLAIMER
This Task Force report provides strategies for
patient management and was developed to assist
physicians in clinical decision making. This Task
Force report, based on a thorough evaluation of
the present scientific literature and relevant clin-
ical experience, describes a range of generally ac-
ceptable approaches for management or preven-
tion of specific diseases or conditions. This report
attempts to define principles of practice that
should generally meet the needs of most patients
in most circumstances.
This report, however, should not be construed
as a rule, nor should it be deemed inclusive of all
proper methods of care or exclusive of other
methods of care reasonably directed at obtaining
the appropriate results. It is anticipated that it will
be necessary to approach some patients’ needs in
different ways. The ultimate judgment regarding
the care of a particular patient must be made by
the physician in light of all the circumstances pre-
sented by the patient, the diagnostic and treat-
ment options available, and available resources.

From the American Society of Plastic Surgeons.

Received for publication November 15, 2011; accepted Jan- Disclosure: The authors have no financial interest
uary 18, 2012. in any of the products, devices, or drugs mentioned
Copyright ©2012 by the American Society of Plastic Surgeons in this article.
DOI: 10.1097/PRS.0b013e318254b4ee

168e www.PRSJournal.com
Volume 130, Number 1 • Venous Thromboembolism Task Force Report
This Task Force report is not intended to de-
fine or serve as the standard of medical care. Stan-
dards of medical care are determined on the basis
of all the facts or circumstances involved in an
individual case and are subject to change as sci-
entific knowledge and technology advance, and as
practice patterns evolve. This Task Force report
reflects the state of knowledge current at the con-
clusion of the Task Force’s activities. Given the
inevitable changes in the state of scientific infor-
mation and technology, periodic review and revi-
sion will be necessary.
TASK FORCE COMPOSITION
In response to the 2009 Partners in Quality
Leadership Summit: Assessing the Impacts of DVT
and the Surgeon General’s Call to Action in Plastic
Surgery, held from July 15 through 16, 2008, in
Chicago, Illinois, the ASPS convened the Venous
Thromboembolism Task Force. The ASPS presi-
dent at the time, Michael McGuire, M.D., selected
Robert X. Murphy, Jr., M.D., to chair the Task
Force. The remaining members of the Task Force
were selected based on their involvement in rel-
evant committees, their clinical content expertise,
and/or their knowledge of evidence-based medi-
cine. None of the Task Force members who are
authors of this report disclosed conflicts of interest
or financial affiliations.
TASK FORCE PURPOSE
One of the primary purposes of the Task Force
was to evaluate the scientific literature in two ar-
eas, venous thromboembolism risk stratification
methods and venous thromboembolism prophy-
laxis regimens including chemoprophylaxis drug,
dosage, length of therapy, efficacy, and complica-
tions associated with chemoprophylaxis. Using a
consensus process, the Task Force developed the
clinical questions, search terms, and inclusion cri-
teria for the two areas before the literature search.
LITERATURE SEARCH
A thorough literature search of the PubMed,
Cumulative Index to Nursing and Allied Health
Literature, and Cochrane Library databases was
performed. Study inclusion criteria for the venous
thromboembolism prophylaxis regimen question
included relevance, evaluates the efficacy of chem-
ical prophylaxis and the chemical prophylaxis
drug was approved by the U.S. Food and Drug
Administration. The plastic surgery–specific liter-
ature search time frame was January 1, 2000, to
May 1, 2011. One hundred nineteen citations were
identified initially, with three meeting both the
inclusion criteria and passing the critical appraisal
process. Because of the very limited evidence on
venous thromboembolism prophylaxis in the plas-
tic surgery literature, the search was expanded to
include the orthopedic and general surgery liter-
ature. Orthopedic and general surgery literature
was included because, from a venous thrombo-
embolism risk perspective, they are similar in pa-
tient population, anatomical location, and degree
of invasiveness. The search time frame was January
1, 2005, to May 1, 2011. Two hundred eighteen
citations were initially identified in the orthopedic
and general surgery literature, with 10 meeting
both the inclusion criteria and passing the critical
appraisal process.
The plastic surgery, orthopedic, and general
surgery literature was searched for studies related
to the effectiveness of the Caprini Risk-Assessment
Module for venous thromboembolism. Study in-
clusion criteria included relevance to the topic
and validated venous thromboembolism risk-as-
sessment scale. Fifty-four citations were initially
identified, with three both meeting the inclusion
criteria and passing the critical appraisal process.
A complete summary of the specific clinical ques-
tions, search terms, Medical Subject Headings,
methods used to conduct the systematic review,
and the critical appraisal process for the report,
Evidence-Based Practices for Thromboembolism Preven-
tion, can be found at http://www.plasticsurgery.
org/vte.
LITERATURE FINDINGS
Venous Thromboembolism Risk-Assessment
Scales
There were several venous thromboembolism
risk-assessment tools reported in the literature,
including the 2005 Caprini Risk-Assessment Mod-
ule,2,3 the 2010 Caprini Risk-Assessment Module,4
the Davison-Caprini scale,5 and numerous propri-
etary tools adopted by individual hospitals. To en-
sure that the Task Force recommendations could
be consistently associated with a set of risk factors,
one risk-assessment tool was needed as a reference
point or benchmark for comparison. The 2005
Caprini scale was selected as this reference point
because it was formally validated to stratify plastic
surgery patients based on their individual risk fac-
tors (Fig. 1).2 The 2010 Caprini Risk-Assessment
Module was not selected because the additional
points allotted for longer surgery times, com-
mon in many plastic surgery procedures, and
higher body mass indexes, could result in an
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 Plastic and Reconstructive Surgery • July 2012

Fig. 1. Thrombosis risk factor assessment.

Table 1. ASPS Evidence Rating Scale for Therapeutic Studies

Level of Evidence Qualifying Studies
I Highest-quality, multicenter or single-center, randomized controlled trial with adequate power;
or systematic review of these studies
II Lesser-quality, randomized controlled trial; prospective cohort or comparative study; or
systematic review of these studies
III Retrospective cohort or comparative study; case-control study; or systematic review of these studies
IV Case series with pre/post test; or only post test
V Expert opinion developed by means of consensus process; case report or clinical example; or
evidence based on physiology, bench research, or “first principles”

Table 2. ASPS Evidence Rating Scale for Diagnostic Studies

Level of Evidence Qualifying Studies
I Highest-quality, multicenter or single-center, cohort study validating a diagnostic test (with criterion
standard as reference) in a series of consecutive patients; or a systematic review of these studies
II Exploratory cohort study developing diagnostic criteria (with criterion standard as reference) in a
series of consecutive patient; or a systematic review of these studies
III Diagnostic study in nonconsecutive patients (without consistently applied criterion standard as
reference); or a systematic review of these studies
IV Case-control study; or any of the above diagnostic studies in the absence of a universally accepted
criterion standard
V Expert opinion developed by means of consensus process; case report or clinical example; or
evidence based on physiology, bench research, or “first principles”

overscoring phenomenon, artificially placing imens did not include the study population’s
patients in a higher than necessary risk category. venous thromboembolism risk levels. To ensure
Many of the therapeutic studies identified in that like groups were evaluated, Task Force
the literature search addressing prophylaxis reg- members analyzed the patient characteristics

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Volume 130, Number 1 • Venous Thromboembolism Task Force Report

and risks in studies without a 2005 Caprini risk See Tables 1 through 3 for ASPS evidence
rating and estimated a venous thromboembo- rating scales. Table 4 includes the litera-
lism risk score using the 2005 Caprini Risk-As- ture findings with corresponding levels of
sessment Module. evidence.2,3,5–19

Table 3. ASPS Evidence Rating Scale for Prognostic/Risk Studies

Level of Evidence Qualifying Studies
I Highest-quality, multicenter or single-center, prospective cohort or comparative study with adequate
power; or a systematic review of these studies
II Lesser-quality prospective cohort or comparative study; retrospective cohort or comparative study;
untreated controls from a randomized controlled trial; or a systematic review of these studies
III Case-control study; or systematic review of these studies
IV Case series with pre/post test; or only post test
V Expert opinion developed by means of consensus process; case report or clinical example; or
evidence based on physiology, bench research, or “first principles”

Table 4. Literature Search: Evidence Summaries

Findings in the Orthopedic, General Surgery, Supporting Literature and
and Plastic Surgery Literature Level of Evidence
1. Risk stratification: Risk studies:
The 2005 Caprini RAM is a valid scoring method that effectively stratifies ● Bahl et al., 20106: level II
patients into a VTE risk category based on their individual risk factors. ● Hatef et al., 20085†: level II
2. Plastic surgery risk stratification: Identified in May of 2011 search:
The 2005 Caprini RAM effectively risk-stratifies plastic and reconstructive Risk study
surgery patients for increased 60-day VTE risk. Among patients with a ● Pannucci et al., 20112†: level II
2005 Caprini score ⬎8, 11.3% had a postoperative VTE when
chemoprophylaxis was not provided. Patients with a Caprini score ⬎8
were significantly more likely to develop VTE when compared with
patients with a Caprini score of 3 to 4, 5 to 6, or 7 to 8. There was no
evidence that VTE risk was limited to the immediate postoperative
period in patients with Caprini score of 7 to 8 or ⬎8.
3. In patients with estimated* 2005 Caprini RAM scores ⬎3, the use of Therapeutic studies:
postoperative chemoprophylaxis, LMWH, UH, and fondaparinux, for 1 ● Turpie et al., 20077: level I
wk was effective in preventing VTE without significantly increasing ● Kim et al., 20098†: level III
bleeding risks. ● Edwards et al., 20089: level II
● Senaran et al., 200610: level II
● Chin et al., 200911: level II
● Colwell et al., 200612: level II
4. In patients with estimated* 2005 Caprini RAM scores ⬎7, extended Therapeutic studies:
LMWH prophylaxis for up to 4 wk is more effective at reducing the risk ● Barrellier et al., 201013: level I
of VTE compared to 1 wk of LMWH, without significantly increasing the ● Bottaro et al., 200814: level II
risk of hematoma or bleeding complications. ● Rasmussen et al., 200615: level II
● Rasmussen et al., 200916: level II
5. Inpatient plastic surgery patients who received general anesthesia and Therapeutic study: level III
received prophylactic-dose enoxaparin during the duration of their ● Pannucci et al., 20113†: level III
hospitalization (starting 6–8 hr after surgery):
● Enoxaparin was effective in reducing VTE rates (compared to no VTE
prophylaxis).
– Minimal risk reduction was seen in 2005 Caprini RAM scores of 3–6.
– Notable risk reduction was present in 2005 Caprini RAM scores ⬎7.
● Enoxaparin was not associated with increased rates of reoperative
hematoma in the overall patient population or the high-risk breast
surgery subgroups.
● Length of stay ⬎4 days and 2005 Caprini RAM score ⬎8 were
independent predictors of VTE.
● When controlling for length of stay and 2005 Caprini RAM score,
postoperative enoxaparin was protective against 60-day VTE.
6. Evidence suggests that combined UH or LMWH plus mechanical Therapeutic studies:
prophylaxis throughout the duration of chemical prophylaxis is more ● Kakkos et al., 200817: level II
effective in preventing VTE in patients than either alone. ● Seruya et al., 200818†: level III
● Liao et al., 200819†: level III
RAM, Risk-Assessment Module; VTE, venous thromboembolism; LMLH, low-molecular weight heparin; UH, unfractionated heparin.
*Task Force members analyzed the patient characteristics and risks in studies without a 2005 Caprini risk rating and estimated a venous
thromboembolism risk score using the 2005 Caprini Risk-Assessment Module.
†Plastic surgery study.

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Table 5. Plastic Surgery Venous Thromboembolism Prophylaxis Study Protocols
Venous Thromboembolism University of Texas Georgetown University Asan Medical Center,
Prevention Study, Southwestern, Hospital, Korea,
Pannucci et al., 20113 Hatef et al., 20085 Seruya et al., 200818 Kim et al., 20098
Patients Various operations, general Excisional body contouring Various; head and neck reconstruction; TRAM flap immediate breast
anesthesia, at least one patients breast reconstruction; abdominal reconstruction patients
overnight stay wall reconstruction
Risk-assessment 2005 Caprini Risk Assessment Caprini-Davison Risk Assessment Caprini-Davison Risk Assessment Model None
scale Model Model
Protocol
Risk score 2005 Caprini RAM Score ⬎3 Moderate, high, and highest risk 2005 Caprini RAM score ⬎4 N/A
groups
Drug Enoxaparin Enoxaparin Enoxaparin Enoxaparin
Dose Sliding scale: 30 mg SQ 40 mg SQ Dose: 40 or 60 mg SQ
● BMI ⬍40: 40 mg SQ every (dependent on weight)
day
● BMI ⬎40: 30 mg SQ two
times per day
Timing First dose 6–8 hr postoperatively, ● 49 patients received first dose Starting 12 hr postoperatively, then 1 hr preoperatively, then
then daily until patient preoperatively daily until ambulatory; additional daily
released ● 88 patients received first dose prophylaxis measures: IPC with
intraoperatively or immediately elastic compression stockings (on at
postoperatively all times when not ambulating)
● Every 12 hr after initial dose
Length of
prophylaxis Varied Varied Varied, averaged 7.4 days 7 days
Results When controlling for independent Enoxaparin significantly decreased Mechanical prophylaxis supplemented Enoxaparin was effective in
risk factors, postoperative DVT risk in patients undergoing with low-molecular-weight heparin preventing VTE without
enoxaparin was protective circumferential abdominoplasty. was effective in preventing VTE significantly increasing
against VTE without increased Enoxaparin administration was without significant increase in bleeding-related
rates of reoperative hematoma. associated with increased bleeding or hematoma rates. complications such as
hematoma and postoperative transfusions or hematoma.
bleeding requiring transfusion.
RAM, Risk-Assessment Model; TRAM, transverse rectus abdominis musculocutaneous; N/A, not applicable; SQ, subcutaneously; BMI, body mass index; IPC, intermittent pneumatic
compression; VTE, venous thromboembolism; DVT, deep vein thrombosis.
Plastic and Reconstructive Surgery • July 2012
Volume 130, Number 1 • Venous Thromboembolism Task Force Report

Prophylaxis Medication Dosage and Timing
The available evidence on chemoprophylaxis
medication choice, postoperative timing, and
dosage varied among the studies. Administra-
tion of the first chemoprophylaxis dosage
ranged from preoperative administration to 1 to
12 hours postoperatively. Several different low-
molecular-weight heparin medications were used
in the studies, including enoxaparin, dalteparin,
tinzaparin, and fondaparinux. Enoxaparin was the
most common low-molecular-weight heparin pre-
scribed; the dosage ranged from 30 to 60 mg/day.
Task Force members agreed that there was not
enough evidence to make all-inclusive recommen-
dations for plastic surgery prophylaxis medica-
tion, dosage, or length of prophylaxis. See Table
5 for study protocols.
Medication Costs
Venous thromboembolism prophylaxis costs
vary greatly because of the specific medication,
regimen, and pharmacy selected. A breakdown of
cost estimates can be found at http://www.
plasticsurgery.org/vte.
RECOMMENDATIONS
Recommendation Development Process
Task Force recommendations were developed
through a consensus process. After thorough re-
view of the evidence, the Task Force members
jointly developed draft statements for each rec-
ommendation during a conference call discus-
sion. After the conference call, Task Force mem-
bers had an opportunity to individually comment
and revise the draft recommendations by means of
an e-mail discussion. The Task Force participated
in several rounds of revisions until unanimous
agreement was achieved on each recommenda-
tion statement.
Rationale for Task Force Recommendations
Based on the types of cases included in the
literature review, Task Force members agreed that
there was not enough evidence to make all-inclu-
sive recommendations for plastic surgery prophy-
laxis medication, dosage, or length of prophylaxis.
However, the Task Force agreed that some plastic
surgery procedures warranted additional prophy-
laxis considerations, and accepted the premise
that the surgical cases included in the orthopedic
and general surgery literature search were similar
enough in their anatomical location, degree of
invasiveness, and patient population to make
them comparable (from a venous thromboem-
bolism risk perspective) to the following plastic
surgery cases: major body contouring, abdomi-
noplasty, major breast reconstruction, major
lower extremity procedures, and major head/
neck cancer procedures. This belief was rein-
forced by the publication in August of 2010 by
Murphy et al. that documented the reality of
venous thromboembolism events in abdomino-
plasty and panniculectomy cases despite compli-
ance with nationally recognized venous thrombo-
embolism prophylaxis measures.20 Therefore,
recommendations 3 to 5 were developed to ad-
dress this subset of plastic surgery procedures. See
Table 6 for the ASPS grading scale and Table 7 for
the Venous Thromboembolism Task Force rec-
ommendations.
TOOLS AND AIDS
The ASPS Web site includes a page dedicated
to its campaign for venous thromboembolism

Table 6. ASPS Grading Scale

Grade Descriptor Qualifying Evidence Implications for Practice
A Strong Level I evidence or consistent findings Clinicians should follow a strong recommendation
recommendation from multiple studies of level II, III, unless a clear and compelling rationale for an
or IV alternative approach is present.
B Recommendation Level II, III, or IV evidence and Generally, clinicians should follow a
findings are generally consistent recommendation but should remain alert to
new information and sensitive to patient
preferences.
C Option Level II, III, or IV evidence, but Clinicians should be flexible in their decision-
findings are inconsistent making regarding appropriate practice,
although they may set bounds on alternatives;
patient preference should have a substantial
influencing role.
D Option Level V: little or no systematic Clinicians should consider all options in their
empirical evidence decision-making and be alert to new published
evidence that clarifies the balance of benefit
versus harm; patient preference should have a
substantial influencing role.

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 Plastic and Reconstructive Surgery • July 2012

Table 7. ASPS Venous Thromboembolism Task Force Risk-Assessment and Prevention Recommendations
Step One: Risk Stratification

Patient Population Recommendation

Inpatient: adult aesthetic and reconstructive plastic surgery patients Should complete a 2005 Caprini risk factor
who undergo general anesthesia assessment tool to stratify patients into a VTE
risk category based on their individual risk
factors. Grade B
Or
Should complete a VTE risk-assessment tool
comparable to the 2005 Caprini RAM to
stratify patients into a VTE risk category
based on their individual risk factors. Grade D
Outpatient: adult aesthetic and reconstructive plastic surgery patients Should consider completing a 2005 Caprini
who undergo general anesthesia risk factor assessment tool to stratify patients
into a VTE risk category based on their
individual risk factors. Grade B
Or
Should consider completing a VTE risk-
assessment tool comparable to the 2005
Caprini RAM to stratify patients into a VTE
risk category based on their individual risk
factors.Grade D
Step Two: Prevention
2005 Caprini
Patient Population RAM Score Recommendations*

Elective surgery patients (when the procedure is ⱖ7 Should consider using risk-reduction strategies
scheduled in advance and is not performed to such as limiting operating room times,
treat an emergency or urgent condition) weight reduction, discontinuing hormone
replacement therapy, and early postoperative
mobilization. Grade C
Patients undergoing the following major procedures 3–6 Should consider the option to use
when the procedure is performed under general postoperative LMWH or UH. Grade B
anesthesia lasting more than 60 minutes:
● Body contouring
● Abdominoplasty
● Breast reconstruction
● Lower extremity procedures
● Head/neck cancer procedures
VTE, Venous thromboembolism; RAM, Risk-Assessment Module; LMWH, low-molecular-weight heparin; UH, unfractionated heparin.
*The scores associated with the recommendations apply to the 2005 Caprini RAM and were not intended for use with alternative VTE
risk-assessment tools.

awareness. There are numerous downloadable re-
sources available, including the full Task Force
Report, the 2005 Caprini Scale accompanied by
the Task Force recommendations, a patient ve-
nous thromboembolism risk self-assessor form,
and a patient handout on venous thromboembo-
lism signs and symptoms. These resources can be
found at http://www.plasticsurgery.org/vte.
The Task Force also developed evidence-based
performance measures that may be used for a
variety of purposes, including as a data point in
the surgeon’s Joint Commission’s Ongoing Pro-
fessional Practice Evaluation profile. In 2012,
the ASPS will release performance-improve-
ment continuing medical education activities
using these venous thromboembolism mea-
sures. The measures are outlined in the full Task
Force Report.
DeLaine Schmitz, R.N., M.S.H.L.
American Society of Plastic Surgeons
444 East Algonquin Road
Arlington Heights, Ill. 60005-4664
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