CORRInsights®: Venous Thromboembolism Prophylaxis After TKA: Aspirin, Warfarin, Enoxaparin, or Factor Xa Inhibitors?

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In the early era of TKA 40% to 80% of patients developed postoperative venous thromboembolism (VTE) [5, 13]. Although clinicians identified a large portion of these patients during routine postoperative screening studies and found those clots were resolved on followup imaging, great efforts were made to decrease VTE and its associated morbidity and mortality. Patients now mobilize much earlier thanks in large part to improvements in controlling pain and nausea with multimodal analgesia. Early mobilization can generally mitigate the venous stasis portion of Virchow's triad of stasis, hypercoaguability, and intimal injury. Pharmacologic prophylaxis seeks to address the hypercoagulable state of the patient who may not be very mobile in the days immediately after surgery.
Bala and colleagues provide us with the first direct comparison of the four major classes of chemoprophylaxis routinely used in TKA; warfarin, low-molecular-weight heparin (LMWH), aspirin, and factor Xa inhibitors. Although warfarin and LMWH are mainstays in the field, the use of aspirin and factor Xa inhibitors have become more prevalent as concerns regarding warfarin and LMWH, including their need for routine monitoring and the potential for increased bleeding [10, 15], grow louder.
The current study represents a fair assessment of the current state of VTE prophylaxis in TKA; with aspirin and factor Xa inhibitors rising in popularity due to decreased cost, favorable risk profiles, and ease of use, while warfarin and LMWH continue to be used by many clinicians given their proven anticoagulation effects and long history in the field.

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