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Correspondence |

Revisiting the Issue of VTE in the Setting of Chronic Liver Disease: An Examination of National Surgical Quality Improvement Program Data FREE TO VIEW

Jason Schwartz, MD; Gabriela Vargas, MD; Heather Thiesset, MPH; Greg Stoddard, MPH; Robin Kim, MD; John Sorensen, MD; Larry Kraiss, MD
Author and Funding Information

From the Department of General Surgery, Section of Transplantation (Drs Schwartz, Kim, and Sorensen and Ms Thiesset), the Department of Surgery (Dr Vargas), the Department of Epidemiology (Mr Stoddard), and the Department of Vascular Surgery (Dr Kraiss), University of Utah School of Medicine.

Correspondence to: Jason Schwartz, MD, University of Utah School of Medicine, 30 N 1900 E 3B110, Salt Lake City, UT 84132; e-mail: jason.schwartz@hsc.utah.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(6):1544-1545. doi:10.1378/chest.10-3285
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To the Editor:

In an article in CHEST (May 2010), Dabbagh and colleagues1 examined the rate of VTE in patients with chronic liver disease (CLD), as stratified by international normalized ratio (INR) levels. Specifically, the authors retrospectively examined the rate of inpatient VTE occurring over a 7-year period. Of 190 patients with CLD, the authors noted a VTE incidence of 6.3%, with no significant differences in the incidence of VTE between INR quartiles. The majority of patients with documented VTE were classified as Child-Pugh stage C. From this, the authors concluded that an elevated INR in the setting of CLD does not appear to protect against the development of hospital-acquired VTE. As the cause of VTE is often multifactorial and early initiating factors are still not fully understood,2 we agree that an elevated INR, in and of itself, is not protective against VTE in the population of patients with CLD.

Like the authors, we were also curious regarding the rate of VTE in patients with CLD, particularly after major hepatic resection. After obtaining the appropriate approval from the University of Utah institutional review board (IRB_00030671), we queried the National Surgical Quality Improvement Program (NSQUIP) database to collect data on the number and type of liver resections performed nationally during the years 2004 to 2009 (Current Procedural Terminology codes 47120, 47122, 47125, and 47130). The incidence of inpatient DVT (International Classification of Diseases, Ninth Revision, codes 453.4 and 453.8) and PE (International Classification of Diseases, Ninth Revision, codes 415.9 and 415.11) were examined retrospectively. During the 5-year study period, 6,084 liver resections were performed among 268 NSQUIP institutions nationwide. During this time, the annualized incidence rate remained relatively constant, with DVT and PE occurring at a rate of 1.97% and 1.36%, respectively (Tables 1, 2). This is not only considerably lower than that experienced by the authors, but also below the estimates typically cited for patients with known malignancies.2 Nevertheless, according to criteria set forth by Bahl et al,3 our data clearly show that patients with CLD undergoing major hepatic resection fall under a high-risk designation. With the decision to use prophylactic methods against VTE frequently predicated on an assessment of individual patient risk, this information may prove valuable when used in conjunction with the American College of Chest Physicians’ Evidence-Based Clinical Practice Guidelines.4

Table Graphic Jump Location
Table 1 —Rate of DVT and PE Nationally, 2004-2009

Table based on NSQUIP data. Data include year-specific incidence proportions (incidence rates) for codes of liver resection, DVT, and PE from ICD-9 as follows: Hepatectomy, resection of the liver, partial lobectomy, 47120; trisegmentectomy, 47122; total left lobectomy, 47125; total right lobectomy, 47130; DVT, 453.4 (0,1,2); embolism of vein, 453.8 (1-9); PE (other), 415.19; PE and infarction, 415.11. ICD-9 = International Classification of Diseases, Ninth Revision; NSQUIP = National Surgical Quality Improvement Program; PE = pulmonary embolism.

a 

Incidence rate ratio (DVT relative to PE).

b 

McNemar test.

Table Graphic Jump Location
Table 2 —Rate of DVT and PE Nationally, All Years Combined (2004-2009), Incidence Proportions, and Incidence Rates

Table based on NSQUIP data. Data include year-specific incidence proportions (incidence rates) for codes of liver resection, DVT, and PE from ICD-9 as follows: Hepatectomy, resection of the liver, partial lobectomy, 47120; trisegmentectomy, 47122; total left lobectomy, 47125; total right lobectomy, 47130; DVT, 453.4 (0,1,2); embolism of vein, 453.8 (1-9); PE (other), 415.19; PE and infarction, 415.11. See Table 1 for expansion of abbreviations.

a 

Incidence rate ratio (DVT relative to PE).

b 

McNemar test.

Dabbagh O, Oza A, Prakash S, Sunna R, Saettele TM. Coagulopathy does not protect against venous thromboembolism in hospitalized patients with chronic liver disease. Chest. 2010;1375:1145-1149. [CrossRef] [PubMed]
 
Meissner MH, Wakefield TW, Ascher E, et al. Acute venous disease: venous thrombosis and venous trauma. J Vasc Surg. 2007;46Suppl S:25S-53S. [CrossRef] [PubMed]
 
Bahl V, Hu HM, Henke PK, Wakefield TW, Campbell DA Jr, Caprini JA. A validation study of a retrospective venous thromboembolism risk scoring method. Ann Surg. 2010;2512:344-350. [CrossRef] [PubMed]
 
Hirsh J, Guyatt GH, Albers GW, Harrington RA, Schunemann HJ, chairs . Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Guidelines (8th Edition). Chest. 2008;1336Suppl:67S-968S
 

Figures

Tables

Table Graphic Jump Location
Table 1 —Rate of DVT and PE Nationally, 2004-2009

Table based on NSQUIP data. Data include year-specific incidence proportions (incidence rates) for codes of liver resection, DVT, and PE from ICD-9 as follows: Hepatectomy, resection of the liver, partial lobectomy, 47120; trisegmentectomy, 47122; total left lobectomy, 47125; total right lobectomy, 47130; DVT, 453.4 (0,1,2); embolism of vein, 453.8 (1-9); PE (other), 415.19; PE and infarction, 415.11. ICD-9 = International Classification of Diseases, Ninth Revision; NSQUIP = National Surgical Quality Improvement Program; PE = pulmonary embolism.

a 

Incidence rate ratio (DVT relative to PE).

b 

McNemar test.

Table Graphic Jump Location
Table 2 —Rate of DVT and PE Nationally, All Years Combined (2004-2009), Incidence Proportions, and Incidence Rates

Table based on NSQUIP data. Data include year-specific incidence proportions (incidence rates) for codes of liver resection, DVT, and PE from ICD-9 as follows: Hepatectomy, resection of the liver, partial lobectomy, 47120; trisegmentectomy, 47122; total left lobectomy, 47125; total right lobectomy, 47130; DVT, 453.4 (0,1,2); embolism of vein, 453.8 (1-9); PE (other), 415.19; PE and infarction, 415.11. See Table 1 for expansion of abbreviations.

a 

Incidence rate ratio (DVT relative to PE).

b 

McNemar test.

References

Dabbagh O, Oza A, Prakash S, Sunna R, Saettele TM. Coagulopathy does not protect against venous thromboembolism in hospitalized patients with chronic liver disease. Chest. 2010;1375:1145-1149. [CrossRef] [PubMed]
 
Meissner MH, Wakefield TW, Ascher E, et al. Acute venous disease: venous thrombosis and venous trauma. J Vasc Surg. 2007;46Suppl S:25S-53S. [CrossRef] [PubMed]
 
Bahl V, Hu HM, Henke PK, Wakefield TW, Campbell DA Jr, Caprini JA. A validation study of a retrospective venous thromboembolism risk scoring method. Ann Surg. 2010;2512:344-350. [CrossRef] [PubMed]
 
Hirsh J, Guyatt GH, Albers GW, Harrington RA, Schunemann HJ, chairs . Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Guidelines (8th Edition). Chest. 2008;1336Suppl:67S-968S
 
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