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Optimal Timing for Initiation of Thromboprophylaxis after Hepatic Angioembolization
*Brianna L. Collie, *Nicole Lyons, *Logan Goddard, *Michael D. Cobler-Lichter, *Jessica Delamater, *Larisa Shagabayeva, *Edward B. Lineen, Carl I. Schulman, *Kenneth G. Proctor, *Jonathan P. Meizoso, Nicholas Namias, *Enrique Ginzburg
University of Miami Miller School of Medicine, Miami, FL

Objective: Thromboprophylaxis (TPX) after hepatic trauma is complicated by a high risk of bleeding, but the relative risk after angioembolization is unknown. We hypothesize that the timing of TPX initiation after hepatic angioembolization determines the risk/benefit. Methods: All trauma patients who underwent hepatic angioembolization within 24 hours of arrival were retrospectively identified from the American College of Surgeons Trauma Quality Improvement Project database from 2017-19. Cases with missing data, <24-hour hospital length of stay, prehospital cardiac arrest, and other serious injuries were excluded. VTE was defined as deep venous thrombosis (DVT) or pulmonary embolism (PE). Bleeding complications were defined as need for hepatic surgery or abdominal packing, additional embolization, or blood transfusion after the initiation of TPX. Univariate and multivariate analyses were used with p<0.05 considered statistically significant. Adjusted odds ratios (OR) and 95% confidence intervals (CI) are presented for the multivariate analyses. Results: Of 1,586 patients, 182 (11.5%) required hepatic surgery prior to angioembolization. In 1,404 with initial angioembolization, 79% received TPX. Bleeding complications were more common in those with TPX initiation within the first 24 hours compared to after 24 hours (20.0% vs 8.9%, p<0.001) and first 48 hours compared to after 48 hours (13.2% vs 8.4%, p=0.013). Subsequent need for surgery after TPX was more common in those with TPX initiation within the first 24 hours (11.3% vs 5.1%, p=0.006) and first 48 hours (7.6% vs 4.6%, p=0.04). However, the incidence of VTE was higher in those with initiation of TPX after 48 hours (6.3%vs 3.3%, p=0.025). In multivariate analysis, time to TPX was associated with both bleeding (OR 0.885, 95% CI 0.795 -0.98) and VTE complications (OR 1.1, 95% CI 1.05-1.18). Moreover, there was a negative association between bleeding complications and time to TPX initiation (τb = -0.073, p =0.003), but a positive association between VTE events and time to TPX initiation (τb = 0.088, p <0.001). In the 182 patients who required surgery first, bleeding complication were more common for those with TPX initiation within the first 24 hours (20.0% vs 4.3%, p=0.014), but not the first 48 hours. The incidence of VTE is the same for those with TPX initiation before and after 24 hours (8.0% vs 4.0%, p=0.694). However, these patients were more likely to have a DVT if TPX was initiated after 96 hours (14.3% vs 3.1%, p =0.023). Conclusion: This is the first study to address specific timing of TPX after hepatic angioembolization in a national sample of trauma patients. For patients who do not require initial hepatic surgery, initiation of TPX at 48 hours achieves the safest balance in minimizing bleeding risk while reducing the risk of VTE. However, after initial surgery, initiation of TPX may be safe after 24 hours.
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