Joint 2022 European Society of Thoracic Surgeons and The American Association for Thoracic Surgery guidelines for the prevention of cancer-associated venous thromboembolism in thoracic surgery

Background: Venous thromboembolism (VTE), which includes deep vein throm-bosis and pulmonary embolism, is a potentially fatal but preventable postoperative complication. Thoracic oncology patients undergoing surgical resection, often after multimodality induction therapy, represent among the highest risk groups for post-operative VTE. Currently there are no VTE prophylaxis guidelines specific to these thoracic surgery patients. Evidenced-based recommendations will help clinicians manage and mitigate risk of VTE in the postoperative period and inform best practice.Objective: These joint evidence-based guidelines from The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons aim to inform clinicians and patients in decisions about prophylaxis to prevent VTE in patients un-dergoing surgical resection for lung or esophageal cancer.Methods: The American Association for Thoracic Surgery and the European Soci-ety of Thoracic Surgeons formed a multidisciplinary guideline panel that included broad membership to minimize potential bias when formulating recommendations. The McMaster University GRADE Centre supported the guideline development pro-cess, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clini-cians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to public comment.Results: The panel agreed on 24 recommendations focused on pharmacological and mechanical methods for prophylaxis in patients undergoing lobectomy and seg-mentectomy, pneumonectomy, and esophagectomy, as well as extended resections for lung cancer.Conclusions: The certainty of the supporting evidence for the majority of recom-mendations was judged as low or very low, largely due to a lack of direct evidence for thoracic surgery. The panel made conditional recommen- dations for use of parenteral anticoagulation for VTE preven- tion, in combination with mechanical methods, over no prophylaxis for cancer patients undergoing anatomic lung resection or esophagectomy. Other key recommendations include: conditional recommendations for using parenteral anticoagulants over direct oral anticoagulants, with use of direct oral anticoagulants suggested only in the context of clinical trials; conditional recommendation for using extended prophylaxis for 28 to 35 days over in-hospital pro- phylaxis only for patients at moderate or high risk of throm- bosis; and conditional recommendations for VTE screening in patients undergoing pneumonectomy and esophagec- tomy. Future research priorities include the role of preoper- ative thromboprophylaxis and the role of risk stratification to guide use of extended prophylaxis.

Automated summary

The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons have jointly released evidence-based guidelines to inform clinicians and patients on VTE prophylaxis in patients undergoing surgical resection for lung or esophageal cancer. The guidelines include recommendations for pharmacological and mechanical methods, but highlight the need for further research.