张志勇,王建法,王鲁川

全关节置换术（TJA）是一种治疗髋关节和膝关节疾病的新技术。能有效根除晚期髋部、膝部疼痛，大大提高患者的生活质量。但由于术中静脉内皮损伤、炎症反应导致高凝状态以及患者围手术期活动减少，容易形成静脉血栓栓塞（VTE）。VTE 包括肺栓塞 (PE) 和深静脉血栓形成 (DVT)，这已被确定为重大公共卫生问题。如何预防术后VTE的形成也是医学界的热门话题。尽管关于关节置换术后VTE预防的指南很多，但尚无最佳预防方案。低分子肝素是临床上最广泛使用的预防外科术后VTE的药物。目前也有研究指出阿司匹林可被认为是预防TJA后VTE的安全有效药物。本文将阐述VTE的危险因素和阿司匹林及低分子肝素预防VTE的国内外最新研究进展，以期为临床决策提供参考。

全关节置换；静脉血栓栓塞症；阿司匹林；低分子肝素；预防

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[17] Crescente M,Armstrong P C,Kirkby N S,et al.Profiling the eicosanoid networks that underlie the anti-and pro-thrombotic effects of aspirin[J].FASEB J,2020,34(8):10027-10040. [18] Tormene D,Campello E,Simion C,et al.Incidence of VTE in asymptomatic children with deficiencies of antithrombin,protein C,and protein S:a prospective cohort study[J].Blood Adv,2020,4(21):5442-5448. [19] Geerts W H,Pineo G F,Heit J A,et al.Prevention of venous thromboembolism:the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy[J].Chest,2004,126(3 Suppl):338S-400S. [20] Haac B E,O'Hara N N,Manson T T,et al.Aspirin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in orthopaedic trauma patients:A patient-centered randomized controlled trial[J].PLoS One,2020,15(8):e0235628. 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[24] Gee E.The National VTE Exemplar Centres Network response to implementation of updated NICE guidance:venous thromboembolism in over 16s:reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism(NG89)[J].Br J Haematol,2019,186(5):792-793. [25] Anderson D R,Morgano G P,Bennett C,et al.American Society of Hematology 2019 guidelines for management of venous thromboembolism:prevention of venous thromboembolism in surgical hospitalized patients[J].Blood Adv,2019,3(23):3898-3944. [26] Muscatelli S R,Charters M A,Hallstrom B R.Time for an Update?A Look at Current Guidelines for Venous Thromboembolism Prophylaxis After Hip and Knee Arthroplasty and Hip Fracture[J].Arthroplast Today,2021,10:105-107. [27] Uzel K,Azboy I,Parvizi J.Venous thromboembolism in orthopedic surgery:Global guidelines[J].Acta Orthop Traumatol Turc,2023,57(5):192-203. [28] Farey J E,An V,Sidhu V,et al.Aspirin versus enoxaparin for the initial prevention of venous thromboembolism following elective arthroplasty of the hip or knee:A systematic review and meta-analysis[J].Orthop Traumatol Surg Res,2021,107(1):102606. [29] Sidhu V S,Kelly T L,Pratt N,et al.CRISTAL(a cluster-randomised,crossover,non-inferiority trial of aspirin compared to low molecular weight heparin for venous thromboembolism prophylaxis in hip or knee arthroplasty,a registry nested study):statistical analysis plan[J].Trials,2021,22(1):564. [30] He T,Han F,Wang J,et al.Efficacy and safety of anticoagulants for postoperative thrombophylaxis in total hip and knee arthroplasty:A PRISMA-compliant Bayesian network meta-analysis[J].PLoS One,2021,16(6):e0250096. [31] Sidhu V S,Naylor J M,Adie S,et al.Is Enoxaparin Associated With a Higher Risk of Persistent Wound Drainage Than Aspirin?A Secondary Analysis of Data From the CRISTAL Randomized Trial[J].Clin Orthop Relat Res,2023,481(7):1351-1359. [32] Sidhu V S,Kelly T L,Pratt N,et al.Effect of Aspirin vs Enoxaparin on 90-Day Mortality in Patients Undergoing Hip or Knee Arthroplasty:A Secondary Analysis of the CRISTAL Cluster Randomized Trial[J].JAMA Netw Open,2023,6(6):e2317838. [33] Meng J,Liu W,Xiao Y,et al.The role of aspirin versus low-molecular-weight heparin for venous thromboembolism prophylaxis after total knee arthroplasty:a meta-analysis of randomized controlled trials[J].Int J Surg,2023,109(11):3648-3655. [34] Migliorini F,Maffulli N,Velaj E,et al.Antithrombotic prophylaxis following total hip arthroplasty:a level I Bayesian network meta-analysis[J].J Orthop Traumatol,2024,25(1):1.[1] Santana D C,Anis H K,Mont M A,et al.What is the Likelihood of Subsequent Arthroplasties after Primary TKA or THA?Data from the Osteoarthritis Initiative[J].Clin Orthop Relat Res,2020,478(1):34-41. [2] Lieberman J R,Bell J A.Venous Thromboembolic Prophylaxis After Total Hip and Knee Arthroplasty[J].J Bone Joint Surg Am,2021,103(16):1556-1564. [3] Jacobs J J,Mont M A,Bozic K J,et al.American Academy of Orthopaedic Surgeons clinical practice guideline on:preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty[J].J Bone Joint Surg Am,2012,94(8):746-747. [4] Panova-Noeva M,Wagner B,Nagler M,et al.Comprehensive platelet phenotyping supports the role of platelets in the pathogenesis of acute venous thromboembolism-results from clinical observation studies[J].EBioMedicine,2020,60:102978. [5] 中华医学会骨科学分会.中国骨科大手术静脉血栓栓塞症预防指南[J].中华骨科杂志,2016(2):65-71. [6] Caprini J A.Risk assessment as a guide to thrombosis prophylaxis[J].Curr Opin Pulm Med,2010,16(5):448-452. [7] Bahl V,Hu H M,Henke P K,et al.A validation study of a retrospective venous thromboembolism risk scoring method[J].Ann Surg,2010,251(2):344-350. [8] Tormene D,Campello E,Simion C,et al.Incidence of VTE in asymptomatic children with deficiencies of antithrombin,protein C,and protein S:a prospective cohort study[J].Blood Adv,2020,4(21):5442-5448. [9] Takemoto C M.Venous thromboembolism in cystic fibrosis[J].Pediatr Pulmonol,2012,47(2):105-112. [10] Hisada Y,Mackman N.Cancer-associated pathways and biomarkers of venous thrombosis[J].Blood,2017,130(13):1499-1506. [11] Heestermans M,Poenou G,Duchez A C,et al.Immunothrombosis and the Role of Platelets in Venous Thromboembolic Diseases[J].Int J Mol Sci,2022,23(21). [12] Ngarmukos S,Kim K I,Wongsak S,et al.Asia-Pacific venous thromboembolism consensus in knee and hip arthroplasty and hip fracture surgery:Part 1.Diagnosis and risk factors[J].Knee Surg Relat Res,2021,33(1):18. [13] Morris G K,Henry A P,Preston B J.Prevention of deep-vein thrombosis by low-dose heparin in patients undergoing total hip replacement[J].Lancet,1974,2(7884):797-800. [14] Anderson D R,Dunbar M,Murnaghan J,et al.Aspirin or Rivaroxaban for VTE Prophylaxis after Hip or Knee Arthroplasty[J].N Engl J Med,2018,378(8):699-707. [15] Sidhu V S,Kelly T L,Pratt N,et al.Effect of Aspirin vs Enoxaparin on Symptomatic Venous Thromboembolism in Patients Undergoing Hip or Knee Arthroplasty:The CRISTAL Randomized Trial[J].JAMA,2022,328(8):719-727. [16] 成杰,丁银亮,王文己,等.阿司匹林预防关节置换血栓栓塞的研究进展[J].中国矫形外科杂志,2023,31(09):810-814. [17] Crescente M,Armstrong P C,Kirkby N S,et al.Profiling the eicosanoid networks that underlie the anti-and pro-thrombotic effects of aspirin[J].FASEB J,2020,34(8):10027-10040. [18] Tormene D,Campello E,Simion C,et al.Incidence of VTE in asymptomatic children with deficiencies of antithrombin,protein C,and protein S:a prospective cohort study[J].Blood Adv,2020,4(21):5442-5448. [19] Geerts W H,Pineo G F,Heit J A,et al.Prevention of venous thromboembolism:the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy[J].Chest,2004,126(3 Suppl):338S-400S. [20] Haac B E,O'Hara N N,Manson T T,et al.Aspirin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in orthopaedic trauma patients:A patient-centered randomized controlled trial[J].PLoS One,2020,15(8):e0235628. [21] Hovik O,Amlie E J,Jenssen K K.No Increased Risk of Venous Thromboembolism in High-Risk Patients Continuing Their Dose of 75 mg Aspirin Compared to Healthier Patients Given Low-Molecular-Weight Heparin[J].J Arthroplasty,2021,36(10):3589-3592. [22] Carrier M,Le Gal G,Cho R,et al.Dose escalation of low molecular weight heparin to manage recurrent venous thromboembolic events despite systemic anticoagulation in cancer patients[J].J Thromb Haemost,2009,7(5):760-765. [23] Falck-Ytter Y,Francis C W,Johanson N A,et al.Prevention of VTE in orthopedic surgery patients:Antithrombotic Therapy and Prevention of Thrombosis,9th ed:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines[J].Chest,2012,141(2 Suppl):e278S-e325S. [24] Gee E.The National VTE Exemplar Centres Network response to implementation of updated NICE guidance:venous thromboembolism in over 16s:reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism(NG89)[J].Br J Haematol,2019,186(5):792-793. [25] Anderson D R,Morgano G P,Bennett C,et al.American Society of Hematology 2019 guidelines for management of venous thromboembolism:prevention of venous thromboembolism in surgical hospitalized patients[J].Blood Adv,2019,3(23):3898-3944. [26] Muscatelli S R,Charters M A,Hallstrom B R.Time for an Update?A Look at Current Guidelines for Venous Thromboembolism Prophylaxis After Hip and Knee Arthroplasty and Hip Fracture[J].Arthroplast Today,2021,10:105-107. [27] Uzel K,Azboy I,Parvizi J.Venous thromboembolism in orthopedic surgery:Global guidelines[J].Acta Orthop Traumatol Turc,2023,57(5):192-203. [28] Farey J E,An V,Sidhu V,et al.Aspirin versus enoxaparin for the initial prevention of venous thromboembolism following elective arthroplasty of the hip or knee:A systematic review and meta-analysis[J].Orthop Traumatol Surg Res,2021,107(1):102606. [29] Sidhu V S,Kelly T L,Pratt N,et al.CRISTAL(a cluster-randomised,crossover,non-inferiority trial of aspirin compared to low molecular weight heparin for venous thromboembolism prophylaxis in hip or knee arthroplasty,a registry nested study):statistical analysis plan[J].Trials,2021,22(1):564. [30] He T,Han F,Wang J,et al.Efficacy and safety of anticoagulants for postoperative thrombophylaxis in total hip and knee arthroplasty:A PRISMA-compliant Bayesian network meta-analysis[J].PLoS One,2021,16(6):e0250096. [31] Sidhu V S,Naylor J M,Adie S,et al.Is Enoxaparin Associated With a Higher Risk of Persistent Wound Drainage Than Aspirin?A Secondary Analysis of Data From the CRISTAL Randomized Trial[J].Clin Orthop Relat Res,2023,481(7):1351-1359. [32] Sidhu V S,Kelly T L,Pratt N,et al.Effect of Aspirin vs Enoxaparin on 90-Day Mortality in Patients Undergoing Hip or Knee Arthroplasty:A Secondary Analysis of the CRISTAL Cluster Randomized Trial[J].JAMA Netw Open,2023,6(6):e2317838. [33] Meng J,Liu W,Xiao Y,et al.The role of aspirin versus low-molecular-weight heparin for venous thromboembolism prophylaxis after total knee arthroplasty:a meta-analysis of randomized controlled trials[J].Int J Surg,2023,109(11):3648-3655. [34] Migliorini F,Maffulli N,Velaj E,et al.Antithrombotic prophylaxis following total hip arthroplasty:a level I Bayesian network meta-analysis[J].J Orthop Traumatol,2024,25(1):1.

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