Symptomatic venous thromboembolism after transsphenoidal surgery in Cushing's disease: incidence and risk factors.

in Pituitary by Masaaki Mikamoto, Ye Rim Chang, Hang Lee, Nicholas A Tritos, Lisa B Nachtigall, Brooke Swearingen, Karen K Miller, Pamela S Jones

TLDR

  • Cushing's Disease patients are at higher risk of developing blood clots after surgery, especially within the first week. Identifying high-risk patients and implementing preventative measures may help reduce this risk.
  • Future research is needed to optimize prevention strategies and determine the optimal timing and duration of prophylaxis for CD patients.

Abstract

Cushing's Disease (CD) has been linked to increased venous thromboembolism (VTE) risk. This study investigates the incidence and risk factors of postoperative VTE in patients undergoing transsphenoidal surgery (TSS) for CD. This retrospective study analyzed patients with CD and non-functioning pituitary adenomas (NFPAs) who underwent TSS at Massachusetts General Hospital from 2005 to 2019. The incidence of VTE within 90 days post-TSS was compared between groups, with early VTE defined as occurring within 7 days. VTE diagnosis was confirmed through imaging, including ultrasound and CT, following clinical suspicion. Of six CD patients with symptomatic post-TSS VTE, five developed VTE within one week ("early"), while no NFPA patients experienced early VTE (p = 0.006). Two CD patients presented with pulmonary embolism (PE) on postoperative day (POD) 1 or 2. Two of three with early deep venous thrombosis (DVT) had a history of prior DVT. The overall post-TSS VTE incidence was similar between CD and NFPA patients [6/315 (1.9%) vs. 4/559 (0.7%), p = 0.18]. Patients with CD who developed post-TSS VTE had significantly higher rates of prior history of VTE (p = 0.003) and hypertension (p = 0.038) and larger tumor sizes (p = 0.045) compared to those without post-TSS VTE on univariate analysis. CD patients are at higher risk for early post-TSS VTE, including symptomatic PE. Identifying high-risk patients and implementing perioperative prophylaxis in the immediate postoperative period may help mitigate these complications. Further research is needed to optimize prevention strategies in this population.

Overview

  • This study investigates the incidence and risk factors of postoperative venous thromboembolism (VTE) in patients with Cushing's Disease (CD) undergoing transsphenoidal surgery (TSS).
  • The study analyzed patients with CD and non-functioning pituitary adenomas (NFPAs) who underwent TSS at Massachusetts General Hospital from 2005 to 2019.
  • The primary objective is to identify high-risk patients and implement perioperative prophylaxis to mitigate postoperative VTE complications.

Comparative Analysis & Findings

  • The incidence of VTE within 90 days post-TSS was similar between CD and NFPA patients (1.9% vs. 0.7%), but CD patients were at higher risk for early post-TSS VTE (5.6% vs. 0%).
  • Most VTE events in CD patients (83.3%) occurred within one week of surgery, while none of the NFPA patients experienced early VTE.
  • Prior history of VTE, hypertension, and larger tumor sizes were significant risk factors for post-TSS VTE in CD patients.

Implications and Future Directions

  • Identifying high-risk patients and implementing perioperative prophylaxis may help mitigate postoperative VTE complications in CD patients.
  • Further research is needed to optimize prevention strategies in this population, considering individual risk factors and tailored prophylaxis.
  • Future studies should aim to determine the optimal timing and duration of prophylaxis to effectively reduce VTE risk in CD patients undergoing TSS.
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