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. 2024 Jan;71(1):55-65.
doi: 10.1007/s12630-023-02639-4. Epub 2023 Dec 15.

Postoperative thrombotic events following major surgery in patients with a history of COVID-19: a retrospective cohort analysis of commercially insured beneficiaries in the USA

Daniel V Lazzareschi  1   2 , Yanting Luo  3   4 , Nicholas Fong  3   5 , John Boscardin  6   7 , Matthieu Legrand  3 , Catherine L Chen  3   4
Affiliations

Postoperative thrombotic events following major surgery in patients with a history of COVID-19: a retrospective cohort analysis of commercially insured beneficiaries in the USA

Daniel V Lazzareschi et al. Can J Anaesth. 2024 Jan.

Abstract
in English, French

Purpose: We sought to evaluate the synergistic risk of postoperative thrombosis in patients with a history of COVID-19 who undergo major surgery. Major surgery and SARS-CoV-2 infection are independently associated with an increased risk of thrombosis, but the magnitude of additional risk beyond surgery conferred by a COVID-19 history on the development of perioperative thrombotic events has not been clearly elucidated in the literature.

Methods: We conducted a retrospective cohort study among commercially insured adults in the USA from March 2020 to June 2021 using the Optum Labs Data Warehouse (OLDW), a longitudinal, real-world data asset containing deidentified administrative claims and electronic health records. We compared patients with prior COVID-19 who underwent surgery with control individuals who underwent surgery without a COVID-19 history and with control individuals who did not undergo surgery with and without a COVID-19 history. We assessed the interaction of surgery and previous COVID-19 on perioperative thrombotic events (venous thromboembolism and major adverse cardiovascular events) within 90 days using multivariable logistic regression and interaction analysis.

Results: Two million and two-hundred thousand eligible patients were identified from the OLDW. Patients in the surgical cohorts were older and more medically complex than nonsurgical population controls. After adjusting for confounders, only surgical exposure-not COVID-19 history-remained associated with perioperative thrombotic events (adjusted odds ratio [aOR], 4.07; 95% confidence interval [CI], 3.81 to 4.36). The multiplicative interaction term (aOR, 1.25; 95% CI, 0.96 to 1.61) and the synergy index (0.76; 95% CI, 0.56 to 1.04) suggest minimal effect modification of prior COVID-19 on surgery with regards to overall thrombotic risk.

Conclusions: We found no evidence of synergistic thrombotic risk from previous COVID-19 in patients who underwent selected major surgery relative to the baseline thrombotic risk from surgery alone.

RéSUMé: OBJECTIF: Nous avons cherché à évaluer le risque synergique de thrombose postopératoire chez les patient·es ayant des antécédents de COVID-19 qui bénéficient d’une intervention chirurgicale majeure. La chirurgie majeure et l’infection par le SRAS-CoV-2 sont indépendamment associées à un risque accru de thrombose, mais l’ampleur du risque supplémentaire d’apparition de complications thrombotiques périopératoires, au-delà de la chirurgie et conféré par des antécédents de COVID-19, n’a pas été clairement élucidée dans la littérature. MéTHODE: Nous avons mené une étude de cohorte rétrospective auprès d’adultes assuré·es commercialement aux États-Unis de mars 2020 à juin 2021 à l’aide de la base de données Optum Labs Data Warehouse (OLDW), un actif de données longitudinales du monde réel contenant des requêtes administratives anonymisées et des dossiers de santé électroniques. Nous avons comparé les patient·es ayant déjà souffert de COVID-19 et ayant bénéficié d’une intervention chirurgicale avec des personnes témoins ayant bénéficié d’une intervention chirurgicale sans antécédents de COVID-19 et avec des personnes témoins n’ayant pas bénéficié de chirurgie, avec et sans antécédents de COVID-19. Nous avons évalué l’interaction de la chirurgie et des antécédents de COVID-19 avec les complications thrombotiques périopératoires (thromboembolie veineuse et événements cardiovasculaires indésirables majeurs) dans les 90 jours à l’aide d’une régression logistique multivariée et d’une analyse des interactions. RéSULTATS: Deux millions deux cent mille personnes admissibles ont été identifiées à partir du registre OLDW. Les patient·es des cohortes chirurgicales étaient plus âgé·es et présentaient une plus grande complexité médicale que les personnes témoins de la population non chirurgicale. Après ajustement pour tenir compte des facteurs de confusion, seule l’exposition chirurgicale – et non les antécédents de COVID-19 – est restée associée aux complications thrombotiques périopératoires (rapport de cotes ajusté [RCa], 4,07; intervalle de confiance [IC] à 95 %, 3,81 à 4,36). Le terme d’interaction multiplicative (RCa, 1,25; IC 95 %, 0,96 à 1,61) et l’indice de synergie (0,76; IC 95 %, 0,56 à 1,04) suggèrent une modification minimale de l’effet d’un diagnostic antérieur de COVID-19 sur la chirurgie en matière de risque thrombotique global. CONCLUSION: Nous n’avons trouvé aucune preuve de risque thrombotique synergique lié à une COVID-19 antérieure chez les patient·es ayant bénéficié d’une intervention chirurgicale par rapport au risque thrombotique de base lié à la chirurgie seule.

Keywords: COVID-19; SARS-CoV-2; perioperative complications; thrombosis.

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Conflict of interest statement

None.

Figures

Fig. 1
Fig. 1
Cohort extraction. This flowchart depicts the stepwise cohort extraction from Optum Labs Data Warehouse. CPT = current procedural terminology; CVA = cerebrovascular accident; Dx = diagnosis; ICD-10 = International Classification of Disease (10th Revision); MI = myocardial infarction
Fig. 2
Fig. 2
Incidence of outcomes. This graph compares the incidence of VTE—including PE and DVT—and MACE—including MI and CVA—across “Surgical / COVID-19 History,” “Surgical / No COVID-19 History,” “Non-Surgical / COVID-19 History,” and “Non-Surgical / No COVID-19 History” groups. CVA = cerebrovascular accident; DVT = deep venous thrombosis; Hx = history; MACE = major adverse cardiovascular events; MI = myocardial infarction; PE = pulmonary embolism; VTE = venous thromboembolism
Fig. 3
Fig. 3
Multivariable logistic regression outcomes. This forest plot depicts the aORs with 95% CIs from multivariable logistic regression for primary and secondary outcomes. The model adjusts for age, sex, race, tobacco use, and geographic region in the USA (West, South, Midwest, or Northeast), as well as for histories of myocardial infarction, cerebrovascular accident, peripheral vascular disease, and/or malignancy. X axis reports aORs along a logarithmic scale. aOR = adjusted odds ratio; CI = confidence interval; MACE = major adverse cardiovascular events; VTE = venous thromboembolism
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