Background

Patients with hematologic malignancy who undergo treatment become thrombocytopenic, and thromboprophylaxis (VTE ppx) is often omitted for concerns of added bleeding risk. This approach leaves patients with high risk of clotting at a precarious state of addressing thromboembolism (VTE) during thrombocytopenia especially during hematopoietic stem cell transplant (HSCT).

We reported the use of VTE ppx in multiple myeloma (MM) patients during autologous HSCT (autoHSCT) where longer duration of VTE ppx was associated with VTE prevention and enoxaparin (LMWH) was superior to heparin (UFH). This study evaluates thrombotic and hemorrhagic events (HE) in lymphoma patients undergoing autoHSCT based on the receipt of VTE ppx then compared to MM patients.

Methods

This is a retrospective, single-center study comparing the rate of thrombotic and hemorrhagic events (HE) within 30 days of autoHSCT based on the use of VTE ppx. Data were obtained from the registry of Cedars Sinai Medical Center (CSMC). This study aimed to assess the safety and efficacy of VTE ppx, risk factors for bleeding or clotting, and factors contributing to the receipt of VTE ppx in autoHSCT.

Patients were adults > 18 years-old with lymphoma or MM admitted for autoHSCT at CSMC between July 2016 and July 2024.  Patients' age, sex, ethnicity, Body Mass Index (BMI), smoking history, antiplatelet and prothrombotic medication history within 6 months prior or 30-days after HSCT, VTE history, Karnofsky Performance Scale (KPS), Hematopoietic Cell Transplantation-specific Comorbidity Index (HCT-CI), and type and duration of VTE ppx were collected.  All received a peripherally inserted central catheter (PICC).  

Results

A total of 577 patients were included and 410 patients (81%) had MM and 167 patients (19%) had lymphoma. Within lymphoma, 127 patients had non-hodgkin lymphoma (NHL) and 40 patients had hodgkin lymphoma (HL). 370 of 577 patients (64%) received VTE ppx for an average of 7.6 days. Patients were more likely to receive VTE ppx with diagnosis of MM (p < 0.0001), older age (p = 0.04), prior use of antiplatelet (p = 0.0003), and higher KPS > 80 (p = 0.0003).  

Three of 577 patients (0.5 %) died within 30 days post HSCT. All three patients developed VTE. One patient received VTE ppx and had a HE 9 days after its discontinuation. Two deaths were related to VTE. 

Forty two of 577 patients (7.3%) had HE by 30 days post HSCT. Two patients developed major HE (major vs minor, 4.8 % vs 95.2 %). The median platelet level during HE was 31,000/ mcL (range 2,000 - 219,000). Of the 42 patients with HE, 29 patients received VTE ppx. But HE occurred on average 7.4 days from last VTE ppx dose. Lymphoma had a higher risk of bleeding (p < 0.0001). HE occurred in 16 of 410 MM patients (3.9%), 26 of 167 lymphoma patients (15.6%). Type of lymphoma did not predict HE. VTE ppx receipt was not associated with HE (p = 0.49). Duration and type of VTE ppx was not associated with HE.

Thirty seven of 577 patients (7.3 %) developed a VTE at a median time of 10.9 days (range –4 – 30 days) post-HSCT. The median platelet count during VTE was 42,000/mcL (range 6,000 –243,000). Among 37 patients with VTE, 17 patients (45.9 %) did not receive VTE ppx. 29 of 37 VTE (78.3%) were PICC-associated VTE. Other VTEs were splenic artery thrombosis, subclavian vein thrombosis (non-PICC arm), cardiac allograft thrombosis, lower extremity DVT, and atrial thrombosis. No clinical factors were associated with the risk of thrombotic events. Each additional day of VTE ppx was associated with decreased risk of VTE (p = 0.01) but not HE (p = 0.89). Receiving LMWH over UFH reduced risk of VTE (p = 0.0221). VTE occurred in 24 of 410 MM patients (5.9%) and 13 of 167 lymphoma patients (7.8%). Type of lymphoma did not predicte VTE.

Conclusion

In this single center retrospective study, we evaluated the safety and efficacy of VTE ppx in MM and lymphoma patients undergoing autoHSCT. Lymphoma patients were more likely to have HE unrelated to VTE ppx and regardless of cancer type. VTE ppx did not increase HE. LMWH was superior to heparin and duration of VTE ppx reduced risk of VTE. 

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2025
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