We identified 3 studies273-275  in this review that fulfilled our inclusion criteria and measured outcomes relevant to this context. We rated the overall certainty in the evidence of effects as very low based on the lowest certainty in the evidence for the critical outcomes and downgrading for study limitations, indirectness, and imprecision. This corresponds to 20 more (1-58 more) or 31 more (2-92 more) per 1000 patients, based on baseline risks of 1.6% and 2.6%, respectively, from observational data.73  We are also uncertain whether rates of symptomatic distal DVT are increased (RR, 2.72; 95% CI, 1.41-5.21; very low certainty in the evidence of effects), corresponding to 2 more (1-6 more) to 4 more (1-9 more) per 1000 patients, based on baseline risks of 0.1% and 0.2%, respectively, from observational data.73. Pharmacological prophylaxis probably reduces mortality slightly following major gynecological surgery (RR, 0.75; 95% CI, 0.61-0.93; low certainty in the evidence of effects). The guideline panel judged that the net benefit favors no pharmacological prophylaxis for patients undergoing radical prostatectomy, based on very low certainty in the evidence of effects. In these settings, estimates of the benefits of prophylaxis were based upon related surgical settings, such as general surgical procedures and hip fracture surgery, respectively. For patients undergoing surgery, the ASH guideline panel suggests using any of the DOACs approved for use (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯). For determining baseline risk of VTEs and major bleeding, we used data, where available, from contemporary large cohort studies that were deemed representative of contemporary patients. There were no relevant adverse events deemed critical for this comparison. Given the lack of direct comparative evidence, the panel identified an important need for high-quality head-to-head studies comparing different DOACs for the prevention of VTEs following total hip or knee arthroplasty. When anticoagulants are used, the panel suggests using direct oral anticoagulants (DOACs) over low-molecular-weight heparin (LMWH) (conditional recommendation based on moderate certainty in the evidence of effects ⊕⊕⊕◯); the panel suggests using any of the DOACs approved for use (conditional recommendation based on low certainty in the evidence of effects ⊕⊕◯◯). Question: Should combined pharmacological and mechanical prophylaxis vs pharmacological prophylaxis alone be used for patients undergoing major surgery? There were no relevant adverse events deemed critical for this comparison. Monthly search alerts were created and monitored to capture relevant new studies up to 1 July 2019, prior to submission of the manuscript for publication. The panel also recognized that mechanical methods of thromboprophylaxis are commonly used in this patient population. Based on these considerations, it was concluded that, in cardiac patients at usual risk for VTE, the harms of anticoagulant prophylaxis outweighed the benefits, whereas anticoagulation may be of net benefit for patients with high-risk characteristics. The panel acknowledges that the overall certainty in the evidence was very low given the issue of indirectness, with most of the available trial data not being specific to gynecological procedures. Formal decision aids are not likely to be needed to help individual patients make decisions consistent with their values and preferences. SIGN publication No. What are others saying and what is new in these ASH guidelines? The panel presumed that, in the absence of specific contraindications (eg, lower limb injuries), patients experiencing major trauma would receive mechanical prophylaxis. Decision aids may be useful in helping patients to make decisions consistent with their individual risks, values, and preferences. The panel did not consider potential harms of IVC filters beyond VTE. These studies should include detailed clinical characteristics of the patient populations. To diagnose deep vein thrombosis, your doctor will ask you about your symptoms. Both patient representatives participated in question prioritization, and 1 participated in all remaining steps of the development process. Draft recommendations were reviewed by all members of the panel, revised, and then made available online on 22 June 2018 for external review by stakeholders, including allied organizations, other medical professionals, patients, and the public. Question: Should pharmacological prophylaxis vs no pharmacological prophylaxis be used for patients undergoing major general surgery? 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