Prevention of venous thromboembolic disease after total hip and knee arthroplasty

Patients undergoing total hip and knee arthroplasty are at increased risk for the development of venous thromboembolic disease, and there is general agreement that these patients require prophylaxis. The selection of a prophylactic agent involves a balance between efficacy and safety and often needs to be individualized for specific patients and institutions. Despite extensive research, the ideal agent for prophylaxis against deep venous thrombosis has not been identified. The results of randomized trials indicate that low-molecular-weight heparin, warfarin, and fondaparinux are the most effective prophylactic agents after total hip arthroplasty and that low-molecular-weight heparin, warfarin, fondaparinux, and pneumatic compression boots are the most effective agents after total knee arthroplasty. The duration of prophylaxis against deep venous thrombosis after total hip and knee arthroplasty remains controversial. Prophylaxis should be continued beyond hospital discharge. In the future, the determination of the duration of prophylaxis will be based on the risk stratification of individual patients. The practice of discharging patients from the hospital without prophylaxis, even when the decision is based on negative results of procedures that screen for the presence of deep venous thrombosis, is not cost-effective.     

The importance of forseeing and early diagnosis of thromboembolic disease

The aim of this study is to assess the incidence of thromboembolism in laparoscopic cholecystectomies. 100 unselected patients undergoing laparoscopic procedures performed by the same team were studied. All patients received preoperative prophylaxis with low/molecular weight heparin (LMWH), which was continued until full mobility. Four cases of deep venous thrombosis of lower limbs were clinically identified and confirmed by means of Doppler ultrasound examination. There were no cases of pulmonary embolus. Deep venous thrombosis occurred during the prophylactic administration of LMWH in the fourth postoperative day, consequently intravenous treatment with Heparin and then with oral anticoagulants was required. In each observation the operation took more than one hour. Among the patient-dependent risk factors, we have identified: age above 40 years, obesity, history of deep venous thrombosis, localized preoperative infection, congestive cardiac failure. Although the thromboprophylaxis has been performed within the laparoscopic surgery similar to that recommended in the classical procedures, when a high risk has developed the illness started. We underline the importance of a careful postoperative clinical monitoring in order to prevent the serious accidents that may appear.     

Color Doppler Flow Imaging For Deep Venous Thrombosis Screening in Patients Undergoing Pelvic Lymphadenectomy and Radical Retropubic Prostatectomy for Prostatic Carcinoma

Patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy are traditionally considered to be at high risk for postoperative venous thromboembolic complications. A prospective deep venous thrombosis screening regimen was initiated at our medical center in 1990 following 2 cases of fatal pulmonary embolism that occurred after hospital discharge. During a 3-year period 245 consecutive patients undergoing radical retropubic prostatectomy for prostate cancer were screened postoperatively for lower extremity deep venous thrombosis using ultrasound duplex scanning with color Doppler flow imaging. The results were correlated only with the development of clinical deep venous thrombosis. No additional diagnostic modalities were used to confirm a normal venous system in asymptomatic patients.

Venous thromboembolic complications were encountered in 9 of the 245 patients (3.6 percent). In 2 patients deep venous thrombosis was associated with nonfatal pulmonary embolism. Only 2 of the 9 cases of deep venous thrombosis were detected by color Doppler flow imaging screening. The striking decrease in the incidence of deep venous thrombosis following radical prostatectomy in the last decade and the low yield of screening at a single point in time may warrant reconsideration of the need for deep venous thrombosis screening among patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy for prostate cancer.     

Factor V Leiden and Postoperative Deep Vein Thrombosis in Patients Undergoing Open Roux-en-Y Gastric Bypass Surgery

Background: Patients undergoing bariatric surgery are at risk for deep venous thrombosis (DVT) and fatal pulmonary embolus. In the presence of genetic hypercoagulable disorders, accepted methods of DVT prophylaxis utilizing sequential compression devices and subcutaneous unfractionated heparin may not be adequate to prevent DVT or fatal PE. Methods and Results: 3 morbidly obese patients are described who underwent open Roux-en-y gastric bypass and either had a previous diagnosis of Factor V Leiden or developed thrombosis in the presence of standard prophylaxis. Each was found to have the most common point mutation for Factor V Leiden, R506Q. All 3 patients had prophylactic inferior vena caval filters placed to prevent recurrent PE. Conclusion: The presence of venous thromboembolism either without known risk factors or in the presence of standard perioperative prophylaxis for DVT should warrant a hypercoagulable work-up. Inferior vena caval filter placement is indicated in the presence of a hypercoagulable disorder prior to surgical intervention in the morbidly obese population. The recent literature is reviewed.     

Physikalische Thromboseprophylaxe mit motorisierten Sprunggelenkbewegungsschienen

Between 1993 and 1994 the value of the “Artroflow” device in deep venous thrombosis was tested in 95 trauma surgical high risk patients. Parallel to the application of Heparin and physical methods, the “Artroflow” device was employed. The test and compare group showed an equal amount of risk parameters and comparable injuries. In all patients until full mobilization a weekly clinical examination, a compression sonography of the deep leg veins and a venous Doppler examination was performed. In the test group 1 deep venous thrombosis (2.3%) and no clinically manifest lung embolism occurred. In the control group, the deep venous thrombosis rate was 21.6%. This showed a highly significant drop of the deep venous thrombosis rate in trauma surgical patients (p<0.0041 Fisher test) and allows us to suggest the use of the “Artroflow” device in high risk patients parallel to heparin prophylaxis.     

Current assessment of thromboembolic disease and pregnancy.

This study was undertaken to assess incidence of deep venous thrombosis and pulmonary emboli in an inner-city pregnant population. Thromboembolic disease is believed to occur in 0.05 to 0.1 per cent of all pregnancies. Historically, postpartum thromboembolic disease was more common; decreased hospital stay may shift the thromboembolic disease to the antepartum period. A 5-year retrospective review of 4910 births assessed for incidence of thromboembolic disease, methods of diagnosis and treatment, and risk factors. A total of 4910 deliveries with 3978 transvaginal resulted in 30 episodes of deep venous thrombosis and five pulmonary emboli. All incidences of deep venous thrombosis but one were left-sided; four of five pulmonary emboli were postpartum. Of the epidsodes of deep venous thrombosis 17 per cent were first trimester, 50 per cent second trimester, 27 per cent third trimester, and 6 per cent postpartum. The diagnosis was confirmed by duplex scan in 24 of 30 patients. Heparin was the standard treatment. Deep venous thrombosis in pregnancy is most common in the second trimester; pulmonary emboli remain most common postpartum.     

Inferior vena cava filters prevent pulmonary emboli in patients with metastatic pathologic fractures of the lower extremity

The records of 47 consecutive patients with metastatic pathologic fractures of the lower extremity were analyzed with respect to thromboembolic complications. All patients were unable to receive pharmacologic deep venous thrombosis prophylaxis, and were stratified into two groups, based on use of an inferior vena cava filter. Group I (n = 24) consisted of patients who had an inferior vena cava filter plus mechanical deep venous thrombosis prophylaxis (compression stockings and sequential compression boots); Group II (n = 23) consisted of a group of patients receiving only mechanical deep venous thrombosis prophylaxis. All patients had routine lower extremity venous duplex imaging preoperatively, postoperatively, and before hospital discharge. At final followup, patients were examined for deep venous thrombosis and reviewed for thromboembolic events. At a mean followup of 11.5 months, Group I had two detectable deep venous thromboses and no pulmonary emboli; Group II had one detectable deep venous thrombosis and five pulmonary embolisms. In Group II, 40% (two of five) of pulmonary embolisms were fatal, yielding an 8.7% (two of 23) group mortality rate. Overall, the entire group had an approximately 17% deep venous thrombosis rate. Only 6.4% (three of 47) of deep venous thromboses were detectable by standard duplex imaging. The majority of deep venous thromboses (five of eight, 62.5%) were nondetectable by duplex imaging. Overall, a 4.3% (two of 47) death rate was attributable to pulmonary embolism. In contrast, an 8.6% (four of 47) mortality rate occurred in Group II alone. All pulmonary embolisms occurred in patients who did not receive an inferior vena cava filter. The majority of venous thromboses (62.5%) were not detectable on duplex scanning, therefore were thought to arise from the pelvic venous system. Complications related to inferior vena cava filter insertion were minimal. For patients with metastatic pathologic fractures of the lower extremities who are unable to receive pharmacologic deep venous thrombosis prophylaxis, the use of inferior vena cava filters, in conjunction with standard mechanical deep venous thrombosis prophylaxis, is a procedure that has a low risk and is useful adjunct to prevent fatal pulmonary embolisms.     

Venous thromboembolic disease after hybrid hip arthroplasty with negative duplex screening

Postoperative duplex ultrasonography screening after total hip arthroplasty has been shown to identify patients who may require treatment or additional monitoring for venous thromboembolic disease. The potential for manifestation of venous thromboembolic disease subsequent to screening remains a concern. The objective of this study was to determine the prevalence of symptomatic venous thromboembolic disease after total hip arthroplasty and after inhospital prophylaxis, inhospital screening with negative results for proximal deep venous thrombosis, and no posthospitalization venous thromboembolic disease prophylaxis. One hundred fifty patients undergoing primary hybrid total hip arthroplasty and using pneumatic compression stockings and aspirin as prophylaxis against venous thromboembolic disease were screened for deep venous thrombosis with duplex ultrasonography on the fourth day after surgery. Duplex ultrasonography screening revealed 17 (11.3%) patients with asymptomatic proximal deep venous thrombosis. In response to duplex ultrasonography screening, these patients with proximal deep venous thrombosis received therapeutic anticoagulation. Of 133 patients with a duplex screen with negative results for proximal deep venous thrombosis, 131 (98.5%) continued to have no symptoms of venous thromboembolic disease and two (1.5%) began to have symptoms for venous thromboembolic disease (one with proximal deep venous thrombosis, one with nonfatal pulmonary embolism) during 12 months of clinical followup after total hip arthroplasty. The overall prevalence of venous thromboembolic disease requiring anticoagulation was 19 of 150 (12.6%) patients. The remaining 131 (87.4%) were not exposed to the risks of postoperative anticoagulation and did not have subsequent symptomatic venous thromboembolic disease.     

Thrombotic complications in children from short‐term percutaneous central venous catheters: What can we do?

The reported incidence of venous thromboembolism (VTE) in children has increased dramatically over the past decade, and the primary risk factor for VTE in neonates and infants is the presence of a central venous catheter (CVC). Although the associated morbidity and mortality are significant, very few trials have been conducted in children to guide clinicians in the prophylaxis, diagnosis, and treatment of CVC‐related VTE. Furthermore, pediatric guidelines for prophylaxis and management of VTE are largely extrapolated from adult data. How then should the anesthesiologist approach central access in children of different ages to lessen the risk of CVC‐related VTE or in children with prior thrombosis and vessel occlusion? A comprehensive review of the pediatric and adult literature is presented with the goal of assisting anesthesiologists with point‐of‐care decision‐making regarding the risk factors, diagnosis, and treatment of CVC‐related VTE. Illustrative cases are also provided to highlight decision‐making in varying situations. The only risk factor strongly associated with CVC‐related VTE formation in children is the duration of the indwelling CVC. Several other factors show a trend toward altering the incidence of CVC‐related VTE formation and may be under the control of the anesthesiologist placing and managing the catheter. In particular, because children with VTE may live decades with its sequelae and chronic vein thrombosis, careful consideration of lessening the risk of VTE is warranted in every child. Further studies are needed to form a clearer understanding of the risk factors, prophylaxis, and management of CVC‐related VTE in children and to guide the anesthesiologist in lessening the risk of VTE.     

Nonpharmacologic thromboembolic prophylaxis in total knee arthroplasty.

Deep venous thrombosis is the most common complication in patients having elective total knee replacement. Pneumatic compression devices play an important role in the prophylaxis of deep venous thrombosis and effectively decrease the risk of distal deep venous thrombosis. The combination therapy with pharmacologic agents has the benefit of decreasing the rate of proximal deep venous thrombosis and therefore is recommended. In the absence of clinical data, recent in vivo flow studies suggest that calf or combined foot and calf compression are superior to foot compression alone. Epidural anesthesia in comparison with general anesthesia decreases the incidence of thromboembolic disease after total knee arthroplasty. Although hypotensive anesthesia and intraoperative heparin have been proven to substantially lower the incidence of deep venous thrombosis after total hip arthroplasty, the current literature does not support its application during the implantation of a total knee replacement. Pneumatic compression devices are an important part of deep venous thrombosis prophylaxis especially in the early postoperative period considering that pharmacologic anticoagulation is contraindicated in the first 12 hours after spinal anesthesia and in the presence of an epidural line.     

Acute Deep Venous Thrombosis and Pulmonary Embolism in Foot and Ankle Trauma in the National Trauma Data Bank: An Update and Reanalysis

The data regarding rates of deep venous thrombosis and pulmonary embolism after foot and ankle trauma remain sparse. In this study of the National Trauma Data Bank Data set (2007–2009 and 2010–2016), these rates were reexamined and risk factors associated with these complications were assessed. Data quality is improved in the later data set; the incidence of deep venous thrombosis and pulmonary embolism was 0.28% and 0.21%, respectively, in the 2010–2016 data. Prophylaxis, male gender, treatment in a university hospital, open reduction, chronic obstructive pulmonary disease, and hypertension were notable significant risk factors for pulmonary embolism. For deep venous thrombosis, male gender, bleeding disorder, angina, and prophylaxis were risk factors. Careful, individualized assessment of the risk factors associated with deep venous thrombosis and pulmonary embolism is important, and the merits of routine prophylaxis remain in question.     

Postoperative dural sinus thrombosis in a patient in a hypercoagulable state. Case report

Spontaneous cerebral venous sinus thrombosis is a rare problem that may be encountered in patients with underlying thrombophilic disorders. It has also been reported as a postoperative complication following suboccipital, transpetrosal, and transcallosal approaches. The authors report on a 67-year-old man with two prior episodes of lower-extremity deep venous thrombosis who underwent transcallosal resection of a colloid cyst and in whom sagittal sinus thrombosis developed 2 weeks thereafter. Results of a subsequent hematological workup revealed both a factor V Leiden mutation and the presence of antiphospholipid antibodies, two thrombophilic risk factors that likely contributed to the development of delayed postoperative sinus thrombosis. Although the safety of low-molecular-weight heparin (LMWH) after craniotomy has not been established in a randomized, controlled study, there is sufficient evidence to justify its use for prophylactic anticoagulation therapy in patients at high risk for postoperative cerebral venous thrombosis. The authors propose using LMWH prophylaxis in patients with thrombophilic disorders who undergo neurosurgical procedures in proximity to dural sinuses in an effort to prevent catastrophic venous infarction.     

Deep vein thrombosis and malignancy: a surgical oncologist's perspective

Oncology patients are at increased risk of developing deep vein thrombosis (DVT) and its potentially fatal sequel, pulmonary embolism. This is due to multiple factors, including the presence of the malignancy itself, comorbid factors and therapy-related interventions. Issues that are peculiar to venous thrombosis in the oncology setting are discussed, based on a MEDLINE search of the English literature. These include the need to screen for malignancy in idiopathic DVT, a high index of suspicion for venous thrombosis in the cancer patient, the use of vena cava filters, and the anti-neoplastic effects of heparin. Asian patients appear to have a lower incidence of DVT compared to Caucasians. A recommended regimen for prophylaxis of DVT must take into account the varying thrombosis risk associated with different malignancies. Cancer patients not undergoing abdominal, pelvic or orthopaedic surgery (e.g. mastectomy) should use elastic compression stockings and be mobilized early, whereas low-molecular-weight heparin should be given to those undergoing more major surgery. In advanced malignancy, treatment of DVT palliates symptoms. These patients may need long-term anticoagulation with warfarin.     

Deep venous thrombosis in the surgical intensive care unit

The ICU patient population is at a high risk for the development of deep venous thrombosis leading to a potentially fatal pulmonary embolism. It is vital to appreciate this risk and apply appropriate prophylaxis. Constant vigilance is required, as deep venous thrombosis and pulmonary emboli can develop and progress despite standard prophylactic measures. In unstable patients, more aggressive prophylaxis may be warranted, including the use of inferior vena cava filters. A high index of suspicion and a low threshold for screening and diagnostic testing will allow earlier recognition and treatment of this lifethreatening condition. Treatment decisions are based on clinical suspicion, diagnostic examination results, and the potential complications of difficult treatment modalities.     

Deep venous thrombosis associated with osteomyelitis in children

BACKGROUND: The association of deep venous thrombosis and deep musculoskeletal infection in children has been reported infrequently. The purpose of the present study was to evaluate the characteristics of children with osteomyelitis in whom deep venous thrombosis developed and to compare them with those of children with osteomyelitis in whom deep venous thrombosis did not develop. METHODS: A retrospective review of the records of children who were managed at our institution because of a deep musculoskeletal infection between January 2002 and December 2004 identified 212 children with osteomyelitis involving the spine, pelvis, or extremities. Children in whom deep venous thrombosis developed were compared with those in whom it did not develop with respect to age, diagnosis, causative organism, duration of symptoms prior to admission, laboratory values at the time of admission, surgical procedures, and required length of hospitalization. RESULTS: Eleven children with osteomyelitis and deep venous thrombosis were identified. The mean C-reactive protein level was 16.9 mg/dL for the group of eleven patients with osteomyelitis in whom deep venous thrombosis developed, compared with only 6.8 mg/dL for the group of 201 patients with osteomyelitis in whom deep venous thrombosis did not develop (p=0.0044). Staphylococcus aureus was the causative organism of infection in all eleven children with deep venous thrombosis and in ninety-three (46%) of the 201 children without deep venous thrombosis. Methicillin-resistant strains of Staphylococcus aureus were identified in eight of the eleven children with deep venous thrombosis and in only forty-nine of the 201 children without deep venous thrombosis. The children with osteomyelitis and deep venous thrombosis were older, had a longer duration of hospitalization, had more admissions to the intensive care unit, and required more surgical procedures than those with osteomyelitis but without deep venous thrombosis. CONCLUSIONS: Deep venous thrombosis in association with musculoskeletal infection is more common in children over the age of eight years who have osteomyelitis caused by methicillin-resistant Staphylococcus aureus and who present with a C-reactive protein level of >6 mg/dL. Diagnostic venous imaging studies should be performed to assess for the presence of deep venous thrombosis in children with osteomyelitis, especially those who have these risk factors.     

Thromboembolic disease in the patient undergoing urologic surgery

There is no question that a substantial risk of venous thrombosis, pulmonary embolism, and lethal pulmonary embolism exist among patients undergoing urologic surgery. Available prophylactic strategies should sharply reduce this risk. Acceptable treatment options exist for patients who develop thromboembolism despite, or in the absence of, prophylaxis. Accurate diagnosis, however, is essential in order to select the most appropriate option. Finally, it should be noted that in making judgments, the comments provided can offer only general guidelines for patients undergoing urologic surgery. Individual patients may have a particular constellation of circumstances that dictates a rational deviation in decision-making from these general guidelines. However, one pivotal decision from which there should be not deviation without extraordinarily special justification is that some form of prophylaxis for deep venous thrombosis should be offered to all patients undergoing major urologic surgical procedures.     

Developments in diagnosis and classification of venous disorders: non-invasive diagnosis.

PURPOSE: This review examines the many techniques that have been used for the non-invasive diagnosis of acute and chronic venous disease and was conducted by members of the Committee on Research of the American Venous Forum. It proposes to identify those techniques with the greatest clinical potential, to suggest algorithms for the clinical application of non-invasive techniques in the identification of acute deep venous thrombosis and chronic venous insufficiency, and to identify areas of deficient knowledge and potential areas for future research initiatives. METHODS: Review of pertinent clinical and research material. RESULTS: Impedance plethysmography and ultrasonic imaging are the primary non-invasive tools used in the diagnosis of acute deep venous thrombosis. At present, ultrasonic imaging techniques are recommended on the basis of greater diagnostic accuracy in recent comparative clinical trials. Data would suggest that serial evaluation should probably be viewed as the preferred option for symptomatic patients with a negative initial examination and the presence of risk factors or physical findings suggesting a proximal deep venous obstruction/thrombosis. Chronic venous disease is the result of valvular incompetence, with or without associated venous obstruction. Duplex imaging can be used to determine the location and extent of reflux; however, there are reported procedural variations in the performance and interpretation of such studies. Recent innovations in air plethysmography may provide a means of quantifying volume changes, and permit an objective characterization of venous reflux and calf pump efficiency. CONCLUSIONS: There are still significant questions that need to be answered by well-designed research initiatives. Research applications that incorporate non-invasive diagnostic techniques may involve the diagnosis, treatment and natural history of acute deep venous obstruction/thrombosis and chronic venous insufficiency, assessment prior to and following venous reconstruction, and the basic science aspects of acute and chronic venous disease. At present, a lack of common standards is, by far, the greatest impediment to an organized research approach to venous disease.     

Incidence and distribution of lower extremity deep vein thrombosis in rehabilitation patients: implications for screening

Patients admitted to in-patient rehabilitation programs have an increased risk for developing deep venous thrombosis (DVT). However, the utility of screening for lower extremity DVT using duplex ultrasound in this high-risk population is not well characterized. The purpose of this study is to identify whether or not screening lower-extremity duplex exams are indicated in this high-risk population. Screening lower extremity duplex exams were performed on all patients admitted to the rehabilitation center at Mt. Sinai Hospital over a 3-year period. Charts were reviewed for patient age, gender, diagnosis, date of screening and follow-up duplex exams, presence and location of venous thrombosis at each duplex exam, history of anticoagulation, and medical DVT prophylaxis. The presence of DVT at screening, the location of DVT along the lower extremity, and the outcome of calf DVT were analyzed in terms of gender, underlying diagnosis, and history of DVT prophylaxis. Lower extremity DVT was detected in 34% of patients. Twenty-three percent of patients had isolated calf vein thrombosis. Men were more likely than women to have DVT. Calf DVTs progressed in 3% of patients over an average follow-up of 2 weeks. The presence of DVT, its location along the lower extremity, and the outcome of calf vein DVT had no significant relationship to underlying diagnosis or history of prophylaxis. Screening duplex exams to detect lower extremity DVT in rehabilitation patients is useful. Screening altered management in 26% of patients, prompting either anticoagulation or repeat duplex exam.     

Extended prophylaxis of venous thromboembolism in major orthopaedic surgery

The risk of postoperative venous thromboembolism continues after discharge from the hospital. Studies in patients undergoing hip replacement or hip fracture surgery consistently found the rate of asymptomatic deep vein thrombosis to be substantially reduced by extended out-of-hospital prophylaxis and meta-analyses demonstrate symptomatic deep vein thrombosis to be reduced in parallel with asymptomatic. On the basis of these data, extended prophylaxis is recommended in hip replacement and hip fractures. The recommendation is particularly strong for patients with additional personal risk factors.     

Prospective randomized trial of warfarin and intermittent pneumatic leg compression as prophylaxis for postoperative deep venous thrombosis in major urological surgery.

Postoperative deep venous thrombosis and pulmonary embolus remain a major source of morbidity and mortality for the urological surgery patient. We report the results of the first 100 patients in a prospective, randomized trial of low dose warfarin and intermittent pneumatic leg compression for deep venous thrombosis prophylaxis. All patients underwent preoperative and postoperative real-time ultrasound imaging and Doppler flow studies of the popliteal, femoral and iliac veins for the evaluation of deep venous thrombosis. Our results indicate that low dose warfarin is as effective as intermittent pneumatic leg compression for prophylaxis of deep venous thrombosis. Low dose warfarin can be used effectively without any significant bleeding complications. We recommend the use of low dose warfarin as an alternative to intermittent pneumatic leg compression for deep venous thrombosis prophylaxis of the urological patient undergoing a major urological operation.