Non pharmacological

method for prevention

and treatment of DVT
Dr L.M.Darlong. MS,FIAGES,FMAS
North-eastern Indira Gandhi Regional Institute of health
and medical sciences (NEIGRIHMS). Shillong. India
 DVT
• An intravascular deposit composed of fibrin
and red blood cells with a variable platelet
and leucocyte component.

• Occurs in region of slow blood flow

• Pulmonary embolism -fragment of this clot

breaks and migrates to the lung and lodges
in the pulmonary artery or its branch.
– Most severe complication-
 Cause
• Usually not known
• Universally attributed
to Virchows triad

– STASIS
– HYPERCOAGULABI
LITY
– INTIMAL INJURY
 Vascular
Venous Injury
Stasis  Surgical
 Tourniquet manipulation
of the limb
 Immobilization and
bed rest  Endothelial injury

Hypercoagulability
 Increase in thromboplastin
agents
 Natural History of DVT

• Without treatment, approx 20 to 25% of calf

vein thrombi extend into the popliteal and
femoral veins causing proximal DVT.

• Without treatment approximately half of

patients with proximal DVT develop PE

• (Hull, RD, (Hull, RD, Raskob Raskob, GE, Hirsh, J Prophylaxis of venous
thromboembolism : an overview.
• Chest1986;89,374S
 Natural History of
Pulmonary Embolism

• The mortality rate of patients

treated for pulmonary embolism has
decreased from 8% to < 5%.
• The majority of deaths due to PE ( ie
> 90%) occur in pts who are not
treated because the diagnosis is not
made.
 Prevention

• Prevention of pulmonary embolism is

of paramount importance because the
disorder is difficult to detect, and
treatment of established pulmonary
embolism is not universally successful.
 DVT risk stratification for surgery
patients
• Low risk Low
• Uncomplicated surgery in patients aged <40 years with minimal
immobility postoperatively and no risk factors factors
• Moderate risk
• Minor surg in pt with additional risk factor
• Surg in 40-60 yrs with no additional risk factor
• High risk
• Surgery in patients aged >60 years,or 40-60 yrs with additional
risk factor
• Very high risk
• Surgery in patients with multiple risk factor (>40 years,previous
venous thromboembolism,cancer or known hypercoagulable state)
• Major orthopedic surgery ( hip/knee arthroplasty)
• elective neurosurgery
• multiple trauma
• spinal cord injury
What Are We Trying To Prevent?
• Asymptomatic DVT?

• Symptomatic DVT?

• All PE’s?

• Fatal PE’s?

• Post-phlebitic Syndrome?
 Mechanism of action
• Stasis – Nonpharmacologic

• Hypercoagulable – Blood thinning agents

( Pharmacologic agents )

• Intimal injury – Minimal trauma / Tissue

handling ( Non-Pharmacologic )
 Non-Pharmacologic

• Early ambulation remains the most

important nonpharmacologic
 Mechanism
• Augmentation of venous blood flow in the
lower limbs via external mechanical
devices.- Decreases venous stasis.
• Venous compression secondary to external
compression device results in the release
of Plasminogen (Natural fibrinolytic ) and
Nitric oxide ( Vasodilator) into the blood
stream from the endothelial layer of the
vein.
• Inferior vena caval
filter ( IVC filter );
This are mechanical
devices to trap blood
clots arising from the
lower limb and
prevent them from
traveling to the
pulmonary circulation.
Non-Pharmacologic
 Early ambulation
• Should be routine part of all
postop care – Unless absolute
contraindicated

• Acceptable as VTE
prophylaxis for low risk
surgical patients
 Elastic stockings
• Improved venous flow ,reduce vessel wall damage
caused by passive venous dilatation ,during surgery
• Applied preop and continued throughout the
hospital
• Recommended as adjunct in moderate and high risk
case
• Avoid improper fitting stockings
 Intermittent Pneumatic
Compression
-Pneumatic Compression Devices (PCD) VasoPress
-Sequential Compression Devices (SCD) Kendall
• Intermittent regimen that delivers a sustained
pressure in distal to proximal manner.
• The difference-Compartments in PCD devices are
uniformly inflated to the same pressure rather than
in a graded-sequential fashion as in SCD devices.
 IPC
• Intermittently inflates and deflates
bladders contained within the garment (20-
40 mmHg).
• Cycle times vary from manufacturer to
manufacturer.
• Typically, the inflation (compression) cycle
is 10-15 seconds with a 45-50 second
relaxation (rest)
 Intermittent Pneumatic
Compression
• Direct pumping effect- Reduce stasis
• Promotes clearance of local pro thrombo
clotting factor, increase local plasminogen
activators
• Obese individual – Doubtful
• Only effective used continously-nonambulat
• Presumed additive prophylactic effect –
pharmacologic
 IPC
•Intraop and postop IPC is specific localized
prophylaxis:
– Decreased venous stasis
• increase venous velocity
• increase venous volume
– Inhibits coagulation cascade
•  tissue factor pathway inhibitor
•  factor VIIa
•  NO and endogenous
NO synthase
•
• Wide variety of devices
– foot pump
– calf
– thigh-calf
 Not recommended – Sole agent

• High risk – Gen Surgical pt

• High risk – Urology surg pt
• Orthopaedics –Hip or knee surgery

Method of choice when pt at increased risk

of bleeding with anticoagulants

Solo thromboprophylaxis for moderate

to high risk gynae surg
 IVC Filter
Current accepted indications
• Absolute contra to anticoagulant
• Life threatening hemorrhage on
anticoagulant
• Failure of adequate anticoagulation

Prophylactic filter not recommended

It is an invasive procedure
 Recommendation Air Travel
Long distance travel ( >6 h
duration):
.Avoid constrictive clothing
.around lower extremities / waist
.Avoid dehydration
.Do frequent calf muscle
stretching

Additional risk factors

.If active prophylaxis/perceived
increased risk
.Suggest the use of properly
fitted, below-knee GCS,providing
15 to 30 mm Hg of pressure at
the ankle
Non pharmacologic management
of PE
 Catheter extraction or fragmentation
for the initial rx of PE

• Against use of mechanical approaches for

most pts with PE.

• Use selected highly compromised pts who

are unable to receive thrombolytic therapy
or whose critical status does not allow
sufficient time to infuse thrombolytic
therapy
» Mortality of aprox 20-30%
 Pulmonary embolectomy
for the initial treatment of PE
• Pulmonary embolectomy continues to be performed in emergency
situations when more conservative measures have failed.
• If it is attempted the following criteria req:
– 1) massive PE (angiographically documented if possible)
– 2) hemodynamic instability (shock) despite heparin, resuscitative efforts;
– 3) failure of thrombolytic therapy or a contraindication to its use.
• Operative mortality from 10 to 75% in uncontrolled retrospective case
series. (in the era of immediately available cardiopulmonary bypass has )
 Risk Factor-
Short-term (30-day) postoperative
• Other additional factors
• -DVT
• > 50 years • -heart failure
• -Obesity
• Varicose veins • -paralysis,
• Myocardial
infarction • inherited conditions,
• Cancer • -factor V Leiden
• -prothrombin gene
• Atrial fibrillation mutation,
• Ischemic stroke • -protein S deficiency
• -protein C deficiency
• Diabetes mellitus • -antithrombin deficiency.
 Barriers in DVT
• Routinely assess the risk / Asses as risk
factor for heart disease.
• Encourage routine prophylaxis for pt at risk
• Prophylaxis underused – Consensus APHA.
• Lack of awareness of DVT risk
• Percieved diff in risk asses and percieved
risk of bleed with prophylaxis
 ACCP Recommendation

• Primarily in patients who are at high risk of

bleeding
• Adjunct to anticoagulant-based prophylaxis
• Careful attention be directed toward
ensuring the proper use of, and optimal
compliance with, the mechanical device
Thank you