Venous Thromboembolism

Dr Shankar Thapa
Ortho resident
NAMS
• One of the commonest complication of lower
limb surgeries
• Comprises of three associated disorders
– Deep vein thrombosis
– Pulmonary embolism
– Chronic venous insuffiency
1 in 30-40 patients develop symptomatic
thromboembolic complication despite
prophylaxis
 Risk factors
• Increasing age
• Obesity
• Prolonged immobility
• Malignancy
• Personal or family history of thromboembolic phenomena
• Pelvic fracture , spinal cord injury with paralysis, head injuries
• Ventilator days >3days
• Major surgical procedures Immobilization Surgery within the
last 3 months
• Malignancy
• Preexisting respiratory disease
• Chronic Heart Disease
• Age >60 Surgery requiring >30mins of anesthesia
• Behçet’s disease
• Varicose veins
• Superficial vein thrombosis
• Central venous catheter/port/pacemaker Additional risk factors in
women:
• Obesity BMI ≥ 29
• Heavy smoking (>25cigs/day)
• Hypertension
• Pregnancy
• OCP’s
 Pathophysiology
• Result of clot formation in venous circulation
• Develop as a result of three primary
components known as virchow’s triad
– Venous stasis
– Vascular injury
– Hypercoagulability
• All of these occur in major orthopedic
operations
• Soft tissue exposure , bone cutting and reaming induce
a systematic hypercoagulable state and fibrinolytic
inhibition
• Blood flow in femoral vein is obstructed by torsion
needed to expose the femoral canal and acetabulum in
hip replacementsdamages the endothelium
• venous obstruction concentration of clotting factors
• In knee replacements , anterior subluxation of tibia
and vibration from the saw local endothelial damage
• Relative immobility following surgery venous stasis
• The thrombus usually originates in the soleal venous
sinuses or valvular sinuses
• the calf vein is the most frequent site.
• Other sites-
• iliac or femoral vein (thigh and pelvic veins)
• the renal veins, upper limb veins, the right side of the
heart
• Larger and more proximal thrombi that fragments
sometimes get carried to the lungs pulmonary
embolism and in small cases fatal pulmonary embolism
 signs and Symptoms of DVT
• Usually asymptomatic
• Pain in the calf or thigh
• Dull pain, heaviness, oedema {non pitting} and warm limb
• Increased girth of the affected limb Hotness, cyanosis and
oedema (non-pitting)
• With extensive DVT : massive oedema, cyanosis, dilated
superficial collateral veins and low grade fever.
• With ilio-femoral DVT : Phlegmasia cerulea dolens
(cyanosed limb due to obstructed vein) Phlegmasia alba
dolens (pale, pulseless cold limb due to concurrent
arterial spasm) They are limb-threatening conditions and
considered vascular emergencies
• usually unilateral Homan’s sign
• Tenderness during passive dorsiflexion of foot:
it is contraindicated because of it’s role in
thrombus detachment and thus emobilization
• Moses sign (tenderness on touching the calf
muscle)
Sign and symptoms of pulmonary Embolism

• Pleuritic chest pain and shortness of breath

• Dyspnea: Acute onset of exertional dyspnea,
usually not associated with orthopnea
• Palpitation: Usually rapid and regular but may be
irregular if atrial fibrillation (AF) or multi-focal atrial
tachycardia (MAT) develop Pleuritic chest pain
Cough: Dry, irritant in nature
• In fatal PE-sudden collapse without any prior
symptoms in legs or chest
– Diagnosis may require post mortem examination
• Tachypnea ,Tachycardia, Right-sided S4 gallop
Fever: Temperature >39°C
• Massive PE: Hemodynamic instability SBP
90mmHg or ≥ 40mmHg drop in baseline SBP,
elevated jugular venous pressure, right-sided S
3 , and para-sternal lift.
 Post thrombotic syndrome
• Debilitating condition –directly influences
quality of life
• Approximately 1/3rd with symptomatic DVT
within 2 yrs
• Leg discomfort
• Swelling
• Skin changes and ulceration
• Chronic Pulmonary Hypertension
Incidence of thromboembolic events
Management
 investigations
• Lab investigations: CBC Hb%, WBC’s or platelets Bleeding and
coagulation profile: prolongation of PT and aPTT (consumption)
• D-dimer: sensitive but unspecific
• Final fragment of the plasmin mediated degradation of cross
linked fibrin.limited specificity-age, hospitalization , systemic
inflammation and surgery can raise d-dimer
• Troponin: High in moderate to large PE

• Arterial blood gases (ABG): May show hypoxemia, hypocapnea,

respiratory alkalosis or respiratory failure in cases of massive PE
•
• ECG: Sinus tachycardia (most common
presentation) Non-specific ST-T changes Right
atrial abnormality Right ventricular strain and
hypertrophy Right axis deviation Right bundle
branch block (RBBB) AF ,Deep S-waves in lead
I with pathological Q-waves and inverted T-
waves in lead III
• Imaging- Chest X-ray: Normal, atelectasis and/or
pulmonary parenchymal abnormality, pleural
effusion or cardiomegaly. A wedge-shaped, pleural-
based opacity (Hampton’s hump) or central
oligemia (Westermark’s sign)
• Duplex U/S: Sensitivity and specificity 95%, Include
both B-mode and Doppler studies. Highly operator-
dependant.
• Ventilation/perfusion (V/Q) scan: Rarely used.
Results are low, intermediate or high probability
• pulmonary angiography: Increased availability
and use nowadays. Echocardiography: May
show right ventricular enlargement, right
atrial enlargement or tricuspid regurgitation.
Other rarely used: Phlebography, magnetic
resonance venography and invasive
pulmonary angiography.
 Hypercoagulability work-up
• Family history of Recurrent clots
• Unprovoked upper extremity clot (no catheter, no
surgeries)
• Patients with warfarin-induced skin necrosis (they may
have protein C deficiency)
• Protein C or S deficiency
• Factor V leiden deficiency
• Anti-thrombin III deficiency
• Antiphospholipid antibody
• High Homocysteine
 General measures
• Neuraxial anaesthesisa-spinal or epidural aneaesthesia
reduces mortality , enhances peri-operative analgesia
and reduces the risk of VTE by about 50%
• Surgical technique –rough surgical technique , prolonged
torsion of major vein –in dislocated hip , aggressive
dorsal retraction of the tibia during knee replacements
inhibits venous return endothelial damage
• tourniquet-accumulated clotting factors flushed out on
deflation
• Early mobilization
• Mechanical: Leg elevation
 Physical measures
• Graded compression stockings –above or below
knee,correct size
• Intermittent plantar venous compression –blood
expressed during weight bearing by intermittent
pressure on venous plexus around lateral plantar arteries
• Intermittent pneumatic compression of the leg
• Inferior venacaval filters-percutaneously passed through
the femoral vein and lodged in the inferior vena cava-
catch embolus and prevent from reaching the lungs
• Electrical stimulation
 Chemical methods
• Aspirin
• Unfractionated heparin- (UFH): Dosing 5000
Units subcutaneously every 8 – 12 hours ,Knee
or hip replacement: give 2 hours before
surgery, resume at full dose after surgery for
at least 7 Adverse Effects -Thrombocytopenia
(up to 30%) – monitor platelets , Hemorrhage
(5-10%), Increased ALT/AST CI in elderly
• Low molecular weight heparin LMWH
• ready bioavailability and wide window of safety
hematological and pharmacokinetic advantage over the
unfractioned heparin,monitoring is not required
• Enoxaparin DVT Prophylaxis Dosing Knee or Hip Replacement:
30 mg subcutaneous every 12 hours , Medical Patients: 40mg
subcutaneously every 24 hours,Dose Reduction is required in
patients with CrCl less than 30 mL/min , Knee or Hip
replacement: 30 mg every 24 hours , Medical patients: 30mg
every 24 hours,Adverse Effects Hemorrhage (7%), AST/ALT
elevation (6%), Fever (5%), Local Site reactions (2-5%)
• Pentasaccharide - Fondaparinux: 2.5mg SC
every 24 hours
• Synthetic injectable anti thrombotic drug-
inhibit Factor X-best given 6-8hrs after surgery
• Direct anti-Xa inhibitors
• Rivaroxaban- Dose: 10mg every 24 hours
• Direct thrombin inhibitors eg. Dabigatran
• Advantage –broad therapeutic and safety
window
• Given after surgery and continued as long as
the patient is at the risk of VTE
• warfarin
• Reduces prevalance of DVT after hip and knee
replacements and FTE is extremely rare
• Drawback-difficulty in establishing appropriate
dosage level and need for constant monitoring
• If used –its level maintained at an International
Normalized Ratio INR level of 2-3
• Reversal with Vitamin K
• Works by inhibiting the formation of Vitamin-K
dependent clotting factors
• Adverse Effects: Alopecia, hemorrhage, tissue
necrosis (rare)
 Thrombolysis

• Indication: Persistent arterial hypotension ,Cardiogenic

shock Right ventricular dysfunction Large perfusion defects
on V/Q scan Severe hypoxemia Intermediate-risk patients
may also be considered candidates for thrombolytic therapy.
• Thrombolysis Approved thrombolytic regimens for PE Agent
Dose Streptokinase 250,000 IU as loading dose over 30 min,
followed by 100,000 IU/h over 12 to 24 h 1,500,000 IU over
2 h Urokinase 4,400 IU/Kg as a loading dose over 10 min,
followed by 4,400 IU/Kg/h over 12-24 h 3 million IU over 2 h
Reteplase (rtPA) 100mg over 2 h 0.6mg/Kg over 15 min (max.
50mg)
 Embolectomy
• Either surgical or catheter-based
• Surgical pulmonary embolectomy is indicated
in patients in whom thrombolysis is absolutely
contra-indicated or has failed
Timing and duration of prophylaxis
• Risk of thromboembolism most pronounced
during surgery
• Pt at risk –hip or major long bone fractures ,
immobility or hypercoagulable status –begin
before the operation In general –given on
admission
• Chemical prophylaxis should not be given too
close to surgery risk of provoking bleeding
complication
• Given too long before surgery –metabolism
and excretion may reduce its potency
• Given too long after surgery –thrombogenic
process will be established
• Traditional recommendation of prophylaxis –
until the patient is fully mobile and continued
for14-35 days following knee replacement and
35 days following hip replacement
Caprini index
 Complications
• Varicose veins
• Chronic venous insufficiency (CVI)
• Post-phlebitic syndrome (pain, edema,
ulceration and pigmentation)
• Chronic pulmonary hypertension and vascular
cor-pulmonale
• Death due to massive or sub-massive PE
 References
• Appleys and Solomons 10th edition
• Rockwood and greens fracture 8th edition
• Thank you