Venous Thrombo-

Embolisum
A.S.Withanage
 Epidemiology
Deep vien thrombosis (DVT)
common disease in lowerlimb
Asymptomatic DVT
DVT detected by screening (Acta Orthop Scand 1998;69)
Symptomatic DVT
(leg pain and swelling)

Complications of DVT
Pulmonary embolism
10% of hospital deaths
1% of all deaths (RSoc Med 1989;82:)
90% cases result from asymptomatic DVT

Post-thrombotic leg syndrome

Leg ulcers 2-10% after 10 years 1st Symptomatic DVT
(Heamostasis 1998;28 suppl0
Pathology
 Rationale for Prophylaxis
Risk of PE increase X10
Hospitalised after trauma, surgery or immobilised with
medical illness, pregnant and puerperal.
Screening studies
I125 Fibrogen
Ultrasound
Ascending Venography

Many remain asymptomatic

Other cause morbidity and mortality

Routine prophylaxis reduces morbidity, mortality and costs

in hospitallied patients developing DVT and PE
(BMJ 1992; 305:567-74)
 Impact on National Mortality
figures
Under reported
Necrospy rate fallen
71% 1966 to 1977
30% 1998-2000(NCEPOD enquiry into peri-operative

deaths
small studies
5% of all Hospital deaths
Non surgical > Surgical patients
(J. clin. Pathol 2004;57)
 Risk factors for Venous
thromboembolism
Age (Thrombo Haemost 1999;81)
<40 years annual risk 1/ 10,000
60-69 years 1/1000
>80 1/100

Obesity
3X risk BMI > 30

Varicose Viens
1.5 X risk after major general / orthopaedic Surgery

Prevoius VTE
Recurrence rate 5%/ year, increase by surgery
 Risk factors for Venous
thromboembolism
Thrombophilias
Low coagulation inhibiters (antithrombin III, protien C or S)
Activated protien c resistance
High coagulation factors (I,II,VIII,IX,XI)
Antiphospholopid syndrome
High homocytiene
Thrombotic state
Malignancy 7X risk
Heart Failure

Recent MI / Stroke

Severe infection

Inflamatory bowel disease, nephrotic syn, polycythaemia,

Paraprotienaemia
 Risk factors for Venous
thromboembolism
Hormone therapy (3X risk)
Oral combined contraceptive
HRT

Tamoxifen

High dose progesteron

Pregnancy, Puerperium (10X risk)

Immobility
Bedrest >3 days
Plastercast

paralysis
 Method of prophylaxis
General Measures
Mobilisation and leg exercises
no evidence of benefit of bed rest for any condition
(Lancet 1999; 354)

Hydration, Haehodilution and venesection

only evidence for Primary polycythaemia
 MECHANICAL METHODS

Graduated Elastic Compression Stockings

Evidence -8.6% of active pt to 27% controls
( Arch Intern Med 1994;154)
Above-knee GECS are preferred

Contraindications
Massive leg oedema

Pulmonary oedema (E.g Heart failure)

Sever peroperal arterial disease

Sever peroperal neuropathy

Major leg deformity

dermatitis
 Intermittent Pneumatic
Compression (IPC)
Periodic ally compress calf and/or thigh muscles

Inflateted pressure 35-40 mmHg at about 10s/min

Stimulate fibrinolysis

Usually applied immediately before or during surgery

and often repalced by GECS

Reduce risk of DVT 68% (Int Angiol 1992;11)

 Mechanical foot pumps and foot impulse
technology
Designs for patients unable to weight bear
Only been used in orthopaedic surgery
Evidence prevention of asymptomatic DVT
(Bone Joint Surg Am1998;80)
Disadvantage
Discomfort from device leads to poor compliance
Skin necrosis reported
 Antiplatelet Agents

Asprin

Significant reduction in risk of of asymptomatic DVT(26% vs

35%) and PE
(BMJ 1994;309)

Significant increase of major bleeds.

No significant reduction of mortality

Pulmonary Embolism Prevention (PEP) trial
Surgery for hip frscture
160mg daily for 35 days (Lacet 2000;355)

Not licensed to use for VTE prophylaxis in UK

 Unfractionated and Low molecular
weight Heparins
Licenced in UK for prophylaxis of VTE
Prophylaxis dose
Given subcutaneously
Lower dose
Little effect of APTT
LMWH has longer half-life than UFH
LMWH once daily
UFH 8-12hourly
Evidence found that UFH significantly reduce DVT and
PE( Lancet 1977;1)

Similar Evidence prophylactic efficacy and risk of bleeding to

UFH ((Br J Suurg 1997;84)
 Unfractionated and Low molecular
weight Heparins
Contraindications
Uncorrected bleeding disorders
Haemophilias
Oral anticoagulants
Platelet count <70X109/L
Bleeding or potentially bleeding lessions
Oesopageal varices
Active peptic ulcer
Recent(3 months) GI or intracranial bleed
Intracranial anurysm or angioma
Allergy
Heparin associated thrombocytopenia
 Coagulation monitoring
UFH-- APTT
LMWH- anti- Xa levels
Monitoring should be performend
High risk pregnancy
Heamorrage or accidental overdose
Patient with renal failure given higher doses
Monitoring Platelet count
Heparin associated thrombocytopenia (HAT)
Immune mediated
Usually occurs between 5-10 days
LMWH less likely than UFH
HAT considered platelat count drops 50% or more
 Prophylaxis General Surgery
Controlled trials have shown UFH(5000U) effective in reducing
the risk of DVT and PE, as well as mortality (Ann Surg 1988;208)
No difference between LMWH and UFH (Br j Surg 1997)
Urological Surgery
TURP: lower risk of DVT on screening 10%
3rd most commonest cause of death is PE (Br J Urol
1997;79)
Routinely not fear of bleeding
trial showed no evidence increase bleeding ( Br J Urol
1988;62)
 Varicose vein surgery
Risk of VTE low absence risk factors (BMJ 1996)
GECS recommended post op in absence of other
risk factors
Minimal Access surgery
Further research required establish the risk of VTE
High risk/ major prolong sx- UFH or LMWH
recommeded
Lower risk -- GECS+-IPC is recommeded
 Spinal and epidural blocks
Vertebral canal haematoma
LMWH
No increase risk as long as ---.10-12 hours
Block is instituted
Catheter removed
1st dose can be given immediately after block (Reg Anesth Pain
Med 1998)
 Clinical Features
Breathlessness / Tachypnoea / Pluratic chest pains/
heamoptysis
Presence of major risk factor
Absence of other clinical explanation
Major PE
Acute Right heart strain----> troponin posistive
(BMJ 2003)

Increase risk of cancer being detected within 6-12 months after

1st episode of PE
(N Eng j Med;1992)
 Diagnosing DVT and PE
Blood investigations
D-dimer

Important role in excluding PE

Raised levels are do not infer presence of VTE
Such results are found commonly in hospitalised patients(ANN
Emerg med; 2002)
Recommendation (British Thoracic society)
D-dimer only be considered following assessment of clinical
probability
D-dimer assay should not be considered high probability of VTE
2nd Generation Rapid D-dimer testing
sensitivity 87-98%
3 systems
Qualitative red cell aglutination test (SimpliRED)
Rapid qualitative ELISA
MDA D-dimer test
 Imaging
Isotope lung scanning
should be considered initial investigation
Availability
Normal chest x-ray
No significant symptomatic concurrent cardiopulmonary disease
non diagnostic always followed by repeat scan

Normal scan reliably exclude PE but significant minority

false positive
(British thorasic society guidelines 2002)
 Computed tomographic pulmonary angiogram
(CTPA)

Recommended Initial investigation for non massive PE(British

thoracic society guide lines)

Patients with good quality negative CTPA does not require

further investigations

Compared to conventional isotope scanning quicker to perform

As well as showing the intra-vascular thrombs CTPA may

show 2nd effects such as wedge shape opacities or right
ventricular changes.
 Conventional pulmonary angiography
limited use
limited radilogical experience
inter observer disagreement occur in 1 in 3

positive predictive value 87-88% compared with

necroscopy(Am j Respir Crit Care med 2000;)

Leg Ultrasound
patient with co-exisiting clinical DVT, leg ultra sound as the
initial imaging test is often sufficient to confirm VTE

a single normal leg USS sould not de relied on for exclusion of

subclinical DVT
 Echocardiography
Diagnostic in massive PE(j Am coll cardiol 1997;30)

CTPA or ECHO will reliably diagnose clinicaly massive PE

Testing for thrombophilia should be considered in patients below

the age 50 years
antiphopholipid syndrome
Deficiencies
Antithrombin III
Factor V laden
protein c / protein s
 Treatment of DVT and PE
Supportive therapy
oxygen
Analgesia
hypotensive -----> use plasma expanders
Thrombolysis and embolectomy
Thrombolysis is the fistline treatment for massive PE(alteplase is
recommended
Thrombus fragmentation and IVC filter insertion should be considered
Anticoagulation is contra-indicated
Recurrent PE from continuing
No reduction in short or long term mortality (N Engl J Med ;
1998)
 Treatment of DVT
Anticoagulation
Heparin should be given to patients with high or intermediate
probability before imaging
LMWH is preferable to UFH
Equal efficacy and easy to use

oral anticoagulation given

Only when VTE reliably confirmed
Target INR 2.0-3.0
Duration
temporary risk factor--->4-6 weeks
1st Idiopathic---->3 months
(British Thoracic Society Guidelines 2003)
Thank You