Venothrombotic Disease&

Urological Surgery

Jeffrey P Schaefer MSc MD FRCPC

April 27, 2007

Biography• 1986 BSc microbiology U Sask• 1991 MD distinction U Sask• 1995 FRCPC Internal Medicine U Calg• 1999 MSc CHS (Epidemiology) U Calg• 2000 RGH Site Chief, Medicine• Interests:

– education– integrative medicine– information technology

Why have this talk?

• Define• Risk• Diagnosis• Prevention• Therapy• Prognosis

Venothrombotic disease (VTED)

• superficial thrombophlebitis

• deep vein thrombosis– lower limb– upper limb

• pulmonary thromboembolism

• post-thrombotic syndrome

Superficial Vein Thrombophlebitis

Superficial Vein Thrombophlebitis

Superficial Leg Veins Saphenous (L & S)

Potentially Lethal Misnomer SFV = deep

Deep Vein Thrombosis

Pulmonary Thromboembolism

Pulmonary Thromboembolism

Post-Thrombotic Syndrome

• Variously defined– pain and swelling post-DVT– 20 – 50%

DVT - diagnosis

• Clinical Suspicion• D-dimer screen• Compression Ultrasound• Venography

• (MRI expensive)• (IPG ‘discredited’)

DVT - diagnosis• Clinical Suspicion - performs poorly

Well’s Criteria

- study excluded those with previous VTED, needed indefinite anti-coagulation, imminent death

D - dimer• D-dimer Assay

– D-dimer is breakdown product of fibrinolysis

– high sensitivity (98%) & modest specificity (~50%)

– useful for excluding DVT and PE– not useful for confirming diagnosis

– SHOULD NOT TO BE USED•post-operative patient• pregnant patient• patient with malignancy

Duplex Ultrasonography

• Duplex US – above knee DVT

• Sens = 96%• Spec = 96%

Haemostasis 23:61-7

• calf dvt– sens = 80%

Venography• Gold standard (sens 100%, spec 100%)

Pulmonary Thromboembolism

Pulmonary Thromboembolism

• Diagnosis– Clinical– Ventilation - Perfusion Scan (V/Q scan)– Spiral CT Scan– Pulmonary Angiogram

PE - clinical diagnosis• Symptoms of PE in 117 previously normal

patients– dyspnea 73%– pleuritic pain 66– cough 37– leg swelling 28– leg pain 26– hemoptysis 13– palpitations 10– wheezing 9– angina-like pain 4 Chest 100:598, 1991

PE - clinical diagnosis• Signs of PE in 117 previously normal patients

– tachypnea (20/min) 70%– rales (crackles) 51– tachycardia (>100/min) 30– fourth heart sound 24– increased P2 23– diaphoresis 11– temperature >38.5°C 7– wheezes 5– Homans' sign 4– right ventricular lift 4– pleural friction rub 3– third heart sound 3

Well’s PE Clinical Prediction Rule• Signs/Symptoms of DVT 3.0

– measured leg swelling AND– pain with palpation in the deep vein region

• Alternative diagnoses less likely than PE 3.0– history, physical exam, chest X-ray, EKG, lab results

• Pulse > 100 beats/min 1.5• Immobilization 1.5

– bedrest (except access to BR) 3 days OR– surgery in previous 4 weeks

• Previous DVT or PE 1.5• Hemoptysis 1.0• Malignancy 1.0

– receiving active treatment for cancer OR– have received treatment for cancer within the past 6 months OR– are receiving palliative care for cancer

• TOTAL: >6 (high 78%), 2-6 (mod 28%), < 2 (low 3%)Thromb Haemost 2000;83;418

PE - diagnosis (V/Q scan)

• high probability V/Q scan (2 defects)

V/Q scan

normal PE ruled outnear normal PE ruled out

low probability can’t rule in nor outindeterminate can’t rule in nor out

high probability PE ruled in

Most V/Q Scans are non-diagnostic

PE - diagnosis (spiral CT scan)

Sprial CT Scanning

PE - diagnosisVenography

- gold standard - (100% / 100%)

Overview of Prevention / Treatment

DVT PE

Prevent DVT

Patient at Risk

Death

Treat PE =Prevent

More PE

Treat DVT =Prevent PE

Treat PE

Magnitude of the Problem

Risk of VTE in absence of prophylaxis

• General medicine patients 10-26%• Congestive heart failure 20-40%• Myocardial infarction 17-34%• Stroke 55%• Orthopedic Surgery 40-80%• Cancer 7-17%

Geerts et al. Chest 2001;119: 132S-175S

Risk of DVT no thrombophylaxis

Major Urological Surgery

15 – 40% risk of DVT

Risk of DVT and PE

Urological Surgery• Low Risk

– cystoscopy– transurethral resection prostate (TURP)

• High Risk– radical prostatectomy– nephrectomy– cystectomy

• Patient Factors– comorbidity, previous DVT-PE,

thrombophilia– hemorrhage

Interventions…

Overview of Prevention / Treatment

DVT PE

Prevent DVT

Patient at Risk

Death

Treat PE =Prevent

More PE

Treat DVT =Prevent PE

Treat PE

Overview of Prevention / Treatment

Prevent DVT

Patient at Risk

(Kendall TED)

Efficacy of Heparins vs Placebo

American College of Chest Physicians

CHEST SupplementSeptember 2004Volume 126(3)

www.chest.org (free)

• TURP Mobilize

• Open Procedures– heparin 5,000 U sq bid or tid– LMWH

• enoxaparin 40 mg sq od• dalteparin 5,000 u sq od

– SCD or GCS

• Mechanical for bleeder / bleeding

• Mechanical + Heparin for multiple risk pts

Overview of Prevention / Treatment

DVT PE

Prevent DVT

Patient at Risk

Death

Treat PE =Prevent

More PE

Treat DVT =Prevent PE

Treat PE

Overview of Prevention / Treatment

DVT PE

Treat PE =Prevent

More PE

Treat DVT =Prevent PE

Why Intervene?

• Risk of PE among untreated DVT ~ 15-25%

• Risk of death among PE ~ 20-30%• Risk of death among untreated DVT ~5%

• Risk of death for treated PE ~ 1.5%/yr• Risk of death for treated DVT ~ 0.4%/yr• Risk of major bleed treated PE/DVT

~1.0%/yr

Suspected DVT

• If high clinical suspicion of DVT, treat with anticoagulants while awaiting the outcome of diagnostic tests (1C+).

Confirmed DVT/PE• Clinical assessment risk / benefit of intervetion.• Draw baseline CBC, PTT, and INR and start:

Low Molecular Weight Heparinor

Adjusted Dose Unfractionated Heparin IVor

Adjusted Dose Unfractionated Heparin SQ

Any one of the three are acceptableLow Molecular Wt Heparin is preferred

(dosing, slightly better efficacy and safety)

Duration of Heparin for acute DVT/PE

• Most Adults– minimum 5 days AND– until INR therapeutic for two consecutive

days

• Active Cancer– minimum 3 – 6 months before

converting to ‘indefinite’ warfarin

Duration of Warfarin for DVT/PE

• Warfarin (if not pregnant)– start concurrently with heparin– target INR 2.0 - 3.0

• Duration of warfarin– time reversible risk factors: > 3 months*– first idiopathic DVT/PE: > 6 months– recurrent DVT/PE: > 12 months– continuing risk factor > 12 months

• cancer and thrombophilias*local tendency to tx PE x 6 months

Calf (below knee) DVT

• Below knee DVT extend proximally in 20% of patients treated with IV heparin for several days

• Recommend: treatment of below knee DVT is SAME AS proximal DVT

Overview of Prevention / Treatment

DVT PE

Prevent DVT

Patient at Risk

Death

Treat PE =Prevent

More PE

Treat DVT =Prevent PE

Treat PE

Overview of Prevention / Treatment

PE Death

Treat PE

Massive PE

• Thrombolytic Therapy– highly individualized– ICU admission

– reserved for echocardiographic right heart failure

Thrombolysis for sub-massive PE

n = 238

Endpoint = escalation of therapy or death. NEJM 2002;347;1143

Post-Thrombotic Syndrome

• Variously defined– pain and swelling post-DVT– 20 – 50%

Post-Phlebitic Syndrome• elastic compression stocking (30-40)

during 2 years after an episode of DVT (1A)

• intermittent pneumatic compression for severe edema (2B)

• elastic compression stockings for mild edema of the leg due to the PTS (2C).

--------------• Rutosides for mild edema due to PTS

(2B)

What are rutosides?• A substance produced from leaves & flowers of the

plant Sophora japonica

What to expect?

• Potential for post-phlebitic syndrome• PE chest pain may come and go• Hemoptysis may occur• Elevate legs when not ambulating• Okay to walk

What happens to the Thrombus?

How well are we doing?

• Chart review of admissions Jewish General Hospital, Montreal 1996-1997 (1 yr post 1995 guidelines)

preventable

17%

Getting better grades

Improving adherence to Thrombophylaxis Guidelines

Summary

• Define ST + DVT + PE + PTS• Risk closed = low open = high• Diagnosis doppler, helical CT or

V/Q• Prevention heparin +/- mechanical• Therapy heparin and warfarin