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Venothrombotic Disease
&
Urological Surgery
Jeffrey P Schaefer MSc MD FRCPC
April 27, 2007
Biography
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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?
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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
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Variously defined
– pain and swelling post-DVT
– 20 – 50%
DVT - diagnosis
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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
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tachypnea (20/min)
rales (crackles)
tachycardia (>100/min)
fourth heart sound
increased P2
diaphoresis
temperature >38.5°C
wheezes
Homans' sign
right ventricular lift
pleural friction rub
third heart sound
70%
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Well’s PE Clinical Prediction Rule
• Signs/Symptoms of DVT
3.0
• Alternative diagnoses less likely than PE
3.0
• Pulse > 100 beats/min
• Immobilization
1.5
1.5
• Previous DVT or PE
• Hemoptysis
• Malignancy
1.5
1.0
1.0
– measured leg swelling AND
– pain with palpation in the deep vein region
– history, physical exam, chest X-ray, EKG, lab results
– bedrest (except access to BR)  3 days OR
– surgery in previous 4 weeks
– 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
near normal
 PE ruled out
 PE ruled out
low probability  can’t rule in nor out
indeterminate  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 - diagnosis
Venography
- gold standard
- (100% / 100%)
Overview of Prevention / Treatment
Patient at
Risk
Prevent DVT
DVT
Treat DVT =
Prevent PE
PE
Treat PE =
Prevent
More PE
Death
Treat PE
Magnitude of the Problem
Risk of VTE in absence of prophylaxis
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General medicine patients
Congestive heart failure
Myocardial infarction
Stroke
Orthopedic Surgery
Cancer
10-26%
20-40%
17-34%
55%
40-80%
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
Patient at
Risk
Prevent DVT
DVT
Treat DVT =
Prevent PE
PE
Treat PE =
Prevent
More PE
Death
Treat PE
Overview of Prevention / Treatment
Patient at
Risk
Prevent DVT
(Kendall TED)
Efficacy of Heparins vs Placebo
American College of
Chest Physicians
CHEST Supplement
September 2004
Volume 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
Patient at
Risk
Prevent DVT
DVT
Treat DVT =
Prevent PE
PE
Treat PE =
Prevent
More PE
Death
Treat PE
Overview of Prevention / Treatment
DVT
Treat DVT =
Prevent PE
PE
Treat PE =
Prevent
More PE
Why Intervene?
• Risk of PE among untreated DVT ~ 1525%
• 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 Heparin
or
Adjusted Dose Unfractionated Heparin IV
or
Adjusted Dose Unfractionated Heparin SQ
Any one of the three are acceptable
Low 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:
– first idiopathic DVT/PE:
– recurrent DVT/PE:
– continuing risk factor
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3 months*
6 months
12 months
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
Patient at
Risk
Prevent DVT
DVT
Treat DVT =
Prevent PE
PE
Treat PE =
Prevent
More PE
Death
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
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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?
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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
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Define  ST + DVT + PE + PTS
Risk  closed = low
open = high
Diagnosis  doppler, helical CT or V/Q
Prevention  heparin +/- mechanical
Therapy  heparin and warfarin