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Deep Vein Thrombosis Extremity Amputation Associated with Lower Deep vein thrombosis associated with lower extremity amputation Richard A. Yeager, MD, Gregory L. Moneta, MD, James M. Edwards, MD, Lloyd M. Taylor, Jr., MD, Donald B. McConnell, MD, and John M. Porter, MD, Portland, Ore. Purpose: Patients undergoing lower extremity amputation are perceived to be at high risk for deep vein thrombosis (DVT). Limited data are available, however, to confirm this impression. The purpose of this study is to prospectively document the incidence of DVT complicating lower extremity amputation. Methods: During a recent 28-month period, 72 patients (71 men, i woman; mean age 68 years) undergoing major lower extremity amputation (31 above-knee and 41 below-knee) were prospectively evaluated with perioperative duplex scanning for DVT. Results: DVT was documented in nine (12.5%) patients (one bilateral, four ipsilateral, and four contralateral to amputation). Patients with a history of venous disease were at significantly higher risk for development ofDVT (p = 0.02). Thrombi were located at or proximal to the popliteal vein in eight patients and were isolated to the tibial veins in one patient. DVT was identified before operation in six patients and after operation in three. Patients with DVT were treated with heparin anticoagulation, with no patient experi- encing clinical symptoms compatible with pulmonary embolism. Conclusions: In our recent experience, lower extremity amputation is associated with DVT at or proximal to the popliteal vein in 11% of patients. Documentation of DVT prevalence is essential to assist surgeons in planning a management strategy for prevention, diagnosis, and treatment of DVT associated with lower extremity amputation. (J VAsc SURG 1995;22:612-5.) Virchow 1 related venous thrombosis to the clini- prevalence of DVT ranging from 0% to 67% after cal triad of hypercoagulability, venous stasis, and lower extremity amputation2 ,4 The purpose of our vascular injury. The patient undergoing lower ex- study was to prospectively ascertain the prevalence of tremity amputation is potentially at high risk for DVT among a large cohort of patients undergoing thromboembolic complications. Immobility and sur- vascular surgery and lower extremity amputation. gically induced venous endothelial trauma may pre- dispose the patient undergoing amputation to devel- PATIENTS AND METHODS opment of lower extremity deep vein thrombosis From September 1992 through December 1994 (DVT). In addition, as many as 25% to 30% of at our Veterans Affairs Medical Center, patients un- patients undergoing vascular surgery may have an dergoing major lower extremity amputation (above- associated hypercoagulable condition. 2 or below-lmee) underwent screening for lower ex- In spite of the perception that lower extremity tremity DVT by use of duplex scanning. Patients amputation is associated with thromboembolic com- were assessed for potential risk factors for DVT in- plications, limited data are available documenting the cluding age, diabetes, kidney failure, preexisting prevalence of DVT after amputation. Two small venous disease, history of malignancy, prior amputa- studies have reported conflicting results with the tion or lower extremity surgery, and extensive pedal infection. Duplex examinations were performed be- From the Division of Vascular Surgery, Department of Surgery, fore (within 3 days of amputation) and after opera- Oregon Health Sciences University and Portland Veterans tion (before discharge.) Patients did not routinely Affairs Medical Center, Portland. Presented at the SeventhAnnual Meeting of the AmericanVenous receive anticoagulants for DVT prophylaxis. Intrave- Forum, Fort Lauderdale, Fla., Feb. 23-25, 1995. nous heparin was administered before and after op- Reprint requests: Richard A. Yeager, MD, Portland Veterans eration to patients on long-term warfarin therapy. In Affairs Medical Center, Surgical Service 112P, PO Box 1034, Portland, OR 97207. addition, patients who were discovered to have DVT 24/6/67838 either before or after operation were given intrave- 612 JOURNAL OF VASCULAR SURGERY Volume 22, Number 5 Yeager et aL 613 nous heparin in the perioperative period and subse- Table I. Prevalence of operative risk factors quently switched to long-term warfarin therapy. before amputation (n = 72) Venous duplex examinations were performed in a Mean age (yrs.) 68 standard fashion by use of a color-flow duplex Hypertension 37 (51%) scanner (Acuson 128; Acuson Corporation, Moun- Coronary symptoms 44 (61%) tain View, Calif.). Criteria for a positive examination Diabetes 42 (58%) Renal impairment 16 (22%) result included abnormal venous Doppler flow sig- nals and visualized evidence of intraluminal thrombi confirmed by inability to coapt the vein walls with application of gentle pressure by the transducer? amputation in four patients. Thrombi were located at Statistical analysis. Analysis of preoperative fac- or proximal to the popliteal vein in eight patients and tors in patients with DVT compared with patients were isolated to infrapoplitealveins in one patient. Without DVT was performed with an exact chi- DVT was identified before operation in six patients. square test. A significant difference was assumed with Three patients were diagnosed early after operation. p < 0.05. Two of the three patients with postoperative DVT had normal preoperative duplex examination results, RESULTS and the remaining patient did not undergo preop- During the study period 72 patients (71 men, 1 erative screening. woman; mean age 68 years) underwent lower Among patients without DVT, 14% (9 of 63) extremity amputation. Indications for amputation were receiving warfarin before operation. Indications included acute ischemia with irreversible muscle, for warfarin included atrial fibrillation, prosthetic nerve, and cutaneous damage (n = 18, 25%), exten- heart valve, lower extremity bypass, or a history of sive ulceration or osteomyelitis and soft tissue infec- recurrent DVTs. These patients received periopera- tion (n = 30, 42%), and chronic ischemia in infirm, tive heparin anticoagulation. All patients with DVT bedridden patients (n = 24, 33%). Initially, there were treated with heparin anticoagulation. One were 31 above-knee and 41 below-knee procedures. patient had preoperative lower extremity swelling Ten patients required a second amputation (six and was clinically suspected of having venous throm- conversions from guillotine to conventional below- bosis that was subsequently confirmed by duplex knee, three amputation revisions, and one amputa- scanning. No patient experienced symptoms compat- tion of the contralateral extremity) for a total of 82 ible with pulmonary embolism. amputations in 72 patients. Preoperative risk factors are shown in Table I. DISCUSSION The operative mortality rate was 4%, with deaths Multiple risk factors may predispose patients (n = 3) caused by pneumonia, kidney failure, and undergoing amputation to thromboembolic compli- myocardial infarction. Twelve patients did not un- cations. From 25% to 30% of patients undergoing dergo screening before operation with duplex studies vascular surgery have an identifiable hypercoagulable because of the requirement for emergency amputa- condition) In addition, many patients requiring tion. Two patients did not undergo screening after lower extremity amputation are elderly, sedentary operation because of early postoperative death. individuals with longstanding arterial disease who in Nine (12.5%) of 72 patients were found to have many cases have undergone previous amputation DVT. Four of 31 (13%) patients undergoing above- (21% in this series). 6 In our series, patients with a knee amputation and 5 of 41 (12%) patients under- history of venous disease and those with preexisting going below-knee amputation were found to have amputation appeared to be at the highest risk for DVT. Risk factors that may predispose to venous development of DVT. Additional clinical features thrombosis among the patients with and without often found in patients requiring lower extremity perioperative DVT are shown in Table II. Patients amputation and that may predispose to venous with a history of venous disease (DVT or chronic thrombosis include diabetes, sepsis, and malignancy.7 venous insufficiency) were at higher risk for periop- Previous authors have, with conflicting results, erative DVT (p = 0.02). There was a similar trend evaluated the association between major lower ex- for patients with preexisting lower extremity ampu- tremity amputation and venous thrombosis. Harper tation (p = 0.08). DVT involvement was contralat- et al. 3 used contrast venography of the ipsilateral eral to the side of extremity amputation in four iliofemoral segment and found DVT in 15 (67%) patients, bilateral in one, and ipsilateral to the patients after above-knee amputation. Barnes and JOURNALOF VASCULARSURGERY 614 Yeager et al. November 1995 Table II. Prevalence of potential DVT risk factors Patients with D VT Patients without D VT (n = 9) (n =63) Age (mean _+ SD) (yrs.) 69 -- 8 68 -+ 12 Diabetes (%) 7 (78%) 35 (56%) Preexisting venous disease (%)* 3 (33%) 3 (5%) Malignancy history (%) 0 (0%) 8 (13%) Prior amputation (%)t 4 (44%) ll (17%) Prior lower extremity vascular surgery 5 (56%) 33 (52%) Dialysis dependent (%) 1 (11%) 8 (12.6%) Extensive ulceration or infection (%) 5 (56%) 25 (40%) "I; = 0.02. ~:o = 0.08. Slaymaker, 4 however, prospectively examined 35 DVT had development of stump swelling and patients undergoing 42 lower extremity amputations infection that required amputation revision.
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