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Home , Amputation

Deep 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 (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 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 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 . 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 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 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, , 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 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 and 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, , 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. (28 below-knee, 14 above-knee) with continuous- All but three of our DVT cases were diagnosed wave Doppler examinations and were unable to before operation. It may be that the debilitated detect a single case of DVT, although one patient had sedentary status of most patients undergoing ampu- a pulmonary embolus. We found no difference in the tation is the most important factor in the develop- prevalence of DVT among our patients undergoing ment of their DVT. The operative procedure itself above-knee (4 of 31, 13%) compared with below- may play only a minor role in the pathogenesis of lmee amputation (5 of 41, 12%). DVT associated with lower extremity amputation. Duplex scanning is currently the most widely However, the procoagulant tendency induced by the used noninvasive confirmatory test for symptomatic operation, superimposed on additional venous endo- DVT. The accuracy of duplex scanning for detecting thelial trauma, may predispose to propagation of proximal DVT is well established. Sensitivity exceeds venous thrombus and pulmonary embolism. 14,1s 90%, and specificity approaches 100%. s Surpris- In our experience, 12.5% of patients were found ingly, no prospective studies with duplex scanning to have perioperative DVT at the time of lower used to document the prevalence of DVT associated extremity amputation, with those with a history of with lower extremity amputation have been pub- chronic venous disease or preexisting amputation at lished, although Kerr et al. 9 have presented data highest risk. Generally, the surgeon has three man- identifying DVT in 17% of 24 patients undergoing agement options regarding DVT associated with amputation prospectively evaluated with periopera- amputation, including a primary prophylaxis strategy tive duplex scanning. Their results closely approxi- with pneumatic compression used on the opposite mate our findings and support the conclusion that leg or anticoagulation, an intensive monitoring DVT is often associated with lower extremity ampu- program with routine Doppler ultrasonography or tation. The potential association may be even greater duplex scanning, or a more conservative approach than suggested by this report in that 14% of our focused on investigating only patients who have patients were receiving heparin anticoagulation, and development of symptoms consistent with DVT or the remainder were on antiplatelet therapy.l° pulmonary embolism, s,16a7 It is not the purpose of It is noteworthy that five of our nine patients with this report to argue in favor of a single management DVT undergoing amputation had involvement of approach. Our results may be useful, however, for the contralateral extremity. DVT screening in this surgeons interested in formulating a management patient population should therefore include duplex strategy. examinations of both lower extremities, n All con- On the basis of the preceding natural history data, tralateral DVT were potentially clinically important our management approach currently focuses on with thrombi located at or cephalad to the popliteal preoperative duplex scanning of patients undergoing vein in four of the five cases. Patients with ipsilateral amputation. DVT prophylaxis, other than aspirin DVT undergoing amputation are at risk for stump therapy, is not routinely administered, m DVT de- swelling and delayed healing of the amputation. It tected before operation is treated with heparin may also be difficult to fit these patients with a anticoagulation for 5 to 7 days to allow for clot . 12aa One of our patients with ipsilateral stabilization before elective amputation. The efficacy JOURNAL OF VASCULAR SURGERY Volume 22, Number 5 Yeager et al. 615 of this approach will require confirmation by addi- amputee diagnosed by color duplex scanning. Presented at tional prospective analysis. 18th Annual Surgical Symposium of the Association of VA Surgeons; May 4-7, 1994; Reno, Nev. REFERENCES 10. Antiplatelet Trialists' Collaboration. Collaborative overview 1. Virchow R. Gesammelte Abhandlungen zur Wissenschaft- of randomized trials of antiplatelet therapy- III: reduction in lichen Medizin. Frankfurt: Meidinger Sohn, 1856:219. venous thrombosis and pulmonary embolism by antiptatelet 2. Taylor LM Jr, Chitwood RW, Dalman RL, et al. Antiphos- prophyl~,is among surgical and medical patients. Br Med J pholipid antibodies in vascular surgery patients: a cross- 1994;308:235-45. sectional study. Ann Surg 1994;220:544-51. 11. Lohr jIM, Hasselfeld KA, Byrne MP, et al. Does the 3. Harper DR, Dhall DP, Woodruff PWH. Prophylaxis in asymptomatic limb harbor deep venous thrombosis? Am J iliofemoral venous thrombosis: the major amputee as a clinical Surg 1994;168:184-7. research model. Br [I Surg 1973;60:831. 12. Chong DK-H, Panju A. Deep vein thrombosis as a cause of 4. Barnes RW, Slaymaker EE. Postoperative deep vein throm- stump swelling in two lower extremity amputee patients. Arch bosis in the lower extremity amputee: a prospective study with Phys Med Rehabil i993;74:1002-3. Doppler ultrasound. Ann Surg 1976;183:429-32. I3. Frost FS, Kelly CM, McCarthy W. High resolution real-time 5. Hobson RW II, Mintz BL, Jamit Z, Breitbart GB. Current ultrasound for the diagnosis of venous thrombosis in the status of duplex ukrasonography in the diagnosis of acute deep rehabilitation setting~ Am J Phys Med Rehabil 1991 ;70:3 -4. venous thrombosis. In: Bergan lJ, Yao IST, eds. Venous 14. Collins GJ, Barber IA, Zajtchuk R, et al. The effects of disorders. Philadelphia: WB Saunders, 1991:55-62. operative stress on the coagulation profile. Am I Surg 6. Kakkar VV, Howe CT, Nicolaides AN, et al. Deep vein I977;I33:612-6. thrombosis of the leg: is there a "high risk" group? Am I Surg 15. McDaniel MD, Pearce WH, Yao IST, et al. Sequential changes 1970;120:527-30. in coagulation and ptatelet function following femorotibial 7. Hoch JR, Silver D. Hematologic factors, anticoagulation, and bypass, l VAsc Suing 1984;1:261-8. anticoagulant complications in venous thromboembolism. In: 16. Kakkar VV, StringerMD. Prophylaxis ofvenous thromboem- Bergan JJ, Yao JST, eds. Venous disorders. Philadelphia: WB bolism. World I Surg i990;14:670-8. Saunders, 1991:19-35, 17. Clagett GP, Anderson FA Jr, Levine MN, et al. Prevention of 8. Weimann EE, Salzman EW. Deep-vein thrombosis. N Engl J venous thromboembolism. Chest I992;102:391S-407S. Med 1994;33I:I630-4i. 9. Kerr TM, LePain MF, Fuhrman T. Prospective analysis of the incidence of venous thrombosis in the lower extremity Submitted March 17, 1995; accepted July 8, 1995.