View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Deep venous thrombosis in postoperative vascular surgical patients: A frequent finding without prophylaxis Maureen Hollyoak, MBBS, MMedSci, FRACS, Peter Woodruff, MBBS, FRCS(Edin), MCh, FRACS, FACS, Michael Muller, MBBS, FRACS, Nicholas Daunt, MBBS, FRCR(Eng), FRACR, and Paula Weir, BSc, DMU (Vasc), Brisbane, Australia Purpose: The place of routine perioperative thromboprophylaxis for vascular surgical patients remains controversial, because the incidence of postoperative deep venous thrombosis (DVT) is said to be quite low. This study was designed to measure the incidence of lower limb DVT after vascular surgical procedures. Methods: All consenting, consecutive patients who came to a metropolitan veterans hospital for abdominal or lower-limb arterial surgery were studied. Clinical and operative data were recorded. Lower-limb color flow duplex scans were per- formed before and after surgery. Results: Fifty patients, age 75 ± 1 (mean ± SEM) years, were studied. Abdominal procedures were performed on 22 patients, and lower-limb procedures were performed on 28 patients. A postoperative DVT was noted in 14 patients (32%), 9 patients (41%) in the abdominal surgical group and 5 patients (18%) in the lower-limb group. Calf DVTs were four times more common than femoropopliteal DVTs. Conclusion: The incidence of postoperative lower-limb DVTs in this cohort of vascular surgical patients was high. The small size of the study population precludes generalized recommendations, but the results indicate an urgent need for definitive investigation. (J Vasc Surg 2001;34:656-60.) Most surgical patients should receive perioperative inability to walk 50 m. All patients underwent a full clini- thromboprophylaxis in accordance with published recom- cal examination. Operation details, including type, length, mendations.1 The situation is less clear for vascular heparin and protamine dosage, and anesthetic method, patients. There have been only a few reports of the inci- were recorded. No patient received pharmacologic or dence of deep venous thrombosis (DVT) in patients mechanical DVT prophylaxis. undergoing vascular procedures. Intraoperative anticoagu- Study patients underwent bilateral lower-limb color lation with intravenous heparin has been widely believed flow duplex venous scanning on the day before surgery to provide adequate protection against thromboembolic and on the day of discharge. Bilateral venous duplex scans phenomenon.2 We hypothesized that there is a significant were performed in the vascular laboratory at Greenslopes incidence of unrecognized DVTs among patients under- Private Hospital with an ATL extreme HDI 5000 system going abdominal or peripheral vascular surgery. (Advanced Technology Laboratories, Bothell, Wash). The preoperative and postoperative scans were randomly per- METHODS formed by one of three qualified and experienced sonog- All consenting patients who came to a metropolitan raphers (each with more than 5 years’ clinical experience veterans hospital for elective abdominal or peripheral vas- in venous imaging). Each patient was placed in the reverse cular surgery from July to November 1998 were included. Trendelenburg position as a means of examining the com- Patients were excluded when they had a history of DVT or mon femoral, profunda femoris, superficial femoral, and pulmonary embolism (PE) or were undergoing emer- popliteal veins. The distal popliteal, gastrocnemial, soleal, gency surgery or carotid or varicose vein surgery. posterior tibial, anterior tibial, and peroneal veins were Clinical data, including risk factors, age, sex, impair- examined with the leg dependent on the sonographer’s ment of mobility, carcinoma, varicose veins, throm- lap. All veins were examined in the transverse and longitu- bophilia, and usage of aspirin or anticoagulants, were dinal planes with a high-resolution 7.5-MHz linear array recorded. Impairment of mobility was defined as the transducer. The scan was considered to be positive when a particular venous segment displayed intraluminal echoes From the Department of Vascular Surgery, Greenslopes Private Hospital. and incomplete coaptation of the vein walls with trans- Competition of interest: nil. Supported by the Department of Veterans Affairs and Queensland X-Ray. ducer pressure. The absence of phasic Doppler signals Reprint requests: Peter W. Woodruff, MD, Silverton, 101 Wickham Terr, with respiration, loss of brisk augmented signals, and Brisbane 4000, Australia (e-mail: [email protected]). incomplete or no filling of a vein with color or power Published online Aug 13, 2001. Doppler ultrasound scanning were used as a means of sup- Copyright © 2001 by The Society for Vascular Surgery and The American porting the diagnosis.2,3 Association for Vascular Surgery. 0741-5214/2001/$35.00 + 0 24/1/116803 Patients were examined daily for signs of DVT or PE. doi:10.1067/mva.2001.116803 Patients were treated appropriately with anticoagulation 656 JOURNAL OF VASCULAR SURGERY Volume 34, Number 4 Hollyoak et al 657 Table I. Patients undergoing abdominal and peripheral Table II. Incidence of DVT in patients undergoing vas- vascular surgery: comparison between groups for the risk cular surgery factors of postoperative DVT Abdominal Peripheral Abdominal Peripheral n2228 Total (n) = 50 22 28 Calf DVT 7 (80%) 4 (80%) Age (y) 73 ± 2 77 ± 1 Femoropoliteal DVT 2 (20%) 1 (20%) Sex (M/F) 21/1 20/8 Total DVT 9 (41%) 5 (18%) Immobility 7 (32%) 13 (46%) OP time (min) 150 ± 9 142 ± 9 DVT, Deep venous thrombosis. Heparin (units) 9095 ± 541 8069 ± 347 Protamine (mg) 98 ± 10 75 ± 7 Spinal anest 0 14 (50%) Clinical suspicion of DVT/PE 0 0 (5) legs. Five patients in the abdominal group had DVTs LOS (d) 8 ± 1 9 ± 1 in both legs (56%), versus one patient in the peripheral DVT/PE, Deep venous thrombosis/pulmonary embolism; LOS, length of group (20%). The operative leg was the frequent side for stay; M/F, male/female ratio; OP time, operation time; Spinal anest, spinal DVTs in the peripheral surgical patients (80%; Table III). anesthesia. The one patient with a proximal DVT in the periph- eral surgical group had 3 cm of clot in his long saphenous vein extending into his common femoral vein, which dis- when the diagnosis of DVT or PE was made. The Institu- lodged and embolized during scanning. However, he did tional Ethics Committee of the Greenslopes Private not have any symptoms and was fully anticoagulated. Hospital approved the study, and informed consent was General anesthesia (GA) and epidural anesthesia were obtained in all cases. Data are presented as raw figures, used for all abdominal vascular patients. The peripheral percentages, and the mean ± the SEM. group had an equal distribution of GA/epidural anesthe- sia and spinal anesthesia. Of the five peripheral patients in RESULTS whom DVT was detected, four had received GA/epidural A total of 53 patients were enrolled, and 50 patients anesthesia. completed the study. The age of the patients ranged from Three patients, all of whom were in the abdominal 49 to 87 years, with a mean age of 75 ± 1 years. The man- group, died during our study and were not included in the woman ratio was 41 to 9. Twenty-two patients underwent analysis. This represented a 5.6% overall death rate or 12% surgery to the abdominal vasculature. Twenty-eight of the abdominal surgical group. An 84-year-old woman patients underwent peripheral lower-limb vascular surgery. with an abdominal aortic aneurysm (AAA) died on day 11 The abdominal group had a mean age of 73 ± 2 years. The of renal and respiratory failure, widespread multiresistant peripheral group was slightly older (77 ± 1 years). There sepsis, and cerebral infarctions. An 81-year-old man with were more women in the peripheral group than in the an AAA died on day 10 of congestive cardiac failure. The abdominal group. More preoperative impairment of third patient, a 75-year-old man with an AAA, continued mobility was apparent in the peripheral group (46%) than to smoke postoperatively and had a respiratory arrest on in the abdominal group (32%). In the abdominal group, day 5, with a mucous plug obstructing his trachea. On day two patients had a history of carcinoma, and 10 patients 8, he had a sudden onset of central chest pain, and ven- were taking aspirin. In the peripheral group, 1 patient had tricular tachycardia developed, rapidly progressing to asys- known varicose veins, 10 patients were taking aspirin, and tole. His family refused a postmortem examination. The 1 patient was being treated with hormone replacement cause of death could not, therefore, be validated, but therapy. No patients had a stroke with preexisting paresis. myocardial infarction or PE was a possibility. This patient No patients had a history of thrombophilia or other did not undergo postoperative duplex scanning. known coagulation abnormality. The length of hospital stay was similar for both groups. The clinical diagnosis of DISCUSSION DVT was not made in any patient. All patients had preop- Eighty percent of the DVTs detected in our study erative scans, by means of which one old nonocclusive were calf DVTs. Anticoagulation and treatment of proxi- thrombus of small size limited to one calf vessel was mal DVT are well accepted. The importance of calf DVT revealed (Table I). is not so well accepted. Postoperative calf thrombosis diag- DVT occurred in nine patients (41%) in the abdomi- nosis and management are controversial. The clinical nal group and five patients (18%) in the peripheral surgi- sequelae become increasingly more significant as the bulk cal group, producing an overall incidence of 32%. Twenty of thrombus increases.4 Lagerstedt et al5 treated 51 percent of all DVTs extended proximally to the patients who had venographically confirmed calf DVT femoropopliteal region (Table II). All of the patients with either with 3 months of oral anticoagulants or with short- DVT in the abdominal group were men. Three of the term therapy.