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 out near normal  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 DVT PE Death Prevent DVT Treat DVT = Prevent PE Treat PE = Prevent More 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 High Risk Patient Factors 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 DVT PE Death Prevent DVT Treat DVT = Prevent PE Treat PE = Prevent More PE 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 SCD or GCS 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 DVT PE Death Prevent DVT Treat DVT = Prevent PE Treat PE = Prevent More PE Treat PE

Overview of Prevention / Treatment DVT PE Treat DVT = Prevent PE Treat PE = Prevent More 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 Heparin or Adjusted Dose Unfractionated Heparin IV 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: > 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 Patient at Risk DVT PE Death Prevent DVT Treat DVT = Prevent PE Treat PE = Prevent More 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%

Improving adherence to Thrombophylaxis Guidelines 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