1. Venothrombotic Disease & Urological Surgery
Jeffrey P Schaefer MSc MD FRCPC
April 27, 2007

2. 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

4. Why have this talk?
Define
Risk
Diagnosis
Prevention
Therapy
Prognosis

5. Venothrombotic disease (VTED)
superficial thrombophlebitis
deep vein thrombosis
lower limb
upper limb
pulmonary thromboembolism
post-thrombotic syndrome

6. Superficial Vein Thrombophlebitis

7. Superficial Vein Thrombophlebitis

8. Superficial Leg Veins  Saphenous (L & S)

9. Potentially Lethal Misnomer  SFV = deep

10. Deep Vein Thrombosis

11. Pulmonary Thromboembolism

12. Pulmonary Thromboembolism

13. Post-Thrombotic Syndrome
Variously defined
pain and swelling post-DVT
20 – 50%

14. DVT - diagnosis Clinical Suspicion D-dimer screen
Compression Ultrasound
Venography
(MRI expensive)
(IPG ‘discredited’)

15. DVT - diagnosis
Clinical Suspicion - performs poorly

16. Well’s Criteria
- study excluded those with previous VTED, needed indefinite anti-coagulation, imminent death

17. 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

18. Duplex Ultrasonography
Duplex US
above knee DVT
Sens = 96%
Spec = 96%
Haemostasis 23:61-7
calf dvt
sens = 80%

19. Venography
Gold standard (sens 100%, spec 100%)

20. Pulmonary Thromboembolism

21. Pulmonary Thromboembolism
Diagnosis
Clinical
Ventilation - Perfusion Scan (V/Q scan)
Spiral CT Scan
Pulmonary Angiogram

22. PE - clinical diagnosis
Symptoms of PE in 117 previously normal patients
dyspnea 73%
pleuritic pain 66
cough
leg swelling 28
leg pain 26
hemoptysis 13
palpitations 10
wheezing
angina-like pain Chest 100:598, 1991

23. 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
Homans' sign
right ventricular lift 4
pleural friction rub
third heart sound

24. Well’s PE Clinical Prediction Rule
Signs/Symptoms of DVT
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
Immobilization
bedrest (except access to BR)  3 days OR
surgery in previous 4 weeks
Previous DVT or PE
Hemoptysis
Malignancy
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

25. PE - diagnosis (V/Q scan)
high probability V/Q scan (2 defects)

26. 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

27. Most V/Q Scans are non-diagnostic

28. PE - diagnosis (spiral CT scan)

29. Sprial CT Scanning

30. PE - diagnosis
Venography
- gold standard
- (100% / 100%)

31. Overview of Prevention / Treatment
Patient at Risk
DVT PE
Death
Prevent DVT
Treat DVT =
Prevent PE
Treat PE =
Prevent
More PE
Treat PE

32. Magnitude of the Problem

33. Risk of VTE in absence of prophylaxis
General medicine patients %
Congestive heart failure %
Myocardial infarction %
Stroke %
Orthopedic Surgery %
Cancer %
Geerts et al. Chest 2001;119: 132S-175S

34. Risk of DVT  no thrombophylaxis
Major Urological Surgery
15 – 40% risk of DVT

35. Risk of DVT and PE

36. 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

37. Interventions…

38. Overview of Prevention / Treatment
Patient at Risk
DVT PE
Death
Prevent DVT
Treat DVT =
Prevent PE
Treat PE =
Prevent
More PE
Treat PE

39. Overview of Prevention / Treatment
Patient at Risk
Prevent DVT

40. (Kendall TED)

41. Efficacy of Heparins vs Placebo

42. American College of Chest Physicians
CHEST Supplement
September 2004
Volume 126(3)
(free)

43. TURP  Mobilize

44. 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

45. Mechanical for bleeder / bleeding

46. Mechanical + Heparin for multiple risk pts

47. Overview of Prevention / Treatment
Patient at Risk
DVT PE
Death
Prevent DVT
Treat DVT =
Prevent PE
Treat PE =
Prevent
More PE
Treat PE

48. Overview of Prevention / Treatment
DVT PE
Treat DVT =
Prevent PE
Treat PE =
Prevent
More PE

49. 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

50. Suspected DVT
If high clinical suspicion of DVT, treat with anticoagulants while awaiting the outcome of diagnostic tests (1C+).

51. 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)

52. 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

53. Duration of Warfarin for DVT/PE
Warfarin (if not pregnant)
start concurrently with heparin
target INR
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

54. 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

55. Overview of Prevention / Treatment
Patient at Risk
DVT PE
Death
Prevent DVT
Treat DVT =
Prevent PE
Treat PE =
Prevent
More PE
Treat PE

56. Overview of Prevention / TreatmentPE
Death
Treat PE

57. Massive PE Thrombolytic Therapy highly individualized ICU admission
reserved for echocardiographic right heart failure

58. Thrombolysis for sub-massive PE
n = 238
Endpoint = escalation of therapy or death. NEJM 2002;347;1143

59. Post-Thrombotic Syndrome
Variously defined
pain and swelling post-DVT
20 – 50%

60. 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)

61. What are rutosides?
A substance produced from leaves & flowers of the plant Sophora japonica

62. 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

63. What happens to the Thrombus?

64. How well are we doing?

65. Chart review of admissions Jewish General Hospital, Montreal 1996-1997 (1 yr post 1995 guidelines)

66. preventable
17%

68. Improving adherence to Thrombophylaxis Guidelines
Getting better grades
Improving adherence to
Thrombophylaxis Guidelines

74. 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