1. Three Phases of Thrombotic Events of the Lower Extremity
Phase 1 – Prevention
Marlin W. Schul, MD, RVT, FACPh
Medical Director, Owner – Lafayette Regional Vein & Laser Center

2. Vein Facts - Present
10x persons suffer from venous insufficiency vs. PAD
All age groups may be affected
Stasis Ulcers affect 500,000 persons
20,000 new stasis ulcers/year

3. Vein Facts - Present VTE occurs in 1/20 persons over lifetime
>500,000 are hospitalized for DVT/PE each year
Fatal PE represents the 3rd most common cause of death among hospitalized patients.

4. Vein Facts - Present DVT and PE are preventable!
Studies have shown >40% of cases failed to receive prophylaxis.*
Patients surviving VTE +/- PE are plagued with chronic pain and swelling
*Spyropoulos A. “Emerging Strategies in the Prevention of Venous Thromboembolism in Hospitalized Medical Patients.” Chest 2005; 128:

5. Vein Facts - Present REITE Registry over 30,000 DVT JAMA Oct/2013
77% occur following hosp. D/C
55% happen after proph. D/C
DVT risk rises over 100 days after ortho surgery
Median time to VTE event 74 days after hospitalization
JAMA Oct/2013
Paradoxical findings
Increased prophylaxis/Inc. incidence
Increased surveillance/Inc. incidence

6. Vein Facts - Present
In 2005, US Senate passed a resolution declaring the month of March as National DVT Awareness Month
Joint Commission and CMS have declared VTE as a area of concern
NEVER EVENTS!

7. The Burden of DVT

8. Population-Based Studies: High Incidence of VTE

9. VTE: An Important Problem Among Hospital Patients

10. Percentage of Patients at Risk for VTE by Country

11. Percentage of At-Risk Patients Receiving Recommended Prophylaxis

12. Pulmonary Embolism Carries a High Mortality Rate

13. Poor Clinical Outcomes After VTE Treatment

14. The Natural History of Acute DVT
DVT is a chronic disease of coagulation
Early natural history is a dynamic balance between
Recanalization
Greatest change in thrombus burden occurs over first 3-6 months
55% with complete recanalization at 6 months
Recurrent thrombotic events
Late natural history dominated by recurrent VTE
Underlying thrombotic risk factors
Extent of recanalization
Degree of active coagulation
Long-term outcomes related to natural history
Rapid recanalization protects valve function
Recurrent DVT predicts reflux & PTS

15. Pre-test Question 1
The three tenets of Virchow's triad carry equal weight. A) True B) False

16. Pathophysiology of VTE
Vessel Injury
Stasis
Virchow’s Triad
Hypercoagulability
Congenital
Acquired
Situational
Combined
FVL
APL Antibodies
Surgery
Elev. Homocys.
C20210A
Malignancy
Trauma
Elev. F VIII
Protein C & S
Adv. Age
Pregnancy
AT III
OCP/HRT

17. Venous Thrombosis: a multi-causal disease Rosendaal FR, Lancet 1999
Risk Factors are SYNERGISTIC NOT ADDITIVE
Oral contraceptives + FVL = X risk
Surgery (1.6%) + ATIII (0.8%) = 12.7%/yr
Risk Curve
Age
Thrombotic Potential
FVL
OCP
Time

18. Background
Use slide with Virchow's triad and assymmetry of effect

19. Case #1
47YOWM has left lower extremity arthroscopy because of knee pain and inability to competitively play basketball with his sons.
What VTE risk factors does this patient possess?

20. Case #1
3 days after scope procedure limb is swollen and painful. He visits his ortho doc three times over a 9 month period and was told everyone has swelling and it will just take time.
LLE Duplex Exam:
Noncompressible FV from proximal FV to POPV;
No evidence of superficial or deep vein reflux;
High antegrade flow of the great saphenous vein
Could this have been prevented?

21. Case #1 LLE Duplex Exam: Noncompressible FV from proximal FV to POPV;
No evidence of superficial or deep vein reflux;
High antegrade flow of the great saphenous vein
Text box…. Could this event have possibly been prevented?

22. Background Epidemic Most preventable cause of hospital death
Surgeon General Focus
CMS Focus – 'Never Events'
Hospitalized subjects vs. outpatient risk assessment
Is risk the same?
Medical patients vs. Surgical patients?
Risk to whom?
Fatal PE image

23. Pre-test Question 2
Which of the following statements of compression therapy is true? A) Compression increases flow rates of the deep venous system; B) Compression is proven to reduce occupational edema; C) Calf high mmHg stockings are proven to reduce the incidence of post-thrombotic syndrome by 50%; D) TED stockings have proven benefit in nonambulatory subjects; E) All of the above

24. Start with Healthy Vein Habits
Ambulation/Active Lifestyle
Avoid prolonged sitting or standing
Target 10k steps per day
Compression Therapy
Increase flow velocities of DVS
Minimize occupational hazards
Maintaining Normal Weight
BMI 40+ increases VTE Risk 3-fold

25. Role of Compression Therapy
Reduce complication rates and symptoms following acute DVT
Reduce the incidence of PTS by 50% when worn in acute DVT for two years (article image)
Reduces occupational edema
Enhances ulcer healing rates
Primary treatment for lymphedema subjects

26. Individualized Risk Assessment: Caprini Score

27. Risk Assessment In Practice?
Outpatient Medical/Surgical
Inpatient Considerations
Primary care tool for patients concerned with this risk;
Pre-surgical risk assessment tool, and guide to safe propylaxis.
All patients carry risk, yet risk varies and cannot be seen by the naked eye;

28. Risk Assessment in Practice

29. Risk Assessment in Practice

30. Overall Risk/Benefit Analysis
Risks without individual assessment
Benefits of individual assessment
Subjects with risk fail to be identified – life/limb threatening events occur
Subjects without risk may be at risk with prophylactic doses of LMWH
Medicolegal consequences
Failure to treat
Economic consequences
Never events, etc.
Appropriate risk stratification protects patients without risk, and identifies subjects with risk that need extra care because of risk
Recongized as a best practice
CMS Measures are met
PQRS credits are met
Lower event rates/Lower readmission rates

31. Value of Individualized Risk Stratification
Identify At-Risk Individuals
Protect based upon risk
Ambulation
Compression
Anticoagulation
Recognize events will still occur
Frequency of events will decline
Boston University
U of Michigan
Texas Health Resources

32. Risk Stratification? Early Ambulation SCD's Either
Low Risk Priorities – Caprini Risk Assessment Score <3
Moderate Risk Priorities – Caprini Assessment Score 3-4
Early Ambulation
SCD's
Either
Early ambulation & SCDs OR
SCD's and pharmacological prophylaxis

33. Risk Stratification? SCDs and appropriate pharmacologic prophylaxis
High Risk Subjects with Caprini Score 5 or greater
Subjects w/High Caprini Scores and High Bleeding Risks
SCDs and appropriate pharmacologic prophylaxis
LMWH (Best Practice)
Heparin (alternative to LMWH)
Xa Inhibitor (Total Joint procedures)
Challenging situation yet more information is known by risk assessment
Options
IVC Filter placement
Compression/Ambulation

34. Caprini Score In Action
Validated
Surgical setting
SICU setting
Hospitalized patients
ENT Surgery
Plastic Surgery
Highly Sensitive Scoring System must be balanced by bleeding risk.

35. Challenges Identifying Individual risk
Education needs
EPIC Platform to facilitate
Evidence Based Recommendations
Simplified Order Sets
Local Thresholds for Intervention
Post hospitalization risk exists
Identifying patients at risk will help facilitate extended prophylaxis when indicated.

36. What’s Next on September 11, 2015
Phase 2 – Acute VTE Management (Focus on DVT Lower Extremity) Phase 3 – Preventing Long-term Complications of PTS/Recurrent DVT