Limited diagnostic workup for deep vein thrombosis after major joint surgery

SummaryWhile deep vein thrombosis (DVT) may be clinically suspected at several time points after major orthopedic surgery, clinical examination is often unreliable, and compression ultrasonography (CUS) screening at discharge is of limited value. A prospective cohort study was carried out in 1,033 consecutive patients who had undergone major hip or knee surgery, aimed to assess the accuracy of a strategy consisting of clinical investigation followed by CUS in the detection of proximal DVT before discharge. The circumferences of both legs were measured in all patients; those exhibiting >2 cm difference between them were considered to have suspected DVT, and underwent bilateral CUS. The same diagnostic workup was repeated on days 45 and 90 after surgery. Three patients developed pulmonary embolism (PE) during admission (one died). Five additional patients died before discharge. Routine clinical evaluation before discharge was done in 1,025 patients, and 105 (10%) had suspected DVT. CUS confirmed the diagnosis in 24 (2.3% of the overall series). After discharge, 59 patients had suspected DVT on day 45, 53 on day 90. DVT diagnosis was confirmed by CUS in 27 (26%).Three additional patients developed PE (1 fatal). This translates into a sensitivity of the routine examinations at discharge of 44%. A limited diagnostic workup for DVT before discharge has the capacity to identify 44% of those patients who will become symptomatic afterwards.

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Rates of proximal deep vein thrombosis as assessed by compression ultrasonography in patients receiving prolonged thromboprophylaxis with low molecular weight heparin after major orthopedic surgery

Thrombosis and Haemostasis ◽

10.1160/th05-01-0077 ◽

2005 ◽

Vol 94 (09) ◽

pp. 532-536 ◽

Cited By ~ 4

Author(s):

Hans-Jürgen Hesselschwerdt ◽

W. Dieter Paar ◽

Karl-Ludwig von Hanstein ◽

Sebastian Schellong

Keyword(s):

Deep Vein Thrombosis ◽

Orthopedic Surgery ◽

Postoperative Phase ◽

Rehabilitation Center ◽

Vein Thrombosis ◽

Rehabilitation Centers ◽

Increased Risk ◽

Major Orthopedic Surgery ◽

Deep Vein ◽

Compression Ultrasonography

SummaryPatients undergoing major orthopedic surgery are at an increased risk of thromboembolism even after the acute postoperative phase. Therefore, prolonged thromboprophylaxis is currently recommended and widely used. The length of hospital stay after major orthopedic surgery is steadily decreasing and most patients are transferred to specialized rehabilitation centers in the early postoperative phase. Consequently, thromboprophylaxis is usually given during the rehabilitation period. Previously there have been no systematic studies of how many patients with asymptomatic thrombosis are transferred to a rehabilitation center or how many patients develop deep vein thrombosis (DVT) during rehabilitation. In the present study, 238 patients who had undergone major orthopedic surgery were examined by compression ultrasonography on day 1 or 2 and on day 20 of their rehabilitation phase in order to detect asymptomatic proximal DVT. Sonograms were read centrally with blinding to the clinical course of the patients. All patients received standard thromboprophylaxis during the acute postoperative phase. Prolonged thromboprophylaxis with enoxaparin was given during the rehabilitation phase. The mean duration of thromboprophylaxis was 36.8 days. At admission to the rehabilitation center, proximal DVT was identified in 16 patients (6.7%). New proximal DVT at discharge from the rehabilitation center was identified in 3.2% of patients following prolonged thromboprophylaxis with enoxaparin. In conclusion, a considerable percentage of patients with asymptomatic proximal DVT are transferred to rehabilitation centers following major orthopedic surgery. Using prolonged thromboprophylaxis, new proximal DVTs will still develop during rehabilitation, but at a low rate.

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Occurrence of late symptomatic deep vein thrombosis (DVT) after major orthopedic surgery

Fibrinolysis and Proteolysis ◽

10.1016/0268-9499(90)90238-f ◽

1990 ◽

Vol 4 ◽

pp. 84

Author(s):

L.N. Jørgensen ◽

E. Albrecht-Beste ◽

A. Leffers ◽

N.T. Nielsen

Keyword(s):

Deep Vein Thrombosis ◽

Orthopedic Surgery ◽

Symptomatic Deep Vein Thrombosis ◽

Vein Thrombosis ◽

Major Orthopedic Surgery ◽

Deep Vein

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Deep Vein Thrombosis and Pulmonary Embolism Considerations in Orthopedic Surgery

Orthopedic Clinics of North America ◽

10.1016/j.ocl.2016.12.003 ◽

2017 ◽

Vol 48 (2) ◽

pp. 127-135 ◽

Cited By ~ 10

Author(s):

Jasmine Saleh ◽

Mouhanad M. El-Othmani ◽

Khaled J. Saleh

Keyword(s):

Pulmonary Embolism ◽

Deep Vein Thrombosis ◽

Orthopedic Surgery ◽

Vein Thrombosis ◽

Deep Vein

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Deep-vein thrombosis rates after major orthopedic surgery in Asia. An epidemiological study based on postoperative screening with centrally adjudicated bilateral venography

Journal of Thrombosis and Haemostasis ◽

10.1111/j.1538-7836.2005.01621.x ◽

2005 ◽

Vol 3 (12) ◽

pp. 2664-2670 ◽

Cited By ~ 117

Author(s):

F. PIOVELLA ◽

C-J. WANG ◽

H. LU ◽

K. LEE ◽

L. H. LEE ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Epidemiological Study ◽

Orthopedic Surgery ◽

Vein Thrombosis ◽

Major Orthopedic Surgery ◽

Deep Vein

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Bleeding and recurrent VTE with apixaban vs warfarin as outpatient treatment: time-course and subgroup analyses

Blood Advances ◽

10.1182/bloodadvances.2019001081 ◽

2020 ◽

Vol 4 (2) ◽

pp. 432-439 ◽

Cited By ~ 2

Author(s):

Derek Weycker ◽

Gail DeVecchis Wygant ◽

Jennifer D. Guo ◽

Theodore Lee ◽

Xuemei Luo ◽

...

Keyword(s):

Pulmonary Embolism ◽

Deep Vein Thrombosis ◽

Outpatient Treatment ◽

Time Points ◽

Vein Thrombosis ◽

Study Population ◽

Recurrent Vte ◽

Deep Vein ◽

Bridge Therapy

Abstract In the phase 3 trial Apixaban for the Initial Management of Pulmonary Embolism and Deep-Vein Thrombosis as First-Line Therapy, apixaban was noninferior to enoxaparin, overlapped and followed by warfarin, in the treatment of venous thromboembolism (VTE) with significantly less bleeding; in a real-world evaluation, risks for bleeding and recurrent VTE were lower with apixaban vs warfarin plus parenteral anticoagulant (PAC) bridge therapy. The present study extends this research by comparing outcomes over time and within selected subgroups. A retrospective observational cohort design and 4 US private health care claims databases were used. Study population included patients who initiated outpatient treatment with apixaban or warfarin (plus PAC bridge therapy) for VTE. Major bleeding, clinically relevant nonmajor (CRNM) bleeding, and recurrent VTE were compared during the 180-day follow-up period, at selected follow-up time points (days 21, 90, 180), and within subgroups (pulmonary embolism [PE] with or without deep vein thrombosis [DVT], DVT only, provoked VTE, unprovoked VTE) using multivariable shared frailty models. Study population consisted of 20 561 apixaban patients and 35 080 warfarin patients; baseline characteristics were comparable. Overall, at selected follow-up time points, and within the aforementioned subgroups, adjusted risks were lower among apixaban vs warfarin patients: major bleeding, by 27% to 39%, CRNM bleeding, by 17% to 28%, and recurrent VTE, by 25% to 39% (all P ≤ .01). In this real-world study of VTE patients, risks of bleeding and recurrent VTE were lower among apixaban (vs warfarin) patients during the 180-day follow-up period, at selected follow-up time points, and within subgroups defined by index VTE episode.

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