- Discussion:
-
indications for treatment:
- proximal DVT:
- proximal propagation of a distal DVT
- some authors advocate that isolated asymptomatic distal DVT can be followed on serial Duplex Ultra-sound, and does not require treatment;
- distal DVT will propagate proximally in less than 10-20% of cases, and has a low risk of PE;
- serial ultrasound can be performed on POD 7 and 14;
- in the review by L. Laird and PW Jorgensen (Orthopedics Jun 2000 Vol 23 No 655), the authors advocate treatment of asymptomatic calf
vein thrombosis inorder to reduce the chance of throbosis extension as well as post-thrombotic venous syndrome;
- refereneces:
-
Is anticoagulation indicated for asymptomatic postoperative calf vein thrombosis
-
The significance of calf thrombi after total knee arthroplasty
-
The clinical course of distal deep venous thrombosis after total hip and total knee arthroplasty, as determined with duplex ultrasonography.
-
Incidence and natural history of below-knee deep venous thrombosis in high-risk trauma patients.
- superficial thrombophlebitis:
- begin treatment with warm compresses, aspirin, and leg elevation;
- more aggressive anticoagulation is required with more advanced symptoms;
-
treatment modalities for DVT:
-
heparin
- IV Heparain is started to keep PTT > 2.0 times normal.
- need to be aware of heparin induced thrombocytopenia.
- references:
-
Heparin for 5 days as compared with 10 days in the initial treatment of proximal venous thrombosis.
-
Original Articles: SubQ LMWH Heparin Compared With Continuous IV Heparin In The Treatment Of Proximal-Vein Thrombosis.
-
warfarin
- patient must be anticoaguated with Heparin before Coumadin is started in order to avoid skin necrosis.
- coumadin is continued for a minimum of 3 months to treat DVT, but longer duration of treatment is
considered with risk factors (such as carcinoma or obesity);
- consider
PUD prophylaxis;
-
dextran:
- used less often, due to concerns about induced CHF;
-
duration of treatment:
- standard recommendations range from 3-6 months;
- in the study by
Paul M Ridker, M.D et al, the authors demonstrated that long-term,
low-intensity warfarin therapy is a highly effective method of preventing recurrent venous thromboembolism;
- patients assigned to placebo or low-intensity warfarin (target INR, 1.5 to 2.0) had a risk reduction of 64 percent P<0.001)
- in the future, patients with DVT may be tested for thrombophilias (inherited suseptibility), and recommendations
for length of treatment are based accordingly;
- patients with DVT need to wear fitted compression stockings for at least two years;
- this will reduce the incidence of the post-thrombotic syndrome by 50 percent;
- in the report by G. Agnelli et al 2001, the authors sought to determine the optimal duration of treatment;
- patients with a first episode of idiopathic proximal DVT who had completed 3 months of oral anticoagulant therapy were
randomly assigned to the discontinuation of oral anticoagulants or to their continuation for 9 additional months;
- analysis showed that of 134 patients assigned to continued oral anticoagulant therapy, 21 had a recurrence of DVT (15.7 %; average follow-up, 37.8 months),
as compared with 21 of 133 patients assigned to the discontinuation of oral anticoagulant therapy (15.8 percent; average follow-up, 37.2 months),
resulting in a relative risk of 0.99 (95 % CI, 0.57 to 1.73);
- incidence of recurrence after the discontinuation of treatment was 5.1 % per patient-year in patients
in whom oral anticoagulant therapy was discontinued after 3 months and 5.0 percent per patient-
year in patients who received an additional 9 months of oral anticoagulant therapy;
- the authors concluded that the clinical benefit associated with extending the duration of anticoagulant therapy
to one year is not maintained after the therapy is discontinued;
-
use of D-dimer to length of treatment:
-
D-Dimer and Duration of Anticoagulation.
-
D-Dimer Testing to Determine the Duration of Anticoagulation Therapy.
- references:
- Three Months versus One Year of Oral Anticoagulant Therapy for Idiopathic Deep Venous Thrombosis
Giancarlo Agnelli, M.D. NEJM Vol 345:165-169 Jul 2001 No 3
-
Long-Term, Low-Intensity Warfarin Therapy for the Prevention of Recurrent Venous Thromboembolism
-
Comparison of Low-Intensity Warfarin Therapy with Conventional-Intensity Warfarin Therapy for Long-Term Prevention of Recurrent Venous Thromboembolism.
- Superficial DVT:
- references:
-
Treatment for superficial thrombophlebitis of the leg.
-
Post-thrombotic syndrome
- compression stockings:
-
Compression stockings to prevent post-thrombotic syndrome: a role for anticoagulation clinics?
-
Non-pharmaceutical measures for prevention of post-thrombotic syndrome.
-
Use of elastic compression stockings after deep venous thrombosis: a comparison of practices and perceptions of thrombosis physicians and patients.
-
Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial.
References
Comparison of Enoxaparin and Warfarin for the Prevention of Venous Thromboembolic Disease After Total Hip Arthroplasty. Evaluation During Hospitalization and Three Months After Discharge
CW Colwell et al JBJS July 1999, Vol 81-A, No 7.
Finding the right fit: Effective thrombosis risk stratification in orthopeadic patients.
JI Arcelus MD PhD et al. Orthopedics. Jun 2000. Vol 23. No 6. p 633.
