Updated: 12/21/2019

Deep Vein Thrombosis

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Introduction
  • Introduction
    • procedures associated with greater frequency of DVT
      • spine fracture with paralysis 
      • elective total knee arthroplasty 
        • 2-3X greater rate of DVT than THA
      • elective total hip arthroplasty 
      • hip fracture 
      • polytrauma 
    • based on AAOS review, the rate of DVT does not correlate with PE or death following THA or TKA
Presentation
  • Symptoms
    • pain in leg
  • Physical exam
    • often more helpful than imaging
      • pain and swelling 
      • Homan's sign is not very specific
Imaging
  • Imaging
    • venography is gold standard
    • for proximal DVTs (proximal to trifurcation)
      • venous duplex ultrasound is 96% sensitive, 97% specific; operator dependent 
        • routine duplex screening is not recommended
      • plethysmography is 75% sensitive, 90% specific
      • CT is 90% sensitive, 95% specific
Studies
  • D-Dimer testing 
    • sensitive marker for VTE and excludes VTE without the need for further testing among patients with of low clinical probability of PE
    • not helpful post-injury or surgery
    • levels > 500 ng/mL suggest the presence of PE
Treatment
  • Nonoperative
    • heparin therapy followed by oral anticoagulation
      • indications
        • postoperative DVT above knee
        • treatment for DVT below knee is controversial
      • medications
        • direct oral anticoagulants, including the direct thrombin inhibitor dabigatran and the factor Xa inhibitors rivaroxaban, apixiban, and edoxaban, are now recommended by the 2016 American College of Chest Physicians and 2014 and 2017 European Society of Cardiology guidelines for both DVT and PE
      • duration
        • in patients with VTE provoked by surgery, the risk of recurrence after treatment is low and anticoagulation is recommended for only 3 months
        • for patients with an unprovoked DVT, there is a high risk of recurrence and anticoagulation should be continued indefinitely unless bleeding risk is high
  • Operative
    • vena cava filter placement
      • indications
        • preoperative identification of DVT in a patient with lower extremity or pelvic trauma who is high risk for DVT development
        • see anticoagulation topic
      • catheter-directed thrombolysis 
        • indications
          • indicated as initial treatment recommended only for patients with threatened limb loss
Complications
  • Postthrombotic syndrome: chronic venous insufficiency
    • venous HTN
    • chronic skin issues (swelling, pain, pigmentation, ulceration, induration)
    • recurrent DVT (4-8x higher after first DVT)
     
the greatest risk of activation of the clotting cascade during total hip arthroplasty occurs during insertion of the femoral component;
 

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