77 – How should patients with post-operative proximal (popliteal or supra-popliteal) DVT be managed?

77 – How should patients with post-operative proximal (popliteal or supra-popliteal) DVT be managed?

Andrew J. Hughes, Emanuele Chisari, Javad Parvizi.

Response/Recommendation: Proximal deep venous thrombosis (DVT) affecting the popliteal or supra-popliteal vessels carries a high risk of propagation after lower limb orthopaedic surgery. Treatment recommendations consist of anticoagulation for three months in the setting of an acute provoked postoperative proximal DVT.

Strength of Recommendation: Moderate.

Rationale: Venous thromboembolism (VTE) is a major healthcare concern, and those undergoing lower limb orthopaedic surgery are one of the highest risk patient groups1,2. The peak onset of DVT is within 2 and 3 weeks postoperatively3,4, with the risk remaining elevated for 6-12 weeks, and falling gradually thereafter until 4-6 months postoperatively5–8. Proximal DVT, affecting popliteal and supra-popliteal vessels, have been reported to occur in 27% of all DVT following total hip arthroplasty (THA) and 15% of all DVT after total knee arthroplasty (TKA)9,10. Proximal DVT are of particular concern given their tendency to propagate and cause pulmonary embolism (PE) in 40-50% of cases11–16. Such DVTs also display a higher rate of recurrence than their distal counterparts that are isolated to the calf11–16. Given their tendency to propagate, proximal DVT carry a mortality risk of up to 25% in the absence of adequate anticoagulation17.

A high index of suspicion is required when assessing a patient with possible proximal DVT. The American College of Chest Physicians (ACCP) and European Society of Cardiology (ESC) suggest commencing treatment with parenteral anticoagulation in patients with a high clinical suspicion, as well as those with an intermediate clinical suspicion in whom diagnosis may be delayed for longer than 4 hours5,18.

In non-cancer patients with a confirmed acute postoperative proximal DVT, the ACCP, ESC and the American Society of Hematology (ASH) suggest first-line treatment with a direct oral anticoagulant (DOAC), such as dabigatran, rivaroxaban, apixaban or edoxaban18–21. All of these guidelines stipulate that dabigatran and edoxaban must be administered after 5-10 days of parenteral low-molecular-weight heparin (LMWH)18,20,21. The ACCP suggests that a vitamin K antagonist should be favored as second-line over LMWH therapy, following appropriate bridging, with a recommended target international normalized ratio (INR) of 2.0 to 3.0 for the duration of treatment5,20–22. In the setting of an acute provoked postoperative proximal DVT, the ACCP, ESC, and ASH guidelines advocate that anticoagulation is continued for a minimum of 3-months5,18,20,21. The decision for extended treatment beyond 3-months must be based on the risk-benefit ratio for each individual patient18.

Special considerations must be made when dealing with perioperative patients and chronic VTE risk factors, owing to unique challenges warranting hematological consultation. In patients with active cancer and a confirmed acute postoperative DVT, the ACCP and ESC suggest LMWH, given its favorable profile in reducing recurrent episodes of VTE18,20,23. For patients at > 1% risk for developing heparin-induced thrombocytopenia (HIT), or heparin-induced thrombocytopenia and thrombosis (HITT), close monitoring of the platelet count every 2 to 3 days until discontinuation of heparin therapy is recommended5. Development of HITT requires the use of non-heparin anticoagulation5. Pregnant patients are recommended to receive adjusted-dose subcutaneous LMWH instead of unfractionated heparin, vitamin K antagonists, oral direct thrombin inhibitors, and anti-Xa inhibitors5,18,20. In addition, it is recommended that pediatric hematologists with subspecialty expertise in thromboembolism manage pediatric patients with VTE disease5.

Anticoagulation is suggested in favor of catheter-directed thrombolysis, systemic thrombolysis and operative venous thrombectomy, in the setting of non-limb-threatening acute postoperative proximal DVT5,18,20,21,24,25. Adjuvant catheter-directed thrombolysis may also be considered in patients with acute iliofemoral disease, with symptoms less than 14 days, and a life expectancy greater than 1 year18. Inferior vena cava (IVC) filters are suggested only for patients with contraindications to anticoagulation therapy. Routine IVC filter insertion in addition to anticoagulation is not recommended, in light of the risks of access site hematoma, lower limb DVT, filter thrombosis, and the need for subsequent removal with possible retrieval failure5,20,21,26–29. Ambulation is recommended, although severe pain and swelling may require deferral5,18. Compression stockings are not routinely recommended in the setting of an acute provoked postoperative proximal DVT unless providing symptomatic relief, as the literature has not proven any significant benefit in preventing the onset of post-thrombotic syndrome18,20,21.

The primary goal of postoperative VTE treatment is to prevent fatal PE30. In addition, prevention of recurrent VTE is sought, which has proven to be equivocal amongst DOAC and vitamin K antagonists, with indirect comparisons showing that no DOAC is superior to another20,22. The concerns of the orthopaedic community pertain to the perioperative anticoagulation-associated risks of major bleeding, hematoma, wound drainage, and infection31–34. Orthopaedic patients are among the highest risk group to sustain a perioperative bleeding event during a course of anticoagulation35. The risk of bleeding has been shown to be lower in the setting of DOAC therapy compared to that of vitamin K antagonists22,36–39. Of the DOAC’s mentioned within this consensus statement, apixaban has been shown to carry the lowest risk of gastrointestinal bleeding, based on indirect comparisons extrapolated in the setting of atrial fibrillation, however this has not yet been proven in the setting of VTE36–38,40. Based on reduced bleeding risk, the lack of required monitoring, and cost-effectiveness, DOAC have been recently favored over vitamin K antagonists in the published clinical practice guidelines20,21,41,42.

The scope of this consensus statement pertains to the setting of acute provoked postoperative proximal DVT. Guidelines have been formulated to prevent DVT and PE based on generalized population characteristics. It is imperative that hematological advice is sought to clarify an individual’s need for alternative or prolonged therapy while accounting for risk factors for recurrent thrombosis or anticoagulation-associated bleeding. Such scenarios requiring particular consideration in the perioperative setting include, but are not limited to, renal impairment, liver disease, prior VTE, bleeding diatheses, extremes of body weight, and malabsorption18,20. Whilst current guidelines suggest anticoagulation therapy based on population characteristics, patient-specific factors, particularly individual and family preferences voiced after informed consent and shared decision-making, will ultimately determine the optimal treatment choice.

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