Andrew J. Hughes, Emanuele Chisari, Javad Parvizi.

Response/Recommendation: In line with the current guidelines, we recommend that consideration should be given to treat proximal deep venous thrombosis (DVT), affecting popliteal or suprapopliteal vessels, arising acutely in patients undergoing orthopaedic procedures.

Strength of Recommendation: Moderate.

Rationale: Venous thromboembolism (VTE) is a well-recognized complication following lower limb orthopaedic surgery^1,2. Peak onset of DVT is within postoperative weeks two and three^3,4, with the risk remaining elevated for 6 – 12 weeks, falling gradually thereafter until 4 – 6 months postoperatively^5-8. Asymptomatic proximal DVT, affecting popliteal and suprapopliteal vessels, have been reported to constitute 27% of all DVT occurring following total hip arthroplasty (THA), and 15% of all DVT post total knee arthroplasty (TKA)^9,10. Unprovoked proximal DVT are a cause for concern given their tendency to firstly recur^11-16, and secondly to have a higher potential to propagate and cause pulmonary embolus (PE)^11-16. Although such causal relationship for patients undergoing orthopaedic procedures has not been proven^17-19. Relating to unprovoked DVT, consensus exists amongst the published guidelines stipulating that proximal DVT should be treated to avoid progression and prevent potential fatal PE. A causal relationship between the provoked postoperative DVT and PE has yet to be clearly demonstrated in the orthopaedic setting, however despite the serious risks associated with administration of anticoagulation, treatment is currently recommended within the published guidelines, whilst awaiting clarification by way of formal investigation^5,19-22.

There are, however, guidelines by various organizations related to this subject matter. The American College of Chest Physicians (ACCP), the European Society of Cardiology (ESC), and the American Society of Hematology (ASH) suggest that acute postoperative proximal DVT should be treated with an anticoagulation agent, preferably a direct oral anticoagulant (DOAC)^20,23-25. The guidelines also stipulate that some DOAC, namely dabigatran and edoxaban, should be administered after 5 – 10 days of parenteral low-molecular-weight heparin (LMWH)^20,24,25. The ACCP suggests that a vitamin K antagonist should be favored as second-line over that of LMWH therapy, following appropriate bridging, with a recommended international normalized ratio (INR) target of 2.0 to 3.0 for the duration of treatment^5,24-26. In patients with active cancer, and a confirmed acute postoperative DVT, the ACCP and ESC suggest LMWH as the first line given its favorable profile in reducing recurrent episodes of VTE in such patients^20,24,27.

The above guidelines recommend that the anticoagulation should be continued for three months^5,20,24,25. The decision for extended treatment beyond three months must be based on the risk-benefit ratio for each individual patient²⁰.

Regarding the suspected postoperative DVT, patients post lower limb orthopaedic surgery almost certainly attain a Well’s score of at least 2, until the twelfth postoperative week. The published guidelines suggest commencing treatment with parenteral anticoagulation in situations where a diagnostic Doppler ultrasound may be delayed longer than 4 hours^5,20,28. Current healthcare services cannot guarantee a Doppler ultrasound within this timeframe, most notably when patients present acutely over a weekend. Given the heightened risks of anticoagulation-associated hematoma, wound drainage, and surgical site infection (SSI) in the perioperative setting, orthopaedic surgeons have reservations about commencing therapeutic anticoagulation before confirming the diagnosis^19-22. Perhaps, in the setting of a suspected DVT, when a Doppler cannot be performed within 4 hours, patients post lower limb orthopaedic surgery should continue on their VTE prophylaxis regimen, unless considered to be of significantly high risk by way of a history of thrombophilia or active cancer, in advance of organizing an urgent scan the next day.

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 DVT^{5,20,24,25,29,30}. Adjuvant catheter-directed thrombolysis may be considered in patients with acute iliofemoral disease, with symptoms less than 14 days, and a life expectancy greater than 1 year²⁰. Inferior vena cava (IVC) filters are suggested only for patients with contraindications to anticoagulation therapy, and routine use of IVC filter in addition to anticoagulation is not recommended^{5,24,25,31-34}. Ambulation is recommended, although severe pain and swelling may require deferral^5,20. 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 benefit in preventing the onset of post-thrombotic syndrome^20,24,25.

Whilst guidelines suggest anticoagulation therapy based on population characteristics, the optimal treatment choice for each individual must be ascertained, based on a careful risk assessment, incorporating the preferences of both the patient and their family, following informed consent and shared decision making.

References:

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2.         Keller K, Hobohm L, Barco S, Schmidtmann I, Münzel T, Engelhardt M, et al. Venous thromboembolism in patients hospitalized for knee joint replacement surgery. Nature Sci Rep. 2020;10:22440.

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17.       Della Valle CJ, Steiger DJ, DiCesare PE. Duplex ultrasonography in patients suspected of postoperative pulmonary embolism following total joint arthroplasty. Am J Orthop. 2003;32(8):386-8.

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20.       Mazzolai L, Aboyans V, Ageno W, Agnelli G, Alatri A, Bauersachs R, et al. Diagnosis and management of acute deep vein thrombosis: a joint consensus document from the European Society of Cardiology working groups of aorta and peripheral vascular diseases and pulmonary circulation and right ventricular function. Eur Heart J. 2018;39(47):4208-18.

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27.       Carrier M, Cameron C, Delluc A, Castellucci L, Khorana AA, Lee AY. Efficacy and safety of anticoagulant therapy for the treatment of acute cancer-associated thrombosis: a systematic review and meta-analysis. Thromb Res. 2014;134(6):1214-9.

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30.       Garcia MJ, Lookstein R, Malhotra R, Amin A, Blitz LR, Leung DA, et al. Endovascular management of deep vein thrombosis with rheolytic thrombectomy: final report of the prospective multicenter PEARL (peripheral use of angiojet rheolytic thrombectomy with a variety of catheter lengths) registry. J Vasc Interv Radiol. 2015;26:777-85.

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34.       Mismetti P, Laporte S, Pellerin O, Ennezat PV, Couturaud F, Elias A, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism: a randomized clinical trial. JAMA. 2015;313:1627-35.