William T. Li, Man Hong Cheung, Kenneth L. Urish.
Response/Recommendation: There is little high-quality literature available regarding treatment of soleal vein thrombosis after orthopaedic surgery. The rate of propagation of soleal vein thrombosis to proximal veins is very low. Thus, these patients may be managed by close monitoring, which may include repeat imaging, and possible administration of aspirin (ASA).
Strength of Recommendation: Limited.
Rationale: Venous thromboembolism (VTE) of the soleal vein has been considered to be the most commonly involved vein in VTE of the distal lower extremity1,2. Soleal VTE is part of a group known as muscular calf VTE, which also includes VTE of the gastrocnemius vein. Muscular deep venous thrombosis (DVT) comprises up to half of distal VTE, and VTE of soleal vein has been associated with proximal VTE and fatal pulmonary embolism (PE) in a number of postmortem studies3–6. Specifically, propagation rates of muscular calf VTE to more proximal DVT vary from 1.2% – 25%, and progression to PE is reported from rare to 20.7%2,3,14,4,7–13. Mortality rates in muscular calf VTE are more limited with a single study reporting a rate of 0.5% secondary to PE15.
There is a paucity of orthopaedic literature on patients with an isolated soleal VTE as a high percentage are found in concurrence with VTE of adjacent veins. This is further complicated by inconsistencies in the current literature with regards to the optimal method of how to manage both soleal and muscular calf DVT. Several studies directly compare therapeutic anticoagulation versus prophylaxis to mechanical treatment. A prospective cohort study compared patients who had acute muscular DVT treated with therapeutic low-molecular-weight heparin (LMWH) and compression therapy versus compression therapy alone. They found that LMWH significantly lowered thrombus progression to deep calf veins (95% confidence interval [CI] 11.5 – 43.4%)16. Other retrospective studies substantiate the aforementioned findings by showing that therapeutic doses of anticoagulation significantly decrease the risk of PE, the time to vein recanalization after DVT, and VTE recurrence in patients with both muscular and distal DVT9,11,17,18. These studies also argue that a therapeutic dosage is more effective than prophylactic dose of anticoagulants11,18.
There are also several studies that argue against the use of therapeutic anticoagulation for the treatment of soleal and muscular calf VTE. A randomized controlled study of 109 patients diagnosed with muscular calf vein thrombosis compared therapeutic LMWH and calf stockings to calf stockings alone. Therapeutic LMWH did not decrease the rate of clot propagation10. Likewise, there are a number of retrospective studies and systematic reviews that examine the conflicting evidence of treating muscular calf DVT. Conclusions of these articles mostly favor compression therapy, prophylactic chemoprophylaxis, and doppler monitoring8,19–22.
The use of high doses of anticoagulation in the prevention of VTE is associated with adverse events and should be approached with caution. Therapeutic anticoagulation results in an increased bleeding risk which is associated with its own postoperative complications23–25. Many studies demonstrate that lowering postoperative bleeding may decrease post-operative surgical infections26–29. Furthermore, patients receiving more aggressive does of anticoagulation had an increase in postoperative wound complications but no change in overall VTE rates30.
In knee and hip arthroplasty, ASA has an increased safety profile and current evidence has demonstrated its non-inferiority to more aggressive forms of VTE chemoprophylaxis. In an institutional registry study comparing warfarin and ASA, no difference was observed in VTE rates while warfarin was associated with increased rates of mortality and infection31,32.
Conclusion: Recommendations for the treatment of soleal VTE remains unclear. There is a paucity of clinical studies in the orthopaedic literature to support standardized guidelines. Most existing studies arise from the vascular field and thus there is a lack of external validity due to inherent differences in patient populations. Furthermore, there is a paucity of literature examining outcomes solely related to soleal vein VTE. Due to these concerns, chemoprophylaxis anticoagulation should be based on stratification of risk of thrombus propagation vs. bleeding in the immediate postoperative period. The American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines on VTE prophylaxis also recommends early mobilization as a consensus recommendation for patients at high-risk of VTE when appropriate. The use of ASA has been shown to be effective for patients with distal DVT32, and may be considered in patients with soleal vein thrombosis32. Finally, the use of repeat imaging after initial diagnosis has proven to be beneficial in guiding further management. This would balance patient safety by avoiding both the risks of VTE propagation and generation of postoperative complications, such as bleeding, arising from administration of aggressive anticoagulation. High-quality studies are needed to further guide treatment recommendations.
References:
1. Ro A, Kageyama N. Clinical Significance of the Soleal Vein and Related Drainage Veins, in Calf Vein Thrombosis in Autopsy Cases with Massive Pulmonary Thromboembolism. Ann Vasc Dis. 2016;9(1):15-21. doi:10.3400/avd.oa.15-00088
2. Singh K, Yakoub D, Giangola P, et al. Early follow-up and treatment recommendations for isolated calf deep venous thrombosis. J Vasc Surg. 2012;55(1):136-140. doi:10.1016/j.jvs.2011.07.088
3. Wang CJ, Wang JW, Weng LH, Huang CC, Yu PC. Clinical significance of muscular deep-vein thrombosis after total knee arthroplasty. Chang Gung Med J. 2007;30(1):41-46.
4. Oishi CS, Grady-Benson JC, Otis SM, Colwell CW, Walker RH. The clinical course of distal deep venous thrombosis after total hip and total knee arthroplasty, as determined with duplex ultrasonography. J Bone Jt Surg – Ser A. 1994;76(11):1658-1663. doi:10.2106/00004623-199411000-00009
5. Kageyama N, Ro A, Tanifuji T, Fukunaga T. Significance of the Soleal Vein and its Drainage Veins in Cases of Massive Pulmonary Thromboembolism. Ann Vasc Dis. 2008;1(1):35-39. doi:10.3400/avd.avdoa07004
6. Ro A, Kageyama N. Clinical Significance of the Soleal Vein and Related Drainage Veins, in Calf Vein Thrombosis in Autopsy Cases with Massive Pulmonary Thromboembolism. Ann Vasc Dis. 2016;9(1):15-21. doi:10.3400/avd.oa.15-00088
7. Wu AR, Garry J, Labropoulos N. Incidence of pulmonary embolism in patients with isolated calf deep vein thrombosis. J Vasc Surg Venous Lymphat Disord. 2017;5(2):274-279. doi:10.1016/j.jvsv.2016.09.005
8. Kret MR, Liem TK, Mitchell EL, Landry GJ, Moneta GL. Isolated calf muscular vein thrombosis is associated with pulmonary embolism and a high incidence of additional ipsilateral and contralateral deep venous thrombosis. J Vasc Surg Venous Lymphat Disord. 2013;1(1):33-38. doi:10.1016/j.jvsv.2012.04.001
9. Park YJ, Lee KB, Kim DI, et al. Risk factors for delayed recanalization of calf vein thrombosis. J Korean Surg Soc. 2012;82(5):306-311. doi:10.4174/jkss.2012.82.5.306
10. Schwarz T, Buschmann L, Beyer J, Halbritter K, Rastan A, Schellong S. Therapy of isolated calf muscle vein thrombosis: A randomized, controlled study. J Vasc Surg. 2010;52(5):1246-1250. doi:10.1016/j.jvs.2010.05.094
11. Lautz TB, Abbas F, Walsh SJN, et al. Isolated gastrocnemius and soleal vein thrombosis: Should these patients receive therapeutic anticoagulation? Ann Surg. 2010;251(4):735-742. doi:10.1097/SLA.0b013e3181c1ae95
12. Gillet JL, Perrin MR, Allaert FA. Short-term and mid-term outcome of isolated symptomatic muscular calf vein thrombosis. J Vasc Surg. 2007;46(3):513-519. doi:10.1016/j.jvs.2007.04.040
13. MacDonald PS, Kahn SR, Miller N, Obrand D. Short-term natural history of isolated gastrocnemius and soleal vein thrombosis. J Vasc Surg. 2003;37(3):523-527. doi:10.1067/mva.2003.149
14. Ohgi S, Tachibana M, Ikebuchi M, Kanaoka Y, Maeda T, Mori T. Pulmonary embolism in patients with isolated soleal vein thrombosis. Angiology. 1998;49(9):759-764. doi:10.1177/000331979804901008
15. Galanaud JP, Sevestre MA, Genty C, et al. Comparison of the clinical history of symptomatic isolated muscular calf vein thrombosis versus deep calf vein thrombosis. J Vasc Surg. 2010;52(4):932-938.e2. doi:10.1016/j.jvs.2010.05.019
16. Schwarz T, Schmidt B, Beyer J, Schellong SM. Therapy of isolated calf muscle vein thrombosis with low-molecular-weight heparin. Blood Coagul Fibrinolysis. 2001;12(7):597-599. doi:10.1097/00001721-200110000-00014
17. Utter GH, Dhillon TS, Salcedo ES, et al. Therapeutic anticoagulation for isolated calf deep vein thrombosis. JAMA Surg. 2016;151(9):1-9. doi:10.1001/jamasurg.2016.1770
18. Yoon DY, Riaz A, Teter K, et al. Surveillance, anticoagulation, or filter in calf vein thrombosis. J Vasc Surg Venous Lymphat Disord. 2017;5(1):25-32. doi:10.1016/j.jvsv.2016.08.007
19. Elfandi A, Anghel S, Sales C. Current management of isolated soleal and gastrocnemius vein thrombosis. J Vasc Surg Venous Lymphat Disord. 2015;3(3):341-344. doi:10.1016/j.jvsv.2015.02.002
20. Yun WS, Lee KK, Cho J, Kim HK, Kyung HS, Huh S. Early treatment outcome of isolated calf vein thrombosis after total knee arthroplasty. J Korean Surg Soc. 2012;82(6):374-379. doi:10.4174/jkss.2012.82.6.374
21. Masuda EM, Kistner RL, Musikasinthorn C, Liquido F, Geling O, He Q. The controversy of managing calf vein thrombosis. J Vasc Surg. 2012;55(2):550-561. doi:10.1016/j.jvs.2011.05.092
22. Sales CM, Haq F, Bustami R, Sun F. Management of isolated soleal and gastrocnemius vein thrombosis. J Vasc Surg. 2010;52(5):1251-1254. doi:10.1016/j.jvs.2010.05.102
23. Sachs RA, Smith JH, Kuney M, Paxton L. Does anticoagulation do more harm than good? A comparison of patients treated without prophylaxis and patients treated with low-dose warfarin after total knee arthroplasty. J Arthroplasty. 2003;18(4):389-395. doi:10.1016/S0883-5403(03)00071-8
24. Patel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Jt Surg – Ser A. 2007;89(1):33-38. doi:10.2106/JBJS.F.00163
25. Drain NP, Gobao VC, Bertolini DM, et al. Administration of Tranexamic Acid Improves Long-Term Outcomes in Total Knee Arthroplasty. J Arthroplasty. 2020;35(6):S201-S206. doi:10.1016/j.arth.2020.02.047
26. Parvizi J, Ghanem E, Joshi A, Sharkey PF, Hozack WJ, Rothman RH. Does “Excessive” Anticoagulation Predispose to Periprosthetic Infection? J Arthroplasty. 2007;22(6 SUPPL.):24-28. doi:10.1016/j.arth.2007.03.007
27. Hughes LD, Lum J, Mahfoud Z, Malik RA, Anand A, Charalambous CP. Comparison of Surgical Site Infection Risk Between Warfarin, LMWH, and Aspirin for Venous Thromboprophylaxis in TKA or THA: A Systematic Review and Meta-Analysis. JBJS Rev. 2020;8(12). doi:10.2106/JBJS.RVW.20.00021
28. Klement MR, Padua FG, Li WT, Detweiler M, Parvizi J. Tranexamic Acid Reduces the Rate of Periprosthetic Joint Infection After Aseptic Revision Arthroplasty. J Bone Joint Surg Am. 2020;102(15):1344-1350. doi:10.2106/JBJS.19.00925
29. Tan TL, Foltz C, Huang R, et al. Potent Anticoagulation Does Not Reduce Venous Thromboembolism in High-Risk Patients. J Bone Jt Surg – Am Vol. 2019;101(7):589-599. doi:10.2106/JBJS.18.00335
30. Novicoff WM, Brown TE, Cui Q, Mihalko WM, Slone HS, Saleh KJ. Mandated Venous Thromboembolism Prophylaxis. Possible Adverse Outcomes. J Arthroplasty. 2008;23(6 SUPPL.):15-19. doi:10.1016/j.arth.2008.04.014
31. Huang RC, Parvizi J, Hozack WJ, Chen AF, Austin MS. Aspirin Is as Effective as and Safer Than Warfarin for Patients at Higher Risk of Venous Thromboembolism Undergoing Total Joint Arthroplasty. J Arthroplasty. 2016;31(9):83-86. doi:10.1016/j.arth.2016.02.074
32. Omari AM, Parcells BW, Levine HB, Seidenstein A, Parvizi J, Klein GR. 2021 John N. Insall Award: Aspirin is effective in preventing propagation of infrapopliteal deep venous thrombosis following total knee arthroplasty. Bone Jt J. 2021;103(7):18-22. doi:10.1302/0301-620X.103B6.BJJ-2020-2436.R1