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.
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
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