Effect of Venous Duplex Surveillance on VTE in the Neurosurgical … · 2019-08-10 · Surveillance for DVT •174 neurosurgical patients •Screening protocol of venous duplex •Patients

Effect of Venous Duplex Surveillance on VTE in the

Neurosurgical Population

Donato Pacione MD FAANS

Assistant Professor

Director of Quality Improvement

Department of Neurosurgery NYU School of Medicine

VTE in the Neurosurgical Population

• 1,777,035 Patients form the NSQIP database

• VTE 1.7%

•DVT 1.3%

• PE 0.6%

• Cranial 3.4% vs Spine 1.1%

• Independent Factors

• Ventilator Dependence

• Immobility (quadraparesis, hemiparesis, paraparesis)

•Malignancy

•Chronic Steroid Use

• Sepsis

Rolston JD et. Al. “What Clinical Factors predict deep venous

thrombosis and pulmonary embolism in Neurosurgical patients”.

Journal Neurosurgery Oct 121 (4) ,2014. 2

Incidence of VTE in Neurosurgical Spine Procedures

• Review of 22,434 patients undergoing spine surgery

•DVT 0.8%

• PE 0.4%

• Score >7 associated with 100 fold increase in VTE

Piper K et. Al. Risk Factors Associated with Venous

Thromboembolism in patients undergoing spine surgery.

J Neurosurg Spine.Sept 2, 2016.3

Incidence of VTE in Neurosurgical Cranial Procedures

• Review of 10,477 patients undergoing craniotomy

•DVT 2.4 %

• PE 1.3 %

Alagattas H et. Al. Analysis of VTE risk in craniotomy

patients. World Neurosurgery 2015.06.033.

4

Effect of Neoplastic Disease

• Review of 3,098 patients undergoing craniotomy

• 1741 patients undergoing craniotomy for neoplasm

• 731 benign

• 1010 malignant

• Rate of DVT

• 3.2 % neoplasm vs 1.4% non neoplasm (OR 2.3)

• Rate of PE

• 1.8% neoplasm vs 0.5% non neoplasm (OR

3.61)

Kimmell K et. Al. Risk Factors for Venous

Thromboembolism in patients undergoign craniotomy for

neoplastic disease. J Neuroncology 2014, 120:567-5735

VTE in Malignant Glioma

• Examined 317 high grade glioma patients

• IDH 1 wild type

• VTE 26-30%

• IDH 1 mutant

• VTE 0%

• No significant difference in length of surgery or neurologic deficit

• IDH 1 wild type tumors found to have microthrombi

• IDH 1 mutant no evidence of microthrombi

• Confirmed IDH 1 mutant cells create antithrombotic activity

• Wild type GBM significantly more likely to develop VTE

PresenUnruh D, Schwarze SR, Khoury L, Thomas C, Wu

M, Chen L, Chen R, Liu Y, Schwartz MA, Amidei C,

Kumthekar P, Benjamin CG, Song K, Dawson C, Rispoli

JM, Fatterpekar G, Golfinos JG, Kondziolka D,

Karajannis M, Pacione D, Zagzag D, McIntyre T,

Snuderl M, Horbinski C. Mutant IDH1 and thrombosis

in Gliomas, Acta Neuropathol. 2016 Dec;132(6):917-

930. Epub 2016 Sep 23. 6

DVT in Spinal Metastasis

• A review of 314 patients undergoing preoperative venous duplex

• DVT 9.48 %

• DVT Ambulatory 6.4% vs NonAmbulatory 24.4% (OR 4.73)

• 41 patients with DVT had placement of IVC filter (no complications from filter)

• 4 (1.3%)patients with postop PE

• 3 had negative preop screening

• 1 had positive DVT preop and IVD filter placement

Zacharia B et. Al. Incidence and risk factors for

preoperative dvt in 314 consecutive patients undergoing

surgery for spinal metastasis. J Neurosurg Spine June2,

2017.7

• 219 patients with prophylactic IVC filter due to risk factors

•History of DVT/PE, Current Malignancy, Hypercoagulable State, Prolonged Immobility,

Staged Procedure >5 levels, Anterior/Posterior, Iliocaval Manipulation, Anesthesia >8h,

Smoker, Estrogen/Progesterone

• 41 (18.7%) patients with DVT

• 8 (3.6%) patients with PE

• 2 (0.9%) developed IVC thrombus

• 1 (0.5%) paradoxical embolism

Presentation Title Goes Here 8

Surveillance for DVT

• 174 neurosurgical patients

• Screening protocol of venous duplex

• Patients non ambulatory for 7 days

•Weekly screening until ambulatory

• 312 venous duplex performed

• 21.8% DVT rate

• 0% PE

• Mechanical prophylaxis in all patients and variable chemoprophylaxis

•DVT rate of 19% vs 41%

• Isolated Calf DVT 37.7%

• 0% developed PE

Dermody M et. La. “The Utility of Screening for Deep

Venous Thrombosis in Asymptomatic, Non-ambulatory

Neurosurgical Patients”. Journal of Vascular Surgery

May 2011.

9

Neurosurgery at NYU VTE Surveillance


• 2017 VTE rate 1.9%

• 1.6 % DVT

• 0.3% PE

• In 2015-2016

• 1606 Discharges

•Ordered 751 dopplers

• 39 DVT

• 25 (64%) IVCF

• 14 (36%) observation

• 5 PE with DVT

• 5 PE with negative duplex

• Neurosurgery accounts for 14% of all

venous duplex studies in the medical

center

Cardiothoracic Surgery Adult Cardiac 8

Cardiothoracic Surgery Thoracic 2

Emergency Medicine 8

Medicine Cardiology 21

Medicine Critical Care Pulmonary 42

Medicine General Internal Medicine 126

Medicine Hematology Oncology 18

Neurology Epilepsy 2

Neurology General 12

Neurology Neuro Critical Care 1

Neurosurgery 52

ObGyn Obstetrics 7

Ortho Surg Adult Reconstructive 1

Ortho Surg Trauma Fracture 1

Otolaryngology Head and Neck

Surgery 4

Radiology 1

Rehabilitation Medicine

Cardiopulmonary 9

Rehabilitation Medicine General 16

Surgery Bariatric Surgery 6

Surgery General Surgery 21

Surgery Transplant Surgery 4

Surgery Vascular Surgery 1

Urology 4

VTE Surveillance Protocol

• Prospective surveillance of neurosurgical inpatients with preoperative venous duplex as

part of the standard preoperative workup:

• Any inpatient that is scheduled for a non emergent neurosurgical procedure will have a

venous duplex ordered on admission/transfer.

• Patients with a DVT will undergo placement of retrievable IVC filter prior to

neurosurgical procedure

• Plan for filter removal once anticoagulation is deemed safe from neurosurgical

prospective.

• Post operative Surveillance:

• A venous duplex should be performed in any patient with signs or symptoms of DVT

• A CT PE chest should be performed in any patient with signs or clinical symptoms of

PE.

• Surveillance Duplex once weekly should be performed in patients who are ventilator

dependent (>48 hours), Unable to ambulate independently, active cancer diagnosis,

history of VTE, BMI>40, were on therapeutic anticoagulation preoperatively


Protocol Effect


VTE and Venous Duplex Comparison

2015-2016 2018-2019

Total Discharges 1606 1832

DVT 1.6% 0.32%

PE 0.3% 0.21%

Venous Duplex 751 349

Post Protocol Results


Preoperative Surveillance

Preoperative Venous Duplex 60

Preoperative DVT Present on

Admission

7 (11.7%)

Location of DVT

Proximal 3

Isolated Calf 4

Preoperative PE 1

Treatment of Preoperative VTE

IVC Filter 3

Observation 4

Postoperative PE 0

Protocol Results


20%

50%

10%

20%

Factors Associated with Positive Preoperative Screening Duplex

Active Cancer

Nonambulatory

Hx DVT

No factors

Post Protocol Deep Dive Comparison

• Pre Protocol Group

• 7/1/17-12/31/17

• Post Protocol Group

• 5/1/18-10/31/18

• Inclusion Criteria

• Age >18

•Neurosurgical Drain left in place

• LOS>= 4 days


Benign Tumor

20%

Malignant Tumor

12%Degenerative Spine

24%

Hemorrhage6%

Vascular Pathology

that has not bled5%

Infection3%

Other30%

Pre Protocol Diagnosis

Benign Tumor

22%

Malignant Tumor

9%

Degenerative Spine30%

Hemorrhage6%

Vascular Pathology

that has not bled4%

Infection4%

Other25%

Post Protocol Diagnosis


Pre and Post Protocol Deep Dive Comparison

Pre Protocol Post Protocol

Total Patients 221 224

Postop DVT 12 (5.4%) 4 (1.8%)

Proximal 1 0

Isolated Calf 11 4

Treatment of DVT

IVC Filter 1 0

Observation 11 4

Propagation to PE 0 0

Postop PE 3 (1.4%) 2 (0.9%)

Concurrent DVT 0 0

Post Protocol Evaluation


69%

13%

12%6%

Indication for Postoperative Venous Duplex

surveillance

edema

fever

pain

Venous Duplex Protocol Change


• Preoperative Screening Criteria

• History VTE

• Nonambulatory

• Active cancer

• Symptomatic

• Postoperative

• Venous Duplex only if symptomatic

• CT PE is symptomatic

• No “Surveillance”

Venous Duplex Protocol Change


• Total Venous Duplex : 24

• Actual Postoperative

Venous Duplex Reasons

• Surveillance : 10

• Edema: 2

• Fever :1

• Prior to TXA: 1

• Duplex Reduction

• Pre Protocol : 62/month

• Post Protocol 1:

29/month

• Post Protocol 2:

12/month

Preoperative Surveillance

Preoperative

Venous Duplex

10

Preoperative

DVT Present

on Admission

4 (40%)

Location of

DVT

Above the Knee 3

Below the Knee 1

Preoperative PE 1

Treatment of

Preoperative

VTE

IVC Filter 3

Observation 1

Postoperative

PE

0

Postoperative Surveillance

Postoperative

Venous Duplex

14

Postoperative

DVT

1(7.1%)

Location of DVT

Above the Knee 0

Below the Knee 1

Treatment of

Postoperative

VTE

IVC Filter 0

Observation 1

Postoperative

PE

0

VTE Lessons Learned

1. Everhardt D, Vaccaro J, et. Al. Retrospective

Analysis of Outcomes following IVC Filter Placement

in a Managed Care Population. J Thromb

Thrombolysis. 2017, Aug 44 (2), 179-189.

2. Charalel RA, et. Al . Statewide Inferior Vena Cave

Placement, Complications, and Retrievals:

Epidemiology and Recent Trends. Med Care 2018,

Mar; 56(3) , 260-265

20

• Venous Duplex surveillance does not prevent PE

• Venous duplex is not a substitute for CT PE

study

• Venous Duplex in asymptomatic patient does not

prevent PE

• Venous Duplex surveillance in asymptomatic

patients increases rate of diagnosis of below

knee DVT

• Below knee DVT does not become PE

• Risk of PE from IVC filter > risk from below knee

DVT1,2

Acknowledgements

• John G. Golfinos MD

• Ariane Lewis MD

•Myra Trang NP

• Julia Bevilacqua NP

• Janine Healey NP

•Danielle Golub

• Aaron Rothstein MD

• Peter Rozman MD

•David Kurland MD


Thank You

Documents

Effect of Venous Duplex Surveillance on VTE in the Neurosurgical … · 2019-08-10 · Surveillance for DVT •174 neurosurgical patients •Screening protocol of venous duplex •Patients