Three Phases of Thrombotic Events of the Lower Extremity
Phase 1 Prevention Marlin W. Schul, MD, RVT, FACPh Medical Director, Owner Lafayette Regional Vein & Laser Center Vein Facts - Present 10x persons suffer from venousinsufficiency vs. PAD All age groups may be affected Stasis Ulcers affect 500,000persons 20,000 new stasis ulcers/year Vein Facts - Present VTE occurs in 1/20 persons over lifetime
>500,000 are hospitalized forDVT/PE each year Fatal PE represents the 3rd mostcommon cause of death amonghospitalized patients. Vein Facts - Present DVT and PE are preventable!
Studies have shown >40% of cases failed toreceive prophylaxis.* Patients surviving VTE +/- PE areplagued with chronic pain andswelling *Spyropoulos A.Emerging Strategies in the Prevention of Venous Thromboembolism in Hospitalized Medical Patients.Chest 2005; 128: Vein Facts - Present REITE Registry over 30,000 DVT JAMA Oct/2013
77% occur following hosp. D/C 55% happen after proph. D/C DVT risk rises over 100 days after ortho surgery Median time to VTE event 74 days after hospitalization JAMA Oct/2013 Paradoxical findings Increased prophylaxis/Inc. incidence Increased surveillance/Inc. incidence Vein Facts - Present In 2005, US Senate passed aresolution declaring the month ofMarch as National DVT AwarenessMonth Joint Commission and CMS havedeclared VTE as a area of concern NEVER EVENTS! The Burden of DVT Population-Based Studies: High Incidence of VTE VTE: An Important Problem Among Hospital Patients Percentage of Patients at Risk for VTE by Country Percentage of At-Risk Patients Receiving Recommended Prophylaxis Pulmonary Embolism Carries a High Mortality Rate Poor Clinical Outcomes After VTE Treatment The Natural History of Acute DVT
DVT is a chronic disease of coagulation Early natural history is a dynamic balance between Recanalization Greatest change in thrombus burden occurs over first 3-6 months 55% with complete recanalization at 6 months Recurrent thrombotic events Late natural history dominated by recurrent VTE Underlying thrombotic risk factors Extent of recanalization Degree of active coagulation Long-term outcomes related to natural history Rapid recanalization protects valve function Recurrent DVT predicts reflux & PTS Pre-test Question 1 The three tenets of Virchow's triad carry equal weight. A) True B) False Pathophysiology of VTE
Vessel Injury Stasis Virchows Triad Hypercoagulability Congenital Acquired Situational Combined FVL APL Antibodies Surgery Elev. Homocys. C20210A Malignancy Trauma Elev. F VIII Protein C & S Adv. Age Pregnancy AT III OCP/HRT Venous Thrombosis: a multi-causal disease Rosendaal FR, Lancet 1999
Risk Factors are SYNERGISTIC NOT ADDITIVE Oral contraceptives + FVL = X risk Surgery (1.6%) + ATIII (0.8%) = 12.7%/yr Risk Curve Age Thrombotic Potential FVL OCP Time Background Use slide with Virchow's triadand assymmetry of effect Case #1 47YOWM has left lower extremityarthroscopy because of knee painand inability to competitively playbasketball with his sons. What VTE risk factors does thispatient possess? Case #1 3 days after scope procedure limbis swollen and painful.He visitshis ortho doc three times over a 9month period and was toldeveryone has swelling and it willjust take time. LLE Duplex Exam: Noncompressible FV fromproximal FV to POPV; No evidence of superficial ordeep vein reflux; High antegrade flow of the greatsaphenous vein Could this have been prevented? Case #1 LLE Duplex Exam: Noncompressible FV from proximal FV to POPV;
No evidence of superficial ordeep vein reflux; High antegrade flow of the greatsaphenous vein Text box. Could this event have possibly been prevented? Background Epidemic Most preventable cause of hospital death
Surgeon General Focus CMS Focus 'Never Events' Hospitalized subjects vs.outpatient risk assessment Is risk the same? Medical patients vs. Surgicalpatients? Risk to whom? Fatal PE image Pre-test Question 2 Which of the following statements of compression therapy is true? A) Compression increases flow rates of the deep venous system; B) Compression is proven to reduce occupational edema; C) Calf high mmHg stockings are proven to reduce the incidence of post-thrombotic syndrome by 50%; D) TED stockings have proven benefit in nonambulatory subjects; E) All of the above Start with Healthy Vein Habits
Ambulation/Active Lifestyle Avoid prolonged sitting or standing Target 10k steps per day Compression Therapy Increase flow velocities of DVS Minimize occupational hazards Maintaining Normal Weight BMI 40+ increases VTE Risk 3-fold Role of Compression Therapy
Reduce complication rates andsymptoms following acute DVT Reduce the incidence of PTS by50% when worn in acute DVT fortwo years (article image) Reduces occupational edema Enhances ulcer healing rates Primary treatment forlymphedema subjects Individualized Risk Assessment: Caprini Score Risk Assessment In Practice?
Outpatient Medical/Surgical Inpatient Considerations Primary care tool for patientsconcerned with this risk; Pre-surgical risk assessmenttool, and guide to safepropylaxis. All patients carry risk, yet riskvaries and cannot be seen by thenaked eye; Risk Assessment in Practice Risk Assessment in Practice Overall Risk/Benefit Analysis
Risks without individual assessment Benefits of individual assessment Subjects with risk fail to be identified life/limb threatening events occur Subjects without risk may be at riskwith prophylactic doses of LMWH Medicolegal consequences Failure to treat Economic consequences Never events, etc. Appropriate risk stratification protectspatients without risk, and identifiessubjects with risk that need extra carebecause of risk Recongized as a best practice CMS Measures are met PQRS credits are met Lower event rates/Lower readmissionrates Value of Individualized Risk Stratification
Identify At-Risk Individuals Protect based upon risk Ambulation Compression Anticoagulation Recognize events will still occur Frequency of events will decline Boston University U of Michigan Texas Health Resources Risk Stratification? Early Ambulation SCD's Either
Low Risk Priorities Caprini RiskAssessment Score