Management of Deep Vein Management of Deep Vein Thrombos in Total Joint Thrombos in Total Joint

ArthroplastyArthroplasty

Total Hip and Knee SymposiumTotal Hip and Knee Symposium

Los Cabos, MexicoLos Cabos, Mexico

Frank R. Ebert, MDFrank R. Ebert, MDAssistant Chief Assistant Chief

DepartmentDepartmentofof

OrthopædicsOrthopædics

The Union Memorial HospitalThe Union Memorial Hospital

Baltimore, MarylandBaltimore, Maryland

Number of Orthopedic Number of Orthopedic Replacement Procedures/YearReplacement Procedures/Year

Total knee replacements:Total knee replacements:267,000/year 267,000/year in the USin the US

Total hip replacements:Total hip replacements: more thanmore than

168,000/year 168,000/year in in the USthe US

AAOS Website availiable at:http://orthoinfo.aaos.org/booklet/bookviacfm?Thread_ID=2&topcategory=kneehttp://orthoinfo.aaos.org/booklet/bookview.cfm?Thread_ID=2&topcategory=hip

The Cost of DVTThe Cost of DVT

Risk persists for a long time following Risk persists for a long time following surgery.surgery.

90% of medical re-admissions following 90% of medical re-admissions following TJR are due to DVT; substantial direct TJR are due to DVT; substantial direct inpatient costs related to DVTinpatient costs related to DVT

Venous Thromboembolism:Venous Thromboembolism:PathogenesisPathogenesis

VenousthrombiVenousthrombiUsually form in regions of sluggish or altered Usually form in regions of sluggish or altered

flow in large venous sinusesflow in large venous sinusesMay break off, travel to lung – PEMay break off, travel to lung – PE

Pathogenic factorsPathogenic factorsActivation of blood coagulationActivation of blood coagulationVenous stasisVenous stasisVascular injuryVascular injury

Venous Thromboembolism:Venous Thromboembolism:Natural HistoryNatural History

Hip ProceduresHip ProceduresHave a higher frequency of proximal clotsHave a higher frequency of proximal clots

Knee ProceduresKnee ProceduresDeep calf veinsDeep calf veins

Usually asymptomaticUsually asymptomaticThrombi tend to be smallThrombi tend to be smallPropagation is an issuePropagation is an issue

Venous Thromboembolism:Venous Thromboembolism:Natural History (cont’d)Natural History (cont’d)

Proximal vein thrombiProximal vein thrombiPoplitealPoplitealSuperficial femoralSuperficial femoralCommon femoralCommon femoral Iliac veinsIliac veins

Spontaneous lysis of large thrombi Spontaneous lysis of large thrombi uncommonuncommon

Strong association between DVT and PEStrong association between DVT and PE

Venous Thromboembolism:Venous Thromboembolism:DiagnosisDiagnosis

Clinical Exam 50/50Clinical Exam 50/50Venous duplex ultrasoundVenous duplex ultrasoundVenographyVenography

Venous Thromboembolism:Venous Thromboembolism:Diagnosis (cont’d)Diagnosis (cont’d)

Venous duplex ultrasoundVenous duplex ultrasoundNoninvasiveNoninvasiveAssesses vein compressibilityAssesses vein compressibilityVery sensitive in proximal thrombiVery sensitive in proximal thrombiLess sensitive in distalLess sensitive in distal

Venous Thromboembolism:Venous Thromboembolism:Diagnosis (cont’d)Diagnosis (cont’d)

VenographyVenographyFDA standard for DVTFDA standard for DVTClinically outmodedClinically outmoded

Pulmonary Embolism:Pulmonary Embolism:DiagnosisDiagnosis

ScreeningScreeningV/Q scanV/Q scan

Effective non-invasive techniqueEffective non-invasive techniqueProbability of PE based on degree of mismatch Probability of PE based on degree of mismatch

between ventilation and perfusionbetween ventilation and perfusion

Pulmonary Embolism:Pulmonary Embolism:Diagnosis (cont’d)Diagnosis (cont’d)

Definitive testDefinitive testPulmonary Pulmonary

angiogramangiogramSpiral CTSpiral CT

Hirsh J, Hoak J. Circulation. 1996;93:2213.

Venous Thromboembolism:Venous Thromboembolism:PrognosisPrognosis

Proximal DVT: postoperative, good, Proximal DVT: postoperative, good, if treated for 3 months with anticoagulant therapyif treated for 3 months with anticoagulant therapy

Recurrent events: 5%Recurrent events: 5% After discontinuation of anticoagulant therapy: After discontinuation of anticoagulant therapy:

5% to 10% after 1 year5% to 10% after 1 year Approximately 30% after 8 yearsApproximately 30% after 8 years

Anderson FA Jr, Wheeler HB. Clin Chest Med. 1995;16:236.

Clinical Risk Factors for DVTClinical Risk Factors for DVT

Major surgery (eg, total joint arthroplasty)Major surgery (eg, total joint arthroplasty) History of DVTHistory of DVT Age ≥40Age ≥40 ObesityObesity Prolonged immobilityProlonged immobility Genetic predisposition to hematologic abnormalitiesGenetic predisposition to hematologic abnormalities TraumaTrauma Other: malignancy, coronary syndromes Other: malignancy, coronary syndromes

(eg, unstable angina)(eg, unstable angina)

* DVT prevalence statistics obtained by use of mandatory postoperative venography.† Represents the upper limit of prevalence statistics for each procedure.

Geerts WH, et al. Chest. 2001;119(suppl):140S.

0

10

20

30

40

50

60

70

80

90

100

All DVT Proximal DVT Fatal PE

Hip arthroplasty

Knee arthroplasty

Hip fracture surgery

% o

f p

atie

nts

*†

57%

84%

60%

36%

20%

36%

0.4%0.7%

12.9%

Hip Fracture, Hip Arthroplasty, Knee Hip Fracture, Hip Arthroplasty, Knee Arthroplasty, and VTE Risk (Upper Limits) in Arthroplasty, and VTE Risk (Upper Limits) in Patients without Anticoagulative ProphylaxisPatients without Anticoagulative Prophylaxis

Patients Not Receiving Patients Not Receiving Anticoagulation Prophylaxis: Anticoagulation Prophylaxis:

SummarySummary Orthopedic surgery creates the ideal conditions Orthopedic surgery creates the ideal conditions

for the development of DVTfor the development of DVT Vascular damageVascular damage Venous stasisVenous stasis HypercoagulabilityHypercoagulability

≥≥50% of patients undergoing orthopedic surgery 50% of patients undergoing orthopedic surgery will develop DVTwill develop DVT Most frequently utilized agents all demonstrate Most frequently utilized agents all demonstrate

superiority compared with placebosuperiority compared with placebo

Current Strategies for DVT Current Strategies for DVT ProphylaxisProphylaxis

Mechanical Mechanical prophylaxisprophylaxis

Pharmacologic Pharmacologic anticoagulant anticoagulant therapytherapy

Combination therapyCombination therapyRegional anesthesiaRegional anesthesia

Current Strategies:Current Strategies:Mechanical ProphylaxisMechanical Prophylaxis

Intermittent pneumatic Intermittent pneumatic compression (IPC)compression (IPC)

Pneumatic plantar Pneumatic plantar compression (foot compression (foot pump)pump)

1.1. Literature supports use – Literature supports use – Sarmiento JBJS 1999Sarmiento JBJS 1999

2.2. Ineffective when BMI > Ineffective when BMI > 25 kg/m25 kg/m22

Current Strategies:Current Strategies:Mechanical Prophylaxis (cont’d)Mechanical Prophylaxis (cont’d)AdvantagesAdvantages

Local antistasis effectsLocal antistasis effectsSystemic humeral effectsSystemic humeral effectsNo increase in bleeding riskNo increase in bleeding risk

DisadvantagesDisadvantagesPatient intolerancePatient intoleranceCompliance difficultiesCompliance difficulties Impractical post-hospital discharge applicationImpractical post-hospital discharge applicationLess effective when BMI >25Less effective when BMI >25

Current Strategies:Current Strategies:Anticoagulant Therapy and Anticoagulant Therapy and

IndicationsIndicationsOral agentsOral agents

Warfarin (dose-adjusted to INR 2.0–3.0)Warfarin (dose-adjusted to INR 2.0–3.0)Prophylaxis of venous thrombosis and its Prophylaxis of venous thrombosis and its

extension, and pulmonary embolismextension, and pulmonary embolism

AspirinAspirinMay be effective when combined with mechanical May be effective when combined with mechanical

agents – Sarmiento JBJS 1999agents – Sarmiento JBJS 1999

Current Strategies:Current Strategies:Anticoagulant Therapy and Anticoagulant Therapy and

IndicationsIndications Injectable/parenteralInjectable/parenteral

Dose-adjusted unfractionated heparin (UFH)Dose-adjusted unfractionated heparin (UFH)Prophylaxis of venous thrombosis and its Prophylaxis of venous thrombosis and its

extensionextension

Low-molecular-weight heparins (LMWH)Low-molecular-weight heparins (LMWH)Dalteparin: total hip replacementDalteparin: total hip replacementEnoxaparin: total hip replacement, total knee Enoxaparin: total hip replacement, total knee

replacementreplacement

Current Strategies:Current Strategies:Oral Anticoagulant TherapyOral Anticoagulant Therapy

WarfarinWarfarinReduces DVT and symptomatic PE rateReduces DVT and symptomatic PE rate

Lieberman, et al. JBJS 1997Lieberman, et al. JBJS 1997

In combination with mechanical agents, has a In combination with mechanical agents, has a reduction in total DVT ratereduction in total DVT rate

Freedman, et al. JBJS 2000Freedman, et al. JBJS 2000

Current Strategies:Current Strategies:Oral Anticoagulant TherapyOral Anticoagulant Therapy

LMWHsLMWHs1.1. Fractionated Heparin 1/3 molecular weight of Fractionated Heparin 1/3 molecular weight of

standard Heparin – inhibits Clotting Factor 10standard Heparin – inhibits Clotting Factor 10

2.2. Binds less to plasma protein, increases Binds less to plasma protein, increases bioavailability of the LMWHsbioavailability of the LMWHs

Current Strategies:Current Strategies:Oral Anticoagulant TherapyOral Anticoagulant Therapy

LMWHsLMWHs EnoxaparinEnoxaparin

1.1. Dosage - 30mg SC twice dailyDosage - 30mg SC twice daily

2.2. Treatment begun within 24hrs after THATreatment begun within 24hrs after THA

3.3. Significant lowering DVT/PE rate comparable to Significant lowering DVT/PE rate comparable to WarfarinWarfarin Colwell, et al. JBJS 1994Colwell, et al. JBJS 1994

Current Strategies:Current Strategies:Oral Anticoagulant TherapyOral Anticoagulant Therapy

LMWHsLMWHs EnoxaparinEnoxaparin

1.1. In TKA may be superior to Warfarin in reducing DVT In TKA may be superior to Warfarin in reducing DVT rate.rate. Heit, et al. Thromb Haemost. 1997Heit, et al. Thromb Haemost. 1997

Current Strategies:Current Strategies:Oral Anticoagulant TherapyOral Anticoagulant Therapy

LMWHsLMWHs DalteparinDalteparin

1.1. Dosage – 2500 IU SC 4hrs post surgery followed by Dosage – 2500 IU SC 4hrs post surgery followed by 5000 IU SC daily5000 IU SC daily

2.2. Dalteparin proved effective in the reduction of total DVT Dalteparin proved effective in the reduction of total DVT and symptomatic PE when compared to Heparinand symptomatic PE when compared to Heparin Hull, et al. Arch Intern Med. 2000Hull, et al. Arch Intern Med. 2000

ANTI-COAGULANT THERAPY ANTI-COAGULANT THERAPY LMWH’sLMWH’s

Organon-Highly selective inhibitor for Organon-Highly selective inhibitor for factor Xfactor X

FDA approved for Hip Fracture, THA, TKAFDA approved for Hip Fracture, THA, TKA

DisadvantagesDisadvantages LMWHLMWH

SQ route SQ route Bleeding risksBleeding risks

1.1. Must initiate at least 12 hrs Must initiate at least 12 hrs post surgerypost surgery

2.2. Contraindicated in regional Contraindicated in regional anesthesia - FDAanesthesia - FDA

AdvantagesAdvantages• Rapid onsetRapid onset• No monitoring (LMWH)No monitoring (LMWH)• Superior efficacy (LMWH)Superior efficacy (LMWH)

Hirsh J, Hoak J. Circulation. 1996;93:2212-2245.

Current Strategies:Current Strategies:Parenteral Anticoagulant TherapyParenteral Anticoagulant Therapy

Current Strategies:Current Strategies:Anticoagulant TherapyAnticoagulant Therapy

Duration of Prophylactic TreatmentDuration of Prophylactic Treatment Clinical trials supports usage of prophylaxisClinical trials supports usage of prophylaxis

1.1. Period of hospitalization – 4-15 daysPeriod of hospitalization – 4-15 days

2.2. Post-hospitalization – (meta-analysis review) 19-28 Post-hospitalization – (meta-analysis review) 19-28 daysdays Hull, et al. Ann Intern Med. 2001Hull, et al. Ann Intern Med. 2001

Current Strategies:Current Strategies:Anticoagulant TherapyAnticoagulant Therapy

Indications for Greenfield Filter PlacementIndications for Greenfield Filter PlacementRecurrent history of pulmonary emboliRecurrent history of pulmonary emboliUnable to use anticoagulant therapy in the Unable to use anticoagulant therapy in the

presence of a DVTpresence of a DVTPresence of pulmonary emboli despite Presence of pulmonary emboli despite

anticoagulation therapyanticoagulation therapy

Hip Knee Hip Replacement Replacement Fracture

Stockings Adjuvant – –

Intermittent Adjuvant Yes Adjuvant pneumatic Grade 2C Grade 1Bcompression

Aspirin – – –

Adjusted-dose Yesunfractionated Grade 2A – –heparin

Warfarin Yes Yes Yes INR 2-3 INR 2-3 INR 2-3

Grade 1A Grade 1A Grade 1B

LMWH Yes Yes Yes Grade 1A Grade 1A Grade 1B

ACCP 2001 Recommendations: Based ACCP 2001 Recommendations: Based on 7 to 10 Days’ Treatmenton 7 to 10 Days’ Treatment

Geerts WH, et al. Chest. 2001;119(suppl):157S.

SUMMARYSUMMARY

Treatment of DVT is required following Treatment of DVT is required following THA, TKA,and Hip FractureTHA, TKA,and Hip Fracture

Aspirin has literature support clearly for Aspirin has literature support clearly for THATHA

Warfarin and LMWH clearly show Warfarin and LMWH clearly show effectivenss for THA,TKA,and Hip Fractureeffectivenss for THA,TKA,and Hip Fracture

Post discharge usage should be for up to Post discharge usage should be for up to 35 days post op35 days post op

SummarySummary

TJA places patients at risk for VTETJA places patients at risk for VTE Thromboprophylaxis: the standard of care Thromboprophylaxis: the standard of care

following TJA due to high rates of VTE without following TJA due to high rates of VTE without prophylaxisprophylaxis Significant variation in prescribing practicesSignificant variation in prescribing practices

There are no data for efficacy of combined There are no data for efficacy of combined mechanical/pharmacologic treatmentsmechanical/pharmacologic treatments

Novel thromboprophylactic agents potentially Novel thromboprophylactic agents potentially may improve risk/benefit ratiomay improve risk/benefit ratio

THANK-YOUTHANK-YOU