Venothrombotic Disease & Urological Surgery

1. Venothrombotic Disease&Urological Surgery Jeffrey P Schaefer MSc MD FRCPC April 27, 2007

2. Biography • 1986  BSc microbiology U Sask • 1991  MD distinction U Sask • 1995  FRCPC Internal Medicine U Calg • 1999  MSc CHS (Epidemiology) U Calg • 2000  RGH Site Chief, Medicine • Interests: • education • integrative medicine • information technology

4. Why have this talk? • Define • Risk • Diagnosis • Prevention • Therapy • Prognosis

5. Venothrombotic disease (VTED) • superficial thrombophlebitis • deep vein thrombosis • lower limb • upper limb • pulmonary thromboembolism • post-thrombotic syndrome

6. Superficial Vein Thrombophlebitis

7. Superficial Vein Thrombophlebitis

8. Superficial Leg Veins  Saphenous (L & S)

9. Potentially Lethal Misnomer  SFV = deep

10. Deep Vein Thrombosis

11. Pulmonary Thromboembolism

12. Pulmonary Thromboembolism

13. Post-Thrombotic Syndrome • Variously defined • pain and swelling post-DVT • 20 – 50%

14. DVT - diagnosis • Clinical Suspicion • D-dimer screen • Compression Ultrasound • Venography • (MRI expensive) • (IPG ‘discredited’)

15. DVT - diagnosis • Clinical Suspicion - performs poorly

16. Well’s Criteria - study excluded those with previous VTED, needed indefinite anti-coagulation, imminent death

17. D - dimer • D-dimer Assay • D-dimer is breakdown product of fibrinolysis • high sensitivity (98%) & modest specificity (~50%) • useful for excluding DVT and PE • not useful for confirming diagnosis • SHOULD NOT TO BE USED • post-operative patient • pregnant patient • patient with malignancy

18. Duplex Ultrasonography • Duplex US • above knee DVT • Sens = 96% • Spec = 96% Haemostasis 23:61-7 • calf dvt • sens = 80%

19. Venography • Gold standard (sens 100%, spec 100%)

20. Pulmonary Thromboembolism

21. Pulmonary Thromboembolism • Diagnosis • Clinical • Ventilation - Perfusion Scan (V/Q scan) • Spiral CT Scan • Pulmonary Angiogram

22. PE - clinical diagnosis • Symptoms of PE in 117 previously normal patients • dyspnea 73% • pleuritic pain 66 • cough 37 • leg swelling 28 • leg pain 26 • hemoptysis 13 • palpitations 10 • wheezing 9 • angina-like pain 4 Chest 100:598, 1991

23. PE - clinical diagnosis • Signs of PE in 117 previously normal patients • tachypnea (20/min) 70% • rales (crackles) 51 • tachycardia (>100/min) 30 • fourth heart sound 24 • increased P2 23 • diaphoresis 11 • temperature >38.5°C 7 • wheezes 5 • Homans' sign 4 • right ventricular lift 4 • pleural friction rub 3 • third heart sound 3

24. Well’s PE Clinical Prediction Rule • Signs/Symptoms of DVT 3.0 • measured leg swelling AND • pain with palpation in the deep vein region • Alternative diagnoses less likely than PE 3.0 • history, physical exam, chest X-ray, EKG, lab results • Pulse > 100 beats/min 1.5 • Immobilization 1.5 • bedrest (except access to BR)  3 days OR • surgery in previous 4 weeks • Previous DVT or PE 1.5 • Hemoptysis 1.0 • Malignancy 1.0 • receiving active treatment for cancer OR • have received treatment for cancer within the past 6 months OR • are receiving palliative care for cancer • TOTAL: >6 (high 78%), 2-6 (mod 28%), < 2 (low 3%) Thromb Haemost 2000;83;418

25. PE - diagnosis (V/Q scan) • high probability V/Q scan (2 defects)

26. V/Q scan normal  PE ruled out near normal  PE ruled out low probability  can’t rule in nor out indeterminate  can’t rule in nor out high probability  PE ruled in

27. Most V/Q Scans are non-diagnostic

28. PE - diagnosis (spiral CT scan)

29. Sprial CT Scanning

30. PE - diagnosis Venography - gold standard - (100% / 100%)

31. Overview of Prevention / Treatment Patient at Risk DVT PE Death Prevent DVT Treat DVT = Prevent PE Treat PE = Prevent More PE Treat PE

32. Magnitude of the Problem

33. Risk of VTE in absence of prophylaxis • General medicine patients 10-26% • Congestive heart failure 20-40% • Myocardial infarction 17-34% • Stroke 55% • Orthopedic Surgery 40-80% • Cancer 7-17% Geerts et al. Chest 2001;119: 132S-175S

34. Risk of DVT  no thrombophylaxis Major Urological Surgery 15 – 40% risk of DVT

35. Risk of DVT and PE

36. Urological Surgery • Low Risk • cystoscopy • transurethral resection prostate (TURP) • High Risk • radical prostatectomy • nephrectomy • cystectomy • Patient Factors • comorbidity, previous DVT-PE, thrombophilia • hemorrhage

37. Interventions…

38. Overview of Prevention / Treatment Patient at Risk DVT PE Death Prevent DVT Treat DVT = Prevent PE Treat PE = Prevent More PE Treat PE

39. Overview of Prevention / Treatment Patient at Risk Prevent DVT

40. (Kendall TED)

41. Efficacy of Heparins vs Placebo

42. American College of Chest Physicians CHEST Supplement September 2004 Volume 126(3) www.chest.org (free)

43. TURP  Mobilize

44. Open Procedures • heparin 5,000 U sq bid or tid • LMWH • enoxaparin 40 mg sq od • dalteparin 5,000 u sq od • SCD or GCS

45. Mechanical for bleeder / bleeding

46. Mechanical + Heparin for multiple risk pts

47. Overview of Prevention / Treatment Patient at Risk DVT PE Death Prevent DVT Treat DVT = Prevent PE Treat PE = Prevent More PE Treat PE

48. Overview of Prevention / Treatment DVT PE Treat DVT = Prevent PE Treat PE = Prevent More PE

49. Why Intervene? • Risk of PE among untreated DVT ~ 15-25% • Risk of death among PE ~ 20-30% • Risk of death among untreated DVT ~5% • Risk of death for treated PE ~ 1.5%/yr • Risk of death for treated DVT ~ 0.4%/yr • Risk of major bleed treated PE/DVT ~1.0%/yr

50. Suspected DVT • If high clinical suspicion of DVT, treat with anticoagulants while awaiting the outcome of diagnostic tests (1C+).