Venous Thromboembolism:

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Venous Thromboembolism
Contemporary Management
Anthony J. Comerota, MD, FACS, RVT
Director, Jobst Vascular Center
Adjunct Clinical Professor, University of
Michigan
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Spectrum of Venous Thromboembolism
Management
Biologic onset
Asymptomatic
Symptomatic
Outcome
Primary prophylaxis
Screening
Clinical suspicion
Treatment
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DVT Prevalence Hospitalized Patients
Patient Group DVT () Medical 10
-20 General surgery 15-40 Major gynecologic
surgery 15-40 Major urologic surgery 15-40 Ne
urosurgery 15-40 Stroke 20-50 Hip/knee
arthroplasty, hip fracture surgery 40-60 Major
trauma 40-80 Spinal cord injury 60-80 Criti
cal care 10-80
Geerts WH et al. Chest 2004126(3
suppl)338S-400S
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Pulmonary embolism remains the most common
preventable cause of death in the hospital.
Hull 1986
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Venous Thrombosis Risk
Without Prophylaxis?
Outcome
Risk Profile
PE
DVT
Risk Factor Equivalents
Risk
lt0.01
lt10
0-1
Low
0.1-0.5
10-30
2-3
Moderate
0.5-1.0
30-40
4-5
High
1-5
40-80
gt6
Highest
? Modified from Geerts W et al CHEST 2001
Includes calf DVT
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Venous Thrombosis Prophylaxis
Risk Factor Equivalents
1 Factor
Age 40-59 Bed Confinement gt48 hrs Varicose
Veins Leg Edema/ulcer/statis Obesity (gt20 ideal
wt.) MI (current) CHF (current) Severe COPD
Crystalliods (gt5L/24 hrs) Confining travel
gt4hrs Pregnancy/Postpartum (1 month) Inflammatory
bowel disease Severe infection Estrogen
Rx Operation gt2 hrs
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Venous Thrombosis Prophylaxis
Risk Factor Equivalents
2 Factors
3 Factors
Age gt 60 Stroke (current) Trauma Pelvic
operation Joint replacement Hip
fracture Malignancy Pelvic/long bone
fracture Hypercoag. state
Hx DVT/PE Spinal Cord Injury
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Rudolf Virchow
Creator of Cellular Pathology 1821-1902
Presented the classic triad of the factors
leading to DVT

1. Venostasis
2. The hypercoagulable state
3. Vein wall injury

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The Beginning
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Stasis
A Permissive Factor

• On table phlebography
• Decrease velocity
• Decrease pulsatility
• Retention of dye in valves
• Radioactive NaCl studies
• Decreased velocity
• Femoral vein blood flow
• Decreased up to 50
• Gen. Anes.