Postoperative Calf Venous Thrombosis: Location, Location, Location From the Publishers of Consult Guys Postoperative Calf Venous Thrombosis: Location, Location, Location COPYRIGHT © 2016, ALL RIGHTS RESERVED

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I need help with an inpatient dilemma! Guys: I need help with an inpatient dilemma! I am following a 58-year-old man who had an L3,4,5 laminectomy. He was ambulating on postop day 2 with a body brace and walker. On postop day 3 he was found to have left knee swelling. Bilateral venous ultrasound was performed. Surprisingly the left lower extremity venous system was normal but a right gastrocnemius vein thrombosis was identified without any propagation into the popliteal vein. The patient has a history of hypertension. Meds: amlodipine, UFH 5000 u Q8hrs (started 24 hrs postop), plus IPC sleeves Labs: Hgb 11.2, Hct 34, Plts 220K, WBC 8, PTT 32, INR 1.1, SCr 1, CrCl 70 cc/min US: Isolated right gastrocnemius vein thrombosis I think that I should treat this patient who has an asymptomatic right gastrocnemius vein thrombosis with 3 months of anticoagulation. I think that now – 3 days postop- he is at low risk of postoperative bleeding and high risk for pulmonary embolism. The orthopedic surgeon though thinks that he needs an IVC Filter. What do the Consult Guys think???? Copyright © 2016

Patient Meds: amlodipine, UFH 5000 u Q8hrs (started 24 hours postop), plus IPC sleeves Labs: Hgb 11.2, Hct 34, Plts 220K, WBC 8, PTT 32, INR 1.1, SCr 1, CrCl 70 cc/min Ultrasound: Isolated right gastrocnemius vein thrombosis Copyright © 2016

Gastrocnemius Muscle Veins Popliteal Vein Gastrocnemius Muscle Veins Anterior Tibial Confluence Peroneal Vein Confluence Posterior Tibial Confluence Posterior Tibial Veins Anterior Tibial Vein Peroneal Veins Soleus Muscle Veins Reprinted from Palareti G, Schellong S. Isolated distal deep vein thrombosis: what we know and what we are doing. J Thromb Haemost. 2012;10:11-9. [PMID: 22082302] doi:10.1111/j.1538-7836.2011.04564.x © 2011 International Society on Thrombosis and Haemostasis

Reprinted from Journal of Vascular Surgery ,55, Singh K. et al Reprinted from Journal of Vascular Surgery ,55, Singh K. et al., Early follow-up and treatment recommendations for isolated calf deep venous thrombosis. 136-140. Copyright © 2012 Society for Vascular Surgery.

* Calf DVT propagated into other calf or muscular veins How often do calf vein thromboses extend into the calf venous system or beyond? * Calf DVT propagated into other calf or muscular veins Reprinted from Journal of Vascular Surgery, 55, Masuda, Elna M. et al., The controversy of managing calf vein thrombosis. 550-561. Copyright © 2012 Society for Vascular Surgery

* 9/11 PE= 5 Nursing Home (4 TKA, 1 Neurosurg) Only 11 of 180 thromboses propagated !!! * 9/11 PE= 5 Nursing Home (4 TKA, 1 Neurosurg) 4 (1-Lung Ca, 1-COPD+Obese, 2-Stroke) Reprinted from Journal of Vascular Surgery ,55, Singh K. et al., Early follow-up and treatment recommendations for isolated calf deep venous thrombosis. 136-140. Copyright © 2012 Society for Vascular Surgery.

Conclusion: During the 3-month study period, the short-term incidence rate of untreated Isolated Gastrocnemius and Soleal Vein Thrombosis (IGDVT) propagation to the level of the popliteal vein, even in the presence of cancer, was only 3%. Follow-up imaging to detect IGSVT propagation beyond 2 weeks from the time of diagnosis may not be necessary. MacDonald, P S et al. Short-term natural history of isolated gastrocnemius and soleal vein thrombosis. Journal of Vascular Surgery , Volume 37 , Issue 3 , 523 - 527

Nadroparin vs Compression Calf Vein Thrombosis Nadroparin vs Compression 107 pts with Symptomatic Calf Vein DVT Soleal or Gastrocnemius veins Reprinted from Journal of Vascular Surgery, 52, Schwarz T. et al., Therapy of isolated calf muscle vein thrombosis: A randomized, controlled study 1246-1250. Copyright © 2010 Society for Vascular Surgery

No Progression or Regression Treatment Group (76) 25 (32.9%) Progressive DVT No Progression or Regression Treatment Group (76) 25 (32.9%) 51 (67.1%) No Treatment Group (65) 18 (27.7%) 47 (72.3%) X2 = 0.45 P = 0.50 NS Conclusion: The results speak to the lack of efficacy of anticoagulation in the management of gastrocnemius and/or soleal vein thrombosis in the hospitalized patient. When measured by thrombus progression, treating these patients without anticoagulation appears to be equally efficacious as subjecting patients to anticoagulant therapy. Reprinted from Journal of Vascular Surgery, 52, Sales C. M. et al., Management of isolated soleal and gastrocnemius vein thrombosis. 1251-1254 Copyright © 2010 Society for Vascular Surgery

ACCP Guideline 2016 In patients with acute isolated distal DVT of the leg and without severe symptoms or risk factors for extension Suggest serial imaging of the deep veins weekly for 2 weeks rather than anticoagulation (Grade 2C) No anticoagulation if the thrombus does not extend (Grade 1B) Suggest anticoagulation if the thrombus extends but remains confined to the distal veins (Grade 2C) Anticoagulation if the thrombus extends into the proximal veins (Grade 1B) With severe symptoms or risk factors for extension, suggest anticoagulation over serial imaging of the deep veins (Grade 2C) Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy For Vte Disease: Chest Guideline And Expert Panel Report. Chest 2016;149(2):315-352. doi:10.1016/j.chest.2015.11.026.

Summary Asymptomatic Isolated Calf Vein Thrombosis Serial U/S once weekly x 2 No propagation into popliteal or other calf veins: No treatment Propagation into the distal proximal system: Treatment therapeutic anticoagulation Copyright © 2016

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