1. Postoperative Calf Venous Thrombosis: Location, Location, Location
From the Publishers of
Consult Guys
Postoperative Calf Venous Thrombosis:
Location, Location, Location
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3. 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????
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4. 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
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5. 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: ] doi: /j x © 2011 International Society on Thrombosis and Haemostasis

6. 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 Copyright © 2012 Society for Vascular Surgery.

7. * 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.
Copyright © 2012 Society for Vascular Surgery

8. * 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 Copyright © 2012 Society for Vascular Surgery.

9. 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 ,

10. 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 Copyright © 2010 Society for Vascular Surgery

11. 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 Copyright © 2010 Society for Vascular Surgery

12. 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): doi: /j.chest

13. 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
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