DVT AND THROMBOEMBOLISM   25A

A 57-year-old man undergoes total knee replacement for severe degenerative joint disease. Four days after surgery, he develops acute onset of shortness of breath and right-sided pleuritic chest pain. His father died after a pulmonary embolism (PE). The patient is now in moderate respiratory distress with a respiratory rate of 28 breaths/min, heart rate of 120 beats/min, and blood pressure of 110/70 mm Hg. Oxygen saturation is 90% on room air. Lung examination is normal. Cardiac examination reveals tachycardia but is otherwise unremarkable. The right lower extremity is postsurgical, healing well, with 2+ pitting edema, calf tenderness, erythema, and warmth; the left leg is normal.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Recent orthopedic surgery; acute dyspnea, pleuritic chest pain, tachycardia and tachypnea suggesting PE; family history of PE; leg edema, tenderness, erythema, and warmth

How to think through: Given the postsurgical context, acute symptoms, and vital sign abnormalities, PE is likely, and heparin should be started immediately. Computed tomography (CT) angiography can be performed when the patient is stable. Whether to use thrombolytic therapy is a key question in this case. Thrombolysis is known to improve outcomes in massive PE but is controversial in submassive PE. The patient has tachycardia is not frankly hypotensive at this point. What study would help with this decision? (Echocardiography to characterize the degree of right heart strain.) When a reversible risk factor for deep venous thrombosis (DVT) or PE is identified, such as immobility, cancer, recent surgery, or injury to a blood vessel wall, the event is said to be “provoked,” evaluation for thrombophilia is often not performed, and anticoagulation is prescribed for 3 to 6 months. When a DVT or PE is unprovoked, the risk of recurrence is as high as 7% to 10% per year, and lifelong anticoagulation is typically indicated. In this case, evaluation for a hypercoagulable state is needed to guide duration of anticoagulation; although recent orthopedic surgery is a major reversible risk factor, the family history of PE, suggests a possible inherited thrombophilia. Evaluation should be delayed for 3 months because protein C and S are consumed during acute PE.

DVT AND THROMBOEMBOLISM   25B

What are the essentials of diagnosis and general considerations regarding deep venous thrombosis and thromboembolism?

Essentials of Diagnosis

Predisposition to venous thrombosis

Pain, swelling, and redness below the level of the thrombus

Presence of thromboembolic disease such as PE

General Considerations

DVT and PE are two manifestations of the same disease.

DVT may be in the upper or lower extremity, although it most commonly occurs in the legs.

DVTs proximal to the knee (popliteal and iliofemoral) embolize more often than distal thrombi.

Risk factors include venous stasis (e.g., immobility, hyperviscosity, low cardiac output), injury to the vessel wall, and hypercoagulability (e.g., oral contraceptives, inherited hypercoagulable states, malignancy).

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