Postphlebitic Limb Research Articles

Venous Thromboembolism Prophylaxis – The Other Side of the Coin: A Review of Literature

Background : There are no local guidelines for prophylaxis against Venous Thrombo-Embolism (VTE). In the absence of any guidelines, most of the information available has been provided mainly by the pharmaceutical industry which is an interested party. There have been publications in local journals that lean more on endorsing guidelines developed elsewhere. Unfortunately, such guidelines have not been embraced by everyone even in their countries of origin yet they are sometimes presented as the universally accepted standard of care. Objective : We sought to elucidate some of the reasons for the opposition to these guidelines in this article. Our aim is not to convince readers to change their practice but to provide information that may be useful to them as they make decisions on this matter. We also hope to stimulate debate on this issue and hopefully contribute to the development of a national guideline for and by the orthopaedic community. Data source : Publications from peer reviewed journals. Results : The assumed relationship between deep vein thrombosis and pulmonary embolism is erroneous. The “post-phlebitic limb” is not always post-phlebitic. Large studies comparing the morbidity and mortality prior to and after introduction of various VTE prophylaxis guidelines find that the measures proposed by various guidelines are not efficacious. Most early deaths occurring after orthopaedic procedures are not a result of pulmonary embolism. There exists a serious conflict of interest in many of the studies that support chemo-prophylaxis for VTE prevention. The risks from chemoprophylaxis for VTE are greater than the anticipated benefit. Conclusions : Evidence adduced in this article casts doubts on the rationale and efficacy of VTE chemoprophylaxis recommendations by various international guidelines and does not support their whole-scale adoption. Recommendations : Kenya Orthopaedic Association needs to put in place mechanisms to develop local guidelines based on the local data and spearheaded by the orthopaedic fraternity.

Functioning portacath with subclavian vein thrombosis: When to remove & when to leave?

Background: The use of portacath became a commonplace in anticancer treatment. However infections and deep venous thrombosis are two serious complications that might be encountered. The mere evidence of infection spells immediate catheter removal, whereas the situation is totally different with deep venous thrombosis and represents a matter of debate. Aim of the study: This study was designed to address the issue of portacath related subclavian vein thrombosis to clarify the pros & cons of either catheter removal or leaving to justify when to adopt each plan. Patients and methods: Twenty-eight patients having portacath with subclavian vein thrombosis were randomly divided between 2 groups (14 patients each) according to the management plan. Group A were subjected to medical treatment without catheter removal and group B were subjected to medical treatment, catheter removal and insertion of a new one as necessary in another vascular bed. Both groups were compared regarding the baseline relevant data and the treatment outcome. Results: There was no statistically significant difference between both groups regarding the duration till start of clinical improvement (P value 0.682), maximum clinical improvement (P value 0.445), and start of recanalization (P value 0.218). However, the duration until complete recanalization was significantly shorter in the catheter removal group B (P value 0.05). Although in the catheter leaving group A the hospital stay was significantly longer (P value 0.001), yet, the overall cost was significantly less (P value 0.05). Re-thrombosis, postphlebitic limb, pulmonary embolism were not encountered in either groups. Conclusion: In addition to the cost and the extra-procedure, removal of a still needed well placed functioning catheter with subsequent insertion of another one in the contra-lateral side has no clinical privilege. It also carries the same risk of subclavian vein re-thrombosis in the old side and the chance of thrombosis in the new side.

Prevention of venous thromboembolism

The aim of prophylaxis in venous thromboembolism is firstly to prevent fatal pulmonary embolism and secondly to reduce the morbidity associated with deep vein thrombosis and the post-phlebitic limb. Particularly high-risk groups are identifiable and include those over 60 years of age undergoing major surgery, patients with malignancy and those undergoing hip operations. Low-dose subcutaneous heparin (5000 U s.c. commenced two hours preoperatively and continued eight to twelve hourly until the patient is fully mobile) is unequivocally effective in preventing deep vein thrombosis in medical and surgical patients and, most importantly, significantly reduces the incidence of fatal postoperative pulmonary embolism and total mortality. Furthermore, in established deep vein thrombosis, low-dose heparin limits proximal clot propagation, which is the prelude to pulmonary embolism. Despite this, surveys have demonstrated an alarming deficiency amongst clinicians in the application of measures to prevent venous thromboembolism. Heparin prophylaxis carries a small risk of increased bleeding complications, mostly evidenced by the frequency of wound haematoma rather than major haemorrhage. Low molecular heparin fragments (e.g. Fragmin, Choay, Enoxaprin) are now emerging as useful alternative agents, having the advantage of once daily administration and yet providing similar efficacy in the prevention of deep vein thrombosis. However, protection against fatal pulmonary embolism has yet to be demonstrated. Mechanical methods of prophylaxis designed to counteract venous stasis, such as graduated elastic compression stockings, are also beneficial in protection against deep vein thrombosis but by themselves do not achieve such consistently good prophylaxis as low-dose heparin. However, clinical trials with combinations of mechanical methods and low-dose heparin indicate that this may be the optimum approach to very high-risk patients. In the presence of established acute deep vein thrombosis, anticoagulant therapy is the mainstay in preventing pulmonary embolism. Vena caval interruption procedures should be reserved for patients in whom anticoagulation is contraindicated or for those who develop recurrent pulmonary embolism despite adequate anticoagulation.

Leg ulcers due to hyperhomocysteinemia

Chronic leg ulcers are rare in young adults and generally indicate a vascular cause. We report a case of a 26-year-old man with leg ulcers of eight months duration. Doppler study indicated venous incompetence and a postphlebitic limb. However, as the distribution and number of ulcers was not consistent with stasis alone and no features of collagen vascular disease were noted, a hyperviscosity state was considered and confirmed with significantly elevated homocysteine level in the serum. Administration of vitamins B1, B2, B6 and B12, trimethyl-glycine, mecobalamine, folic acid and povidone iodine dressings with culture-directed antibiotic therapy led to a satisfactory healing of ulcers over a period of one month. Hyperhomocysteinemia must be considered in the differential diagnosis of leg ulcers in young individuals.

Lower limb vein trauma: a long-term clinical and physiological assessment.

The aim of this study was to assess the long-term clinical and physiological sequelae of lower limb venous trauma in a civilian practice. Twenty-six patients who had undergone surgery for lower limb venous trauma (median elapsed time 19.5 months) underwent assessment. Injuries had been sustained to the external iliac, common femoral superficial femoral and popliteal veins in two, four, nine and eleven limbs respectively. Using clinical assessment, photoplethysmography recovery time, the presence of popliteal reflux and venographic evidence of thrombosis, the final outcome was graded as good, fair or poor. Fourteen patients had pedal oedema, including two with a postphlebitic limb. The overall photoplethysmography recovery time (mean and s.d.) was 20.6 (8.7) s in the injured and 32.1 (6.7) s in the non-injured limbs (P = 0.002). Patients with a venographically occluded vein had a shorter photoplethysmography recovery time than those in whom the vein was patent (13.4 (5.6) versus 21.6 (8.7) s; P = 0.07). Popliteal reflux was present in 12 injured limbs. Seven of 12 venograms performed on limbs with a vein repair had evidence of previous thrombosis. Vein ligation carried considerable morbidity and all end-to-end anastomoses initially failed. In retrospect, saphenous vein grafts were too narrow for the recipient veins and panel grafts might have been more appropriate. Overall 11 of 26 patients (42 per cent) had a poor result. The repair of choice is a saphenous vein patch for lesser injuries and a saphenous panel graft for major injuries. Vein ligation should be avoided unless another life-threatening injury demands priority.

Early changes in the post-phlebitic limb: their clinical significance.

Abstract The long-term results of treatment of the established post-phlebitic syndrome by compression sclerotherapy or by ligation of incompetent perforating veins were unsatisfactory in approximately 40 per cent of patients. Changes in superficial venous pressure during exercise occurred when the deep veins were recanalized and the perforating veins became incompetent. These pressure changes could be used to select patients likely to develop the full syndrome. It is suggested that development of an intractable syndrome might be prevented if ligation of incompetent perforating and deep veins is performed before tissue changes become established.

Effect of venous hypertension on canine hind limb lymph.

The effect of acute and chronic venous hypertension on the lymph draining from the hind limb has been studied in 10 dogs. Acute venous hypertension was produced by venous occlusion, and chronic venous hypertension by fashioning an arteriovenous fistula in the groin. Acute venous hypertension trebled the lymph flow and doubled its fibrinogen concentration thus increasing the net transport of fibrinogen across the interstitial space by 600 per cent. Chronic venous hypertension had a similar effect and caused the appearance of alpha-2-antiplasmin in the lymph. The fibrinolytic activity of the lymph did not change significantly in either group of experiments. These results suggest that the deposition of interstitial fibrin seen in the skin of the postphlebitic limb is related to an increased concentration of interstitial fluid fibrin, and to the appearance of the fibrinolytic inhibitor, alpha-2-antiplasmin, without a concomitant increase of fibrinolytic activator.

Anatomy, physiology and venous ulceration.

For many years it was believed that disease within the deep venous system, such as a deep vein thrombosis or post-phlebitic limb, was the main cause of venous ulceration. There is, however, increasing awareness of the impact of both deep and superficial venous valvular incompetence and reflux on the aetiology and healing of venous ulceration. It is now widely accepted that superficial venous disease alone can result in increased venous pressure at the ankle and subsequent skin damage and ulceration.

Laser Doppler Flux in the Venous Wall

Objectives: To evaluate in vivo the perfusion of the venous wall in normal veins, varicose veins and in femoral veins of post-phlebitic limbs recording wall flux with laser Doppler flowmetry. As there is some evidence that both structure and microcirculatory dynamic responses are altered in the abnormal vein wall, we also aimed to study the response of vein wall perfusion to locally induced vasodilatation following papaverine infusion. Design: Open prospective study in patients with venous insufficiency and in patients undergoing coronary revascularization with a normal venous system. Setting: Cardiovascular Institute, Chieti University, Pierangeli Clinic, Italy and Irvine Laboratory, St Mary's Hospital, London, UK. Patients: Twenty-four normal long saphenous veins and 11 common femoral veins (35 normal veins, 35 subjects) and 42 varicose veins (42 patients). Measurements: Venous wall flux was measured on the external surface of normal long saphenous veins and common femoral veins. Measurements were also made on varicose veins before ligation of the sapheno-femoral junction. All measurements were made when at least three-quarters of the adventitia and periadventitia tissue were still intact for a length of 3 cm. Results: Flux in the normal vein wall was higher ( t = 5.88; p<0.05) than in varicose veins and in veins of post-phlebitic limbs. There was no difference in flux between varicose veins and post-phlebitic veins. After intravenous papaverine injection in a subgroup of eight normal and eight varicose veins, in the wall of normal veins there was a significant increase in flux (from 8.5 (SD 5.1) units to 13.2 (SD 3.8) units; p<0.05) which was not observed in varicose veins. Conclusions: A higher vein wall perfusion was observed in normal veins compared with varicose veins and post-phlebitic limb veins. Greater vascular reactivity to intraluminal papaverine injection was observed in normal veins.

Development of a newly designed venous valve cutter and its clinical use

Colour Doppler ultrasound is accurate in the diagnosis of acute lower limb venous thrombosis. Some patients, however, will re-present with recurrent lower limb swelling following the acute event, and ultrasound may also become the primary imaging modality in these patients. We, therefore, undertook a prospective study of 20 patients with a diagnosis of deep venous thrombosis proven initially on both venography and ultrasound. Sixteen patients had thrombosis in the femoro-popliteal segment and four patients had isolated calf vein thrombosis. Patients with above knee thrombosis were scanned at 1, 3 and 6 months and those with isolated calf lesions at intervals of 1 week, 1 and 3 months.Results showed that in cases of above knee thrombosis, only 50% of patients showed complete recanalization by 6 months. The remaining 50%, by this time, showed only partial recanalization of thrombus, the features of which cannot be distinguished from acute non-occlusive thrombus.With respect to the four cases of isolated calf vein thrombosis, one case showed evidence of popliteal extension of thrombus, which by 3 months had fully recanalized. The remaining three cases recanalized completely without further thrombus extension.These results show that interpretation of the ultrasonic features of the post-phlebitic limb may be difficult in patients who re-present with lower limb swelling. Based on this study, we would advise routine scanning of all patients with above knee venous thromboses at 6 months to provide a baseline scan, permitting more accurate ultrasonic assessment of any future thrombotic events. This study also highlights the question of whether isolated calf vein thrombosis can safely be regarded as a benign entity.

9 Thrombolytic therapy of non-cardiac disorders

Patients with a recent (less than 10 days) proximal deep vein thrombosis of the leg or pelvis are candidates for thrombolysis as the major benefit over heparin seems to be the prevention of the postphlebitic limb, an aim which is still not proven in a satisfactory manner. Nonocclusive thrombi appear to lyse more readily than occlusive thrombi. For this indication the optimal dose regimens for the three thrombolytic drugs (streptokinase, urokinase, alteplase) are not established. Acute massive pulmonary embolism with hypotension or shock should be treated with thrombolytic drugs and, pending the outcome in the first hour, be considered for pulmonary embolectomy. Major acute pulmonary embolism with haemodynamic instability responds well to thrombolysis. Whether thrombolysis is superior to heparin in subacute intermediate pulmonary embolism has not been proven unequivocally in terms of mortality or clinically important endpoints. Systemic administration of thrombolytic drugs for peripheral arterial occlusion has been abandoned for catheter-directed and intraoperative intra-arterial repeated bolus or short-term infusions. The efficacy and safety of intravenous thrombolytic treatment following a major ischaemic stroke is presently being tested in large scale trials; its use must be restricted to experimental protocols.

ABC of vascular diseases. Deep venous insufficiency and occlusion.

Sequence of events leading to venous ulc?ration Pulmonary embolus is a serious complication of deep vein thrombosis but deep venous insufficiency or occlusion, or both, are much more common long term problems and many venous ulcers occur each year, putting strains on both the work force and health service resources. It has long been recognised that deep vein thrombosis is usually followed by recanalisation of the veins and that this process results in destruction of the venous valves, which in turn results in deep venous insufficiency. Failure to recanalise results in chronic venous occlusion with the development of a collateral circulation that is also without valves. Either event has a deleterious effect on the function of the calf muscle pump, resulting in high venous pressure in the leg and foot even during exercise. This is the fundamental abnormality that results in a postphlebitic limb with venous ulc?ration or venous claudication. In addition, some patients have a congenital absence of competent valves without evidence of previous thrombosis.

Colour Doppler ultrasound of the post-phlebitic limb: Sounding a cautionary note

Colour Doppler ultrasound is accurate in the diagnosis of acute lower limb venous thrombosis. Some patients, however, will re-present with recurrent lower limb swelling following the acute event, and ultrasound may also become the primary imaging modality in these patients. We, therefore, undertook a prospective study of 20 patients with a diagnosis of deep venous thrombosis proven initially on both venography and ultrasound. Sixteen patients had thrombosis in the femoro-popliteal segment and four patients had isolated calf vein thrombosis. Patients with above knee thrombosis were scanned at 1, 3 and 6 months and those with isolated calf lesions at intervals of 1 week, 1 and 3 months. Results showed that in cases of above knee thrombosis, only 50% of patients showed complete recanalization by 6 months. The remaining 50%, by this time, showed only partial recanalization of thrombus, the features of which cannot be distinguished from acute non-occlusive thrombus. With respect to the four cases of isolated calf vein thrombosis, one case showed evidence of popliteal extension of thrombus, which by 3 months had fully recanalized. The remaining three cases recanalized completely without further thrombus extension. These results show that interpretation of the ultrasonic features of the post-phlebitic limb may be difficult in patients who re-present with lower limb swelling. Based on this study, we would advise routine scanning of all patients with above knee venous thromboses at 6 months to provide a baseline scan, permitting more accurate ultrasonic assessment of any future thrombotic events. This study also highlights the question of whether isolated calf vein thrombosis can safely be regarded as a benign entity.

Prophylaxis of venous thromboembolism

The objective of prophylaxis in venous thromboembolism is, first, to prevent fatal pulmonary embolism and, second, to reduce the morbidity associated with deep vein thrombosis (DVT) and the postphlebitic limb. This should now be standard practice for most patients over 40 years of age undergoing major surgery and for younger patients with a history of venous thromboembolism. Particularly high-risk groups include patients over 60 years of age undergoing major surgery, those with malignancy, and those requiring hip operations. Low-dose subcutaneous heparin 5,000 IU commencing 2 hours preoperatively and continuing 12 hourly until the patient is fully mobile is unequivocally effective in preventing DVT in medical and surgical patients and, most importantly, significantly reduces the incidence of fatal postoperative pulmonary embolism and total mortality. Such prophylaxis, in the presence of established DVT, also limits proximal clot propagation, which is the precursor of major pulmonary embolism. Low-dose heparin prophylaxis is associated with a small risk of bleeding complications, evidenced mostly by an increased frequency of wound hematoma rather than major clinical hemorrhage. Low molecular weight heparin fragments (e.g., Fragmin, Choay, Enoxaparine) are emerging as useful alternative agents, having the advantage of once daily administration and yet providing similar efficacy in the prevention of DVT. Mechanical methods of prevention which counteract venous stasis, such as graduated elastic compression stockings, are also useful in protecting against DVT but have not been shown to prevent fatal postoperative pulmonary embolism. They are recommended particularly for patients in whom heparin prophylaxis is best avoided (e.g., neurosurgery) and possibly in combination with heparin in very high-risk patients.

Occult antithrombin III deficiency: A potentially lethal complication of the postphlebitic limb

Chronic venous insufficiency is a frequent sequel to lower extremity venous thrombosis. A relatively uncommon, but potentially lethal, cause of the thrombosis is congenital antithrombin III deficiency. Recognition and treatment of this occult deficiency is critical. The following report describes a family treated by the authors for this problem. In one generation of nine siblings, three males had documentation of the disease with functional antithrombin III levels in the range of 50% to 60%. Before evaluation for the deficiency one female sibling died at the age of 20 years as a consequence of a proven pulmonary emoblus. Antithrombin III levels in another female sibling, who was free of symptoms, were normal (80% to 120%). Four other siblings who were free of symptoms (one female, three males) refused evaluation. All three men with the deficiency had severe, chronic, bilateral, lower extremity, venous insufficiency manifested by pain, varicosities, edema, pigmentation, and ulceration. Despite chronic warfarin therapy, one experienced recurrent pulmonary embolization with eventual loss of perfusion of the entire right lung. Ascending venography in the symptomatic males with the deficiency revealed evidence of recurrent and diffuse venous thrombosis with partial recanalization. Recurrent lower extremity venous thrombosis consequent to antithrombin III deficiency causes a particularly fulminant postphlebitic syndrome with characteristic venographic findings. Although potentially lethal if unrecognized and treated simply as venous insufficiency, chronic therapy with warfarin offers palliation and prolongs life.

Surgical treatment of the postphlebitic limb

Surgical treatment of the postphlebitic limb

Subcutaneous and intramuscular pressures in the post-phlebitic limb.

The mechanisms of pain in patients with chronic iliac vein obstruction and venous claudication is not fully understood. Ten patients with severe to moderate unilateral post-thrombotic syndrome with chronic iliac vein obstruction were studied. Subcutaneous tissue pressures and intramuscular pressures were measured using the slit-catheter technique in both legs, at rest and during exercise. The subcutaneous tissue pressure was higher, but not significantly higher, in the leg with iliac vein obstruction, +2 (-2 to +10) mmHg, than in the contralateral healthy legs, 0 (-4 to +4) mmHg in supine position at rest. During exercise in the standing position the subcutaneous tissue pressure rose significantly (p less than 0.01) in the diseased leg to 9 (+4 to +15) mmHg, while no such increase was seen in the control limb, 0 (-4 to +4) versus -1 (-5 to +4) mmHg. The intramuscular pressures were significantly higher (p less than 0.01) in the leg with iliac vein obstruction 26 (15 to 42) mmHg, than in the control leg, 11 (1 to 15) mmHg at rest in supine position as well as during exercise in standing position, 64 (35 to 82) mmHg and 26 (10 to 36) mmHg, respectively.

Effect of Elastic Compression on Venous Hemodynamics in Postphlebitic Limbs

To determine whether elastic compression alters the venous hemodynamics in the postphlebitic limb, we measured venous pressure patterns in 11 postphlebitic limbs with and without elastic compression stockings. Following cannulation of a dorsal vein of the foot, the patients underwent measurements of basal resting pressure, maximum percent decrease in venous pressure with exercise (delta VPex), peak systolic venous pressure during exercise (SVPmax), the amplitude of the pressure swing, and venous return time. Elastic compression did not alter basal resting pressure, delta VPex, or venous return time. By contrast, SVPmax decreased from 139 +/- 0.3 mm Hg to 11 +/- 8 mm Hg with elastic compression. If venous ulcers are related to the high pressure developed in the superficial veins during calf muscle systole, then elastic compression may be beneficial by decreasing systolic venous pressure and its subsequent deleterious consequences.

Effect of elastic compression on venous hemodynamics in postphlebitic limbs

To determine whether elastic compression alters the venous hemodynamics in the postphlebitic limb, we measured venous pressure patterns in 11 postphlebitic limbs with and without elastic compression stockings. Following cannulation of a dorsal vein of the foot, the patients underwent measurements of basal resting pressure, maximum percent decrease in venous pressure with exercise (ΔVP_ex), peak systolic venous pressure during exercise (SVP_max), the amplitude of the pressure swing, and venous return time. Elastic compression did not alter basal resting pressure, ΔVP_ex, or venous return time. By contrast, SVP_maxdecreased from 139±0.3 mm Hg to 111±8 mm Hg with elastic compression. If venous ulcers are related to the high pressure developed in the superficial veins during calf muscle systole, then elastic compression may be beneficial by decreasing systolic venous pressure and its subsequent deleterious consequences. (<i>JAMA</i>242:2766-2768, 1979)

Deep Thrombophlebitis: Pathophysiology and Treatment.

The general purpose of this monograph is to bring into more realistic focus the acute and chronic problems of inflammation and thrombosis in the veins; its specific objective is to correlate the pathophysiology with altered hemodynamics in acute thrombophlebitis and in the postphlebitic limb. Doctor Haller accomplishes these aims admirably. He provides an interesting discussion of the historical development of the subject along with a detailed but concise description of the clinical, diagnostic, and therapeutic aspects of deep thrombophlebitis. His material is well organized and timely. Particularly informative are his chapters on the pathophysiology of extensive deep thrombophlebitis and the serious complications of deep thrombophlebitis and their treatment. He argues convincingly for prompt medical and aggressive surgical management of deep thrombophlebitis, and with certain exceptions, presents his views carefully and clearly, supporting them with numerous, well-chosen references. Other advantages of this monograph are brevity, large print, high quality paper, and