fHR041BOSIS RESEARCH Printed in the Pnited
Vol. States
7, ppo 1$1--1!t8, 197j Pergamon Press, Inc.
THE INCIDENCE OF POSTOPERATIVE DEEP VEIN THROMBOSIS
Stephen N. Joffe From Department of Surgery, University of Cape Town, Cape Town. Present address: Department of Surgery, Royal Infirmary, Glasgow&i4 , U.K.
(Received
12.11.19'74;
Accepted ABSTRACT
in revised form 16.5.19'75. by Editor R.C. Elston)
A prospective study of the incidence of deep vein thrombosis in surgical patients was carried out in 130 general surgical patients, undergoing a major elective operation requiring a general anaesthetic of more than 30 minutes' duration and followed by at least 7 days in hospital. An additional 23 neurosurgical cases, 31 ophthalmic and otorhinolaryngology patients and 7 renal transplant recipients were studied. All patients were screened with radioactive fibrinogen employing a Pitman ratemeter and with Doppler ultrasonography, and 32 patients with positive results were examined by bilateral ascending venography. The incidence of deep vein throtiosis by these criteria in the general surgical patients was 51%. In 76% of cases, it was apparent within 72 hours of surgery and bilateral in 64% of cases. The calf alone was involved in only 43% of cases, and more proximal extension occurred in the remaining 57%. Venography confirmed the diagnosis of deep vein thrombosis in 29 of 32 patients tested. Objective clinical evidence of venous thrombosis was present in only 3.8% of the positive cases, but the subjective symptom of pain in the calf was present in 29% of positive cases. The incidence of positive cases in neurosurgical patients was 43%, in ophthalmology and otorhinolaryngological patients 6%, and in renal transplant patients 57%
INTRODUCTION Deep vein thrombosis and its sequel pulmonary embolus are now perhaps the single greatest threat to recovery after surgical operations (1). Thromboembolic disease kills 5,000 people in Britain annually and contributes to 12.5% of all postoperative deaths (2).
It is therefore a serious cause for
concern. In a review of the literature Bruzelius (3) found the clinical 141
incidence of postoperative deep vein thrombosis [Z.Y.T.) varies from 2.5 to 3.5':. Hoi~iever Sevitt (4j, in
a combined clinicc-pathological study
estimated that as many as 2 out of 3 O.V.T. were symptom-free, and found no clinical evidence of venous thrombosis in 50:.of patients dying of pulmonary embolism.
Similarly Welch and Faxon (5) found that only 5% of fatal
pulmonary enboli had clinical evidence of D.V.T. As a result of the use of the newer techniques of diagnosis involving 125 either the I-fibrinogen or Doppler ultrasound, a greater frequency of recognition of postoperative D.V.T. has been reported (6 - 10).
This study
was aimed to determine the incidence of postoperative D.V.T. in surgical patients undergoing a major elective operation using a combination of 125 I-fibrinogen, Doppler ultrasound, venography and clinical examination,
PATIENTS AND METHODS Selection of Patients One hundred and thirty patients undergoing a major elective general surgical operation at Groote Schuur Hospital, Cape Town, were studied. This was defined as any surgical procedure under general anaesthesia which lasted more than 30 minutes and followed by at least seven days in hospital. Patients excluded were those undergoing surgery to the lower limb, or a left 125 mastectomy, because of the difficulty in I-fibrinogen counting. The mean age of the patients was 52 years and 85% were over the age of 40 years. The patients were the control group of a computerized random study of drug prophylaxis of postoperative D.V.T., who were informed and gave their consent to the study. The patients studied from the surgical specialties included 23 neurosurgical patients, in whom the conditions referred to were observed; 31 ophthalmic and otorhinolaryngological patients who underwent a general anaesthetic lasting more than 30 minutes and at least 3 days hospitalisation and 7 renal transplant recipients. The age and sex of the patients are given in Table 1. Diagnosis of Deep Vein Thrombosis
i)
The diagnosis of D.V.T. was made by using a combination of methods:125 I-fibronogen technique. Oral or intravenous sodium iodide, 100 mgm was given 24 hours preoperatively and thereafter daily for the duration of the investigation to block the thyroid uptake of the isotope.
This was followed by the
DEEP VEI?; THRO'IBCSIS
TABLE 1
Age and Sex of Patients
Age (years1
General Surgery Total* D.V.T.**
Neurosurgery D.V.T. Total
Ophthalmology and E.N.T. Total D.V.T.
Renal Transplant D.V.T. Total
21-30
13
5
5
2
10
0
4
2
31-40
16
6
6
2
3
0
3
2
41-50
18
10
5
2
5
0
51-60
31
14
2
1
5
61-70
32
21
4
2
4
71-80
13
7
1
1
4
81-90
7
3
Male
59
27
13
6
14
0
4
3
Female
71
39
10
4
17
2
3
1
0
Sex
injection of 100 uCi of '251-labelled human fibrinogen (Radiochemical Centre, Amersham).
Each patient was examined before the operation and
then daily postoperatively using the Pitman ratemeter and Kakkar's criteria for the diagnosis of a D.V.T.(6). ii) Doppler ultrasound method. Venous patency was further assessed at the same examination by the Doppler ultrasound method of Strandness and Yao, using a Sonicaid D205M (9, 10).
For the purpose of this study the presence of a sound
indicated venous patency and,if absent, was indicative of venous obstruction. iii)
Venography. Bilateral percutaneous dorsal venography was initially performed in all cases to confirm the diagnosis (11).
However, later in the
study, due to the lack of false positives when compared to venography and the complications attendant, it was only carried out when there was difficulty in interpretation of the results.
* Total number of patients ** Diagnosed postoperative deep vein thrombosis (D.V.T.)
The incidence of postoperative D.V.T. in general surgery by these combined methods of diagnosis was 51% (66/130).
The onset of the D.V.T. in
502 of cases was with in the first 24 hours and a further 26:;between the 2nd and 3rd postoperative day. there were no cases
Only
7.6% became positive on the 7th-10th day and
recorded after the 10th day (see Table 2). Table 2
Onset of Postoperative Deep Vein Thrombosis
Day
General Surgery
Neurosurgery
Ophthalmology and E.N.T.
o-1
33
4
1
2-3
17
2
1
46
11
3
0
7-10
5
1
0
3
10-14
0
0
0
1
66
10
2
4
Total No.
Renal Transplant
All patients were examined preoperatively to confirm that they were negative.
In 40 cases screened within 1-2 hours postoperatively, i.e. on
returning to the ward from theatre, it was found that 10% already had 125 evidence of D.V.T. shown by the I-fibrinogen technique. In the 66 patients who developed D.V.T., 42 were bilateral (64%), with the thrombosis occurring twice as commonly if unilateral, on the right side. sites in which the D.V.T. occurred are shown in Table 3. was involved in 43% of cases;
The different
The Calf alone
the popliteal vein or popliteal and calf
veins in 33%, and the thigh alone or in combination in 24%.
Thus the
iiio-femoro-popliteal venous segment was involved in 57% of the patients. The lower
limbs
of all the patients were examined daily for the
classical signs of D.V.T. clinically.
In only six cases was a D.V.T. detected
Swelling and tenderness of the calf was found in five
patients, pedal oedema in four, and in nonewas Homan's sign present. 125 I-fibrinogen and Doppler Five of the six had their D.V.T. confirmed by ultrasound. presented with signs of a D.V.T. in the calf on the right 125 I-fibrinogen test, which in fact This was not confirmed by the
The sixth side.
i-0
llcj
1
! .I,?;O.
TABLE 3 Incidence and Site of Postoperative Deep Vein Thrombosis General surgery 130
Number of patients
Neurosurgery
Ophthalmology and E.N.T.
23
Renal Transplant
31
7
Number positive
66
10
2
4
Percentage positive
5'
43
6
57
Calf only
43%
60%
0%
0%
Popliteal Popliteal and calf
11% 21%
0% 30%
0% 50%
50%
Femoral Femoral and popliteal Femoral and calf Femoro-popliteal and calf
:; 6% 14%
10% 0% 0% 0%
0% 0% 0% 50%
0% 0% 0% 50%
6%
10%
0%
25%
Site of venous thrombosis
Pulmonary emboli
revealed an asymptomatic D.V,T. on the left side.
0%
On careful questioning
29% with proven D.V.T. admitted experiencing the symptom of pain in the lower limb. Only
None of these patients had any clinical signs of D.V.T.
four
patients with ilio-femoro-popliteal D.V.T. developed clinical
evidence of pulmonary emboli.
A much greater incidence of pulmonary emboli
could not be excluded as a postoperative X-ray of the chest, electrocardiograph and lung scan, were not routinely performed. The incidence of deep vein thrombosis by the above criteria in neurosurgery, ophthalmology and otorhinolaryngology, and after renal transplantation was 43%, 6% and 57% respectively.
The onset and site of these
thrombi are shown in Tables 2 and 3.
DISCUSSION The lz5I-labelled fibrinogen test is a simple, accurate and noninvasive method of detecting D.V.T. in the calf and lower thigh (6).
The
Doppler ultrasound technique is also a non-invasive and quick method of detecting D.V.T. in the popliteal and ilio-femoral veins, and if positive is reliable in indicating obstruction of the major veins (10).
It is in
these anatomical regions where the D.V.T. is a potential hazard to the life of the patient.
However it will not detect minor calf D.V.T. or a partially
occluded vein and is only reliable in 80% of cases if there is good collateral
circulation
around
the venous obstruction (9).
Ascending
$ilaterai
percutaneous
was performed in t5.eii I-St
venography
32 patients shown to have postoperative D.Y.T. by the Doppler ultrasound techniques.
125. I-fibronogen and/or
The advantages ijere that it demonstrated
'rli th the exception of 125I_ three cases with small thrombi in the calf muscle veins shown by
the veins from the ankle to the inferior vena cava.
fibrinogen, venography confirmed the reliability and efficacy of 125I_ fibrinogen and Doppler ultrasound in the diagnosis of D.V.T. In general surgery, the results revealed an unsuspected and very high incidence of postoperative D.V.T. in the group of patients studied.
The
early onset, with 76% occurring within the first 48-72 hours postoperatively, is of considerable importance in prophylaxis.
This means that the thrombi
probably begin to form on the operating table or shortly thereafter.
Pro-
phylactic measures must therefore be instituted interoperatively or even preoperatively and continue throughout the postoperative period until the patient is fully mobilized. Deep vein thrombosis may be considered to occur in the i) peripheral, calf or lower segment veins, and ii) ilio-femoral or upper segment which includes the popliteal veins. 125 Using I-fibrinogen, Negus (12) and Kakkar (6) showed that the majority of D.V.T. (80-902) occurred in the calf.
Approximately 10 to 25% of these
extended into the popliteal and ilio-femoral veins (13, 14),and ilio-femoral venous alone was present in 10.5% (6). However, 57% of these general surgical patients had involvement of the ilio-femoro-popliteal veins. This is probably due to the fact that the 125 I-fibrinogen technique is unreliable in the upper two thirds of the thigh, due to the increased blood flow in this area. Therefore a combination of 125 Doppler ultrasound and I-fibrinogen techniques will reveal a much greater incidence.
Furthermore the patients studied may differ epidemiologically and
this required further investigation. A statistically significantly higher risk (~(0.05)
in general surgery
was found in patients over the age of 40 years, or in the presence of severe
obesity, varicose veins or having an irresectable carcinoma. groups were at risk. operative
All racial
The survey extended into the incidence of post-
D.V.T. in patients undergoing different forms of operations.
In neurosurgery, the incidence on a clinical diagnosis was presumed to be low.
However 43% were shown to develop D.V.T.
This was equally as high
in patients undergoing a spinal operation or craniotomy. In ophthalmology and otorhinolaryngology the incidence was only 6X.
The 2 patients clinically
who developed
asymptomatic.
mobilization
D.V.T. were obese
Minimal
are thus probably
operative
and over 40 years
tissue damage
two important
factors
and were
and early
in the aetiology
of
D.V.T. Four of the seven
(57%) unselected
cadaveric
renal transplantation
pulmonary
embolus
in one.
An analysis
of the reasons
possibility
of heparin
systemically patients
were
treated with
heparin,
and this probably
The results reveal
an unsuspected
surgery, method
neurosurgery
of diagnosis
of patients
high
agent.
and postoperatively
as an effective
acting
the D.V.T.
cause or causes
The importance tion that efforts
using
the newer methods
of postoperative
D.V.T.
interoperative
of diagnosis,
in general
The time-honoured Certain
signs has been superseded.
for research
groups into
of D.V.T.
of the recently
to prevent
began passing
the side of the transplanted
are at high risk and this is the next target
the ultimate
prophylactic
and the D.V.T.
renal transplantation.
from clinical
the
occurred.
study,
incidence
and after
was discontinued
between
were
was primed with
Once the patients
pericd.
to the
The patients
continued
in the present
a
in all cases
points
The machine
the haemodialysis
and that on which
kidney
developed
late development
the operation
There was no relationship
ensued.
D,V.T. with
renal dialysis.
postoperative
urine spontaneously,
thrombosis
homograft
in one as late as the 14th day (Table 2).
for this
during
undergoing
postoperative
acting as a prophylactic
heparinized
drug in the early
developed
The venous
after the 8th day and occurred
patients
D.V.T.
acquired
knowledge
must be directed
lies in the realiza-
to the preoperative
and
periods. REFERENCES
Pharmacological 1. EDITORIAL. Lancet, 1, 789, 1971. 2. kEM!GLE, J.V.H . 6, 721, 1971.
Incidence
fibrinolysis
after
surgical
of deep vein thrombosis.
operations.
Brit. J. Hosp. Med.
Studies on its prophylactic Dicoumarin in clinical use. 3. BRUZELIUS, S. Acta chir. and therapeut ic value in the treatment of thromboembolism. stand. Suppl. 100, 92, 1945. Venous 4. SEVITT, S. and GALLAGliER, N.G. A clinicopathological study in injured 48, 475, 1961.
thrombosis and burned
Thrombophlebitis 5. idELCH, C.E. and FAXON, H.H. J. Amer. med. Ass. 117, 1502, 1941.
and pulmonary embolism. subjects. Brit. J. Surg.
and pulmonary
embolism.
:
nr
6. KAKKAR, Y.Y. The diagnosis of deep vein thrombosis using the 1’ fibrinogen test.
LJ
Arch. Surg. 104, 152, 1972.
7. BROWSE, i'4.L.The '25i-fibrinogen uptake test. 1972.
Arch. Surg. 124, 150,
8. EVANS, U.S. The early diagnosis of deep vein thrombosis by ultrasound. Brit. J. Surg, 57, 726, 1970. 9. STRANDNESS, D.E. and SUPPER, D.S. Ultrasonic velocity detector diagnosis of thrombophlebitis. F.rch. Surg. 104, 180, 1972.
in the
10. YAO, S.T., GOURMOS, C. and HOBBS, J.T. Detection of proximal vein thrombosis by Doppler ultrasound flow detection method. Lancet, 1, 1, 1972. 11. LEA THOMAS, M. Radiology of deep vein thrombosis. 6, 735, 1971. 12. NEGUS, C., PINK,
Brit. J. Hosp. Fled,
LE QUESNE, L.P., BROWN, h., and CHAP!lAN,M. lz51in the diagnosis of deep vein thrombosis and its correlation with phlebography. Brit. J. Surg. 55, 835, 1968.
labelled
D.J.,
fibrinogen
13. KAKKAR, V.V., HOWE, C.T., FLANC, C. and CLARKE, ("i-B.Natural history cf postoperative deep vein thrombosis. Lancet, 2, 230, 1969. 14. MAVOR, G.E. 1971.
Surgery of deep vein thrombosis.
Brit. J.
Hosp. Med. 6, 755,
Vol. States
7, ppo 1$1--1!t8, 197j Pergamon Press, Inc.
THE INCIDENCE OF POSTOPERATIVE DEEP VEIN THROMBOSIS
Stephen N. Joffe From Department of Surgery, University of Cape Town, Cape Town. Present address: Department of Surgery, Royal Infirmary, Glasgow&i4 , U.K.
(Received
12.11.19'74;
Accepted ABSTRACT
in revised form 16.5.19'75. by Editor R.C. Elston)
A prospective study of the incidence of deep vein thrombosis in surgical patients was carried out in 130 general surgical patients, undergoing a major elective operation requiring a general anaesthetic of more than 30 minutes' duration and followed by at least 7 days in hospital. An additional 23 neurosurgical cases, 31 ophthalmic and otorhinolaryngology patients and 7 renal transplant recipients were studied. All patients were screened with radioactive fibrinogen employing a Pitman ratemeter and with Doppler ultrasonography, and 32 patients with positive results were examined by bilateral ascending venography. The incidence of deep vein throtiosis by these criteria in the general surgical patients was 51%. In 76% of cases, it was apparent within 72 hours of surgery and bilateral in 64% of cases. The calf alone was involved in only 43% of cases, and more proximal extension occurred in the remaining 57%. Venography confirmed the diagnosis of deep vein thrombosis in 29 of 32 patients tested. Objective clinical evidence of venous thrombosis was present in only 3.8% of the positive cases, but the subjective symptom of pain in the calf was present in 29% of positive cases. The incidence of positive cases in neurosurgical patients was 43%, in ophthalmology and otorhinolaryngological patients 6%, and in renal transplant patients 57%
INTRODUCTION Deep vein thrombosis and its sequel pulmonary embolus are now perhaps the single greatest threat to recovery after surgical operations (1). Thromboembolic disease kills 5,000 people in Britain annually and contributes to 12.5% of all postoperative deaths (2).
It is therefore a serious cause for
concern. In a review of the literature Bruzelius (3) found the clinical 141
incidence of postoperative deep vein thrombosis [Z.Y.T.) varies from 2.5 to 3.5':. Hoi~iever Sevitt (4j, in
a combined clinicc-pathological study
estimated that as many as 2 out of 3 O.V.T. were symptom-free, and found no clinical evidence of venous thrombosis in 50:.of patients dying of pulmonary embolism.
Similarly Welch and Faxon (5) found that only 5% of fatal
pulmonary enboli had clinical evidence of D.V.T. As a result of the use of the newer techniques of diagnosis involving 125 either the I-fibrinogen or Doppler ultrasound, a greater frequency of recognition of postoperative D.V.T. has been reported (6 - 10).
This study
was aimed to determine the incidence of postoperative D.V.T. in surgical patients undergoing a major elective operation using a combination of 125 I-fibrinogen, Doppler ultrasound, venography and clinical examination,
PATIENTS AND METHODS Selection of Patients One hundred and thirty patients undergoing a major elective general surgical operation at Groote Schuur Hospital, Cape Town, were studied. This was defined as any surgical procedure under general anaesthesia which lasted more than 30 minutes and followed by at least seven days in hospital. Patients excluded were those undergoing surgery to the lower limb, or a left 125 mastectomy, because of the difficulty in I-fibrinogen counting. The mean age of the patients was 52 years and 85% were over the age of 40 years. The patients were the control group of a computerized random study of drug prophylaxis of postoperative D.V.T., who were informed and gave their consent to the study. The patients studied from the surgical specialties included 23 neurosurgical patients, in whom the conditions referred to were observed; 31 ophthalmic and otorhinolaryngological patients who underwent a general anaesthetic lasting more than 30 minutes and at least 3 days hospitalisation and 7 renal transplant recipients. The age and sex of the patients are given in Table 1. Diagnosis of Deep Vein Thrombosis
i)
The diagnosis of D.V.T. was made by using a combination of methods:125 I-fibronogen technique. Oral or intravenous sodium iodide, 100 mgm was given 24 hours preoperatively and thereafter daily for the duration of the investigation to block the thyroid uptake of the isotope.
This was followed by the
DEEP VEI?; THRO'IBCSIS
TABLE 1
Age and Sex of Patients
Age (years1
General Surgery Total* D.V.T.**
Neurosurgery D.V.T. Total
Ophthalmology and E.N.T. Total D.V.T.
Renal Transplant D.V.T. Total
21-30
13
5
5
2
10
0
4
2
31-40
16
6
6
2
3
0
3
2
41-50
18
10
5
2
5
0
51-60
31
14
2
1
5
61-70
32
21
4
2
4
71-80
13
7
1
1
4
81-90
7
3
Male
59
27
13
6
14
0
4
3
Female
71
39
10
4
17
2
3
1
0
Sex
injection of 100 uCi of '251-labelled human fibrinogen (Radiochemical Centre, Amersham).
Each patient was examined before the operation and
then daily postoperatively using the Pitman ratemeter and Kakkar's criteria for the diagnosis of a D.V.T.(6). ii) Doppler ultrasound method. Venous patency was further assessed at the same examination by the Doppler ultrasound method of Strandness and Yao, using a Sonicaid D205M (9, 10).
For the purpose of this study the presence of a sound
indicated venous patency and,if absent, was indicative of venous obstruction. iii)
Venography. Bilateral percutaneous dorsal venography was initially performed in all cases to confirm the diagnosis (11).
However, later in the
study, due to the lack of false positives when compared to venography and the complications attendant, it was only carried out when there was difficulty in interpretation of the results.
* Total number of patients ** Diagnosed postoperative deep vein thrombosis (D.V.T.)
The incidence of postoperative D.V.T. in general surgery by these combined methods of diagnosis was 51% (66/130).
The onset of the D.V.T. in
502 of cases was with in the first 24 hours and a further 26:;between the 2nd and 3rd postoperative day. there were no cases
Only
7.6% became positive on the 7th-10th day and
recorded after the 10th day (see Table 2). Table 2
Onset of Postoperative Deep Vein Thrombosis
Day
General Surgery
Neurosurgery
Ophthalmology and E.N.T.
o-1
33
4
1
2-3
17
2
1
46
11
3
0
7-10
5
1
0
3
10-14
0
0
0
1
66
10
2
4
Total No.
Renal Transplant
All patients were examined preoperatively to confirm that they were negative.
In 40 cases screened within 1-2 hours postoperatively, i.e. on
returning to the ward from theatre, it was found that 10% already had 125 evidence of D.V.T. shown by the I-fibrinogen technique. In the 66 patients who developed D.V.T., 42 were bilateral (64%), with the thrombosis occurring twice as commonly if unilateral, on the right side. sites in which the D.V.T. occurred are shown in Table 3. was involved in 43% of cases;
The different
The Calf alone
the popliteal vein or popliteal and calf
veins in 33%, and the thigh alone or in combination in 24%.
Thus the
iiio-femoro-popliteal venous segment was involved in 57% of the patients. The lower
limbs
of all the patients were examined daily for the
classical signs of D.V.T. clinically.
In only six cases was a D.V.T. detected
Swelling and tenderness of the calf was found in five
patients, pedal oedema in four, and in nonewas Homan's sign present. 125 I-fibrinogen and Doppler Five of the six had their D.V.T. confirmed by ultrasound. presented with signs of a D.V.T. in the calf on the right 125 I-fibrinogen test, which in fact This was not confirmed by the
The sixth side.
i-0
llcj
1
! .I,?;O.
TABLE 3 Incidence and Site of Postoperative Deep Vein Thrombosis General surgery 130
Number of patients
Neurosurgery
Ophthalmology and E.N.T.
23
Renal Transplant
31
7
Number positive
66
10
2
4
Percentage positive
5'
43
6
57
Calf only
43%
60%
0%
0%
Popliteal Popliteal and calf
11% 21%
0% 30%
0% 50%
50%
Femoral Femoral and popliteal Femoral and calf Femoro-popliteal and calf
:; 6% 14%
10% 0% 0% 0%
0% 0% 0% 50%
0% 0% 0% 50%
6%
10%
0%
25%
Site of venous thrombosis
Pulmonary emboli
revealed an asymptomatic D.V,T. on the left side.
0%
On careful questioning
29% with proven D.V.T. admitted experiencing the symptom of pain in the lower limb. Only
None of these patients had any clinical signs of D.V.T.
four
patients with ilio-femoro-popliteal D.V.T. developed clinical
evidence of pulmonary emboli.
A much greater incidence of pulmonary emboli
could not be excluded as a postoperative X-ray of the chest, electrocardiograph and lung scan, were not routinely performed. The incidence of deep vein thrombosis by the above criteria in neurosurgery, ophthalmology and otorhinolaryngology, and after renal transplantation was 43%, 6% and 57% respectively.
The onset and site of these
thrombi are shown in Tables 2 and 3.
DISCUSSION The lz5I-labelled fibrinogen test is a simple, accurate and noninvasive method of detecting D.V.T. in the calf and lower thigh (6).
The
Doppler ultrasound technique is also a non-invasive and quick method of detecting D.V.T. in the popliteal and ilio-femoral veins, and if positive is reliable in indicating obstruction of the major veins (10).
It is in
these anatomical regions where the D.V.T. is a potential hazard to the life of the patient.
However it will not detect minor calf D.V.T. or a partially
occluded vein and is only reliable in 80% of cases if there is good collateral
circulation
around
the venous obstruction (9).
Ascending
$ilaterai
percutaneous
was performed in t5.eii I-St
venography
32 patients shown to have postoperative D.Y.T. by the Doppler ultrasound techniques.
125. I-fibronogen and/or
The advantages ijere that it demonstrated
'rli th the exception of 125I_ three cases with small thrombi in the calf muscle veins shown by
the veins from the ankle to the inferior vena cava.
fibrinogen, venography confirmed the reliability and efficacy of 125I_ fibrinogen and Doppler ultrasound in the diagnosis of D.V.T. In general surgery, the results revealed an unsuspected and very high incidence of postoperative D.V.T. in the group of patients studied.
The
early onset, with 76% occurring within the first 48-72 hours postoperatively, is of considerable importance in prophylaxis.
This means that the thrombi
probably begin to form on the operating table or shortly thereafter.
Pro-
phylactic measures must therefore be instituted interoperatively or even preoperatively and continue throughout the postoperative period until the patient is fully mobilized. Deep vein thrombosis may be considered to occur in the i) peripheral, calf or lower segment veins, and ii) ilio-femoral or upper segment which includes the popliteal veins. 125 Using I-fibrinogen, Negus (12) and Kakkar (6) showed that the majority of D.V.T. (80-902) occurred in the calf.
Approximately 10 to 25% of these
extended into the popliteal and ilio-femoral veins (13, 14),and ilio-femoral venous alone was present in 10.5% (6). However, 57% of these general surgical patients had involvement of the ilio-femoro-popliteal veins. This is probably due to the fact that the 125 I-fibrinogen technique is unreliable in the upper two thirds of the thigh, due to the increased blood flow in this area. Therefore a combination of 125 Doppler ultrasound and I-fibrinogen techniques will reveal a much greater incidence.
Furthermore the patients studied may differ epidemiologically and
this required further investigation. A statistically significantly higher risk (~(0.05)
in general surgery
was found in patients over the age of 40 years, or in the presence of severe
obesity, varicose veins or having an irresectable carcinoma. groups were at risk. operative
All racial
The survey extended into the incidence of post-
D.V.T. in patients undergoing different forms of operations.
In neurosurgery, the incidence on a clinical diagnosis was presumed to be low.
However 43% were shown to develop D.V.T.
This was equally as high
in patients undergoing a spinal operation or craniotomy. In ophthalmology and otorhinolaryngology the incidence was only 6X.
The 2 patients clinically
who developed
asymptomatic.
mobilization
D.V.T. were obese
Minimal
are thus probably
operative
and over 40 years
tissue damage
two important
factors
and were
and early
in the aetiology
of
D.V.T. Four of the seven
(57%) unselected
cadaveric
renal transplantation
pulmonary
embolus
in one.
An analysis
of the reasons
possibility
of heparin
systemically patients
were
treated with
heparin,
and this probably
The results reveal
an unsuspected
surgery, method
neurosurgery
of diagnosis
of patients
high
agent.
and postoperatively
as an effective
acting
the D.V.T.
cause or causes
The importance tion that efforts
using
the newer methods
of postoperative
D.V.T.
interoperative
of diagnosis,
in general
The time-honoured Certain
signs has been superseded.
for research
groups into
of D.V.T.
of the recently
to prevent
began passing
the side of the transplanted
are at high risk and this is the next target
the ultimate
prophylactic
and the D.V.T.
renal transplantation.
from clinical
the
occurred.
study,
incidence
and after
was discontinued
between
were
was primed with
Once the patients
pericd.
to the
The patients
continued
in the present
a
in all cases
points
The machine
the haemodialysis
and that on which
kidney
developed
late development
the operation
There was no relationship
ensued.
D,V.T. with
renal dialysis.
postoperative
urine spontaneously,
thrombosis
homograft
in one as late as the 14th day (Table 2).
for this
during
undergoing
postoperative
acting as a prophylactic
heparinized
drug in the early
developed
The venous
after the 8th day and occurred
patients
D.V.T.
acquired
knowledge
must be directed
lies in the realiza-
to the preoperative
and
periods. REFERENCES
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