Japanese Deep Vein Thrombosis

Transcription

1 Japanese Deep Vein Thrombosis and Pulmonary Embolism after Total Knee Arthroplasty Artificial joint and cartilage implantation center, Kitasato institute hospital, Kitasato university Yasunori Tsukimura

2 Yasunori Tsukimura MD I have no financial conflict to disclose. [Purpose] The purpose of this study is to investigated Japanese deep vein thrombosis: DVT and pulmonary embolism: PE after total knee arthroplasty: TKA using enhanced CT. [Cases and methods] There were 618 knees investigated DVT and PE after TKA between January 2008 and December knees were investigated, 112 drug allergy and 28 asthma patients were excluded from this study. All cases were checked preoperative DVT using ultrasound ECHO; two patients having DVT were treated using heparin drip infusion preoperatively.

3 [Purpose] The purpose of this study is to investigated Japanese deep vein thrombosis: DVT and pulmonary embolism: PE after total knee arthroplasty: TKA using enhanced CT. [Cases and methods] There were 618 knees investigated DVT and PE after TKA between January 2008 and December knees were investigated, 112 drug allergy and 28 asthma patients were excluded from this study. Enhanced CT were taken at both one and fourteen days postoperatively, because risky period of DVT and PE after the TKA was considered from one to fourteen days after the TKA. All cases were checked preoperative DVT using ultrasound ECHO; two patients having DVT were treated using heparin drip infusion preoperatively.

4 Cases Bilateral side TKA was 139 (278 knees) / one side TKA was 200(200 knees) total 339 cases (478 knees) Mean age was 74±9.5 (49-91) years old Side was 246 right and 232 left BH 152±10 ( ) BW ( ) BMI 27.6±14.1( ). Operative time was 122±28.3 (71-180)minuets. 358 primary and 20 revisions.

5 Methods Tourniquet was used in all cases Femoral nerve block + general, multimodal anesthesia. Bilateral side TKA was underwent by two stage on one side to opposite side. Tranexamic acid was injected into the knee after closing capsule, before closing skin. Patient stay on bed using elastic stocking and intermittent air compression machine in operative day only/ Next day, full weight bearing gait, range of motion exercise. Fondaparinux, enoxaparin, edoxavan were used at random after removing drain on 1st or 2nd days after the TKA. Confirmation of both PE and DVT used enhanced CT on 1 st day and on 14 th day after the TKA.

6 Deep Vein Thlombosis: DVT Pulmonary Embolism: PE Peroneal V Gastrocunemius muscle V Posterior Tibial Vein Anterior Tibial Vein Peroneal Vein Gastrocunemial Vein Soleus Vein

7 Methods Frequency DVT and PE Progress of DVT and PE Comparison bilateral side TKA with one side TKA Statistical analysis of DVT risk factors 1)DVT+ vs DVT- univariate analysis Mann-Whitney Age/Gender/BH/BW/BMI/Extension/Flexion/ Operative time/ FTA 2)multiple logistic regression analysis (6 factors) Hyper tension/hyperglycemia/malignant tumor/dm/vte episode /heart disease

8 Frequency, site, emergenct time of DVT and PE DVT frequency 38.3% (130/339) PE frequency POD1 occurence POD14 occurence Total 3.5% (12/339) Distal 96.9% (126) Proximal 3.1% (4) 13.9% (47/339) 2.1% (7/339) Distal 91.5% (43) Proximal 8.5% (4) 52.2% (177/339) 5.6% (19/339) Frequency of DVT occurrence on 1 st day 38.3% > on 14 th days 13.9% Frequency of PE occurrence on 1 st day 3.5%> on 14 th days 2.1% All DVT & PE cases were asymptomatic. All PE or DVT above the knee cases were used heparin. DVT below the knee cases were used anticoagulant. Dstal 94.4% (167) Proximal 5.6% (10)

9 Site of DVT and PE Distal 177 cases Proximal 19 cases POD1 POD14 Total Posterior tibial vein 34.6% (45) 29.8%(14) 33.3% (59) Peroneal vein 21.5% (28) 21.7% (10) 21.5% (38) Soleus & gastrocunemius vein 26.9% (35) 34% (16) 8.5% (15) Anterior tibial vein 1.5% (2) 0% (0) 1.1% (2) PTV+PV PTV+SV PV+SV 1.5% (2) 2.3% (3) 2.3% (3) 4.3% (2) 4.3% (2) 6.4% (3) 2.3% (4) 2.8% (5) 3.4% (6) Common iliac vein 0.7% (1) 2.1% (1) 1.1% (2) Femoral Vein 0.7% (1) 6.4% (3) 2.3% (4) Popliteal 7.7% (10) 2.1% (1) 6.2% (11)

10 Isolate or bilateral TKA of DVT and PE Total DVT 69/200 (34.5%) Posterior tibial vein POD1 POD14 One side Bilateral side One side Bilateral side 46/200 (23%) Peroneal vein 16/200 (8%) 24/139 (17.3%) 10/139 (7.2%) 10/139 (7.2%) 72/200 (36%) 26/200 (14%) 20/200 (10%) 56/139 (40.3%) 19/139 (54%) 13/139 (9.4%) Soleus and gastrocunemius vein 7/200 (3.5%) 0/139 (0%) 10/200 (5%) 3/139 (2.2%) Frequency of DVT occurrence was no difference between one side cases and bilateral side cases.

11 PE progress R Lt POD1 63.7% (12/19) POD % (7/19) 5.6% (19/339) UL UL ML LL LL upper lobe: UL / middle lobe: ML / lower lobe: LL Frequency of PE was 5.4%, but all PE cases was asymptomatic. PE occurrence on POD1 was lager than on POD14 PE occurrence was almost right linge. R UL ML LB Lt UL LB - Disappear 1 Stable 1 Decreasing 1 Disappear 6 Stable 2 Disappear 1 R UL 2 ML LB 5

12 Statistical analysis of DVD Risk factors Risk factor DVT +(172cases) DVT (178cases) Significant Age 75±8.8(53-91) 74±9.6(53-80) ns Mann-whitney Gender Male 70, Female プ, Female121 ns Mann-whitney BH 152.9±8.9( ) 153±9( ) ns Mann-whitney BW 61.4±13.5( ) 63.8±14.8( ) ns Mann-whitney BMI 27.7±10.1(17-43) 27.6±14.9( ) ns Mann-whitney FTA 180.6±21.6( ) 179.3±17.1( ) ns Mann-whitney Extension 8.9±11(0-30) 10.3±14(0-31) ns Mann-whitney Flexion 118.7±20.7(95-140) 128±22.8(90-151) ns Mann-whitney Operative time 121.9±24.9(890158) 122±26.1(91-151) ns Mann-whitney HT P= multiple logistic regression HG ns multiple logistic regression malignant tumor ns multiple logistic regression DM * P<0.05 n=378 VTE 2 4 ns multiple logistic regression Heart disease ns multiple logistic regression

13 Consideration PE and DVT was major complication of TKA 1-2). ACCP guideline reported DVT occurrence after TKA without prevention was 41-85% 1). Symptomatic that was 2.8%(PE1%/DVT1.8%) on0-14 days and 1.5%(PE0.5%/ DVT1%) 2).That of our study was 52.2%DVT, 5.2% PE, but all PE and DVT was asymptomatic. When PE and DVT above the knee was confirmed on 1 st day enhanced CT, heparin div was started immediately after drain removal. When DVT below the knee was confirmed, anticoagulant therapy was started after drain removal. In this fact, anticoagulant was effective to prevent symptomatic PE and DVT. But, prevention of operative day and 1 st day after the TKA remains issue, because PE and DVT occurred mainly on 1 st day. Reference 1)Geerts WH et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guideline (8 th Edition). Chest 2008, 133: 381 S-453 S. 2)Falck-Yetter Y, Francis CW, et al: Prevention of VTE in Orthopedic Surgery Patients Antithrombotic Therapy and Prevention of Thrombosis, 9 th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guideline (8 th Edition). Chest 2012, 141: e278s-e325s.