Girish R. Mood, MD, Heather L. Gornik, MD, MHS, Vidyasagar Kalahasti, MD, Donald Hammer, MD, W. H. Wilson Tang, MD, FAHA.

High Incidence of Venous Thrombosis following Cardiac Surgery

High Incidence of Venous Thrombosis following Cardiac Surgery l November 7, 2007 l 2

Background:

General Surgery 15-40%

Major gynecologic surgery 15-40%

Major urologic surgery 15-40%

Neurosurgery 15-40%

Hip or Knee surgery 40-60%

Spinal cord surgery 60-80%

Critical care patients 10-80%

Absolute risk of DVT in hospitalized patients

Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S

High Incidence of Venous Thrombosis following Cardiac Surgery l November 7, 2007 l 3

Deep venous thrombosis after open heart surgery:10,638 patients

(1975-1988)

7,979 (75%) had CABG2,659 had valve ± CABG

77 (0.7%) had DVT

41 patients had PE36 patients had DVT

without PE

Patients with LE edema, pain, ↑ temp underwent

Imaging studies

16 patients had DVT being treated with heparin

25 patients without DVT

DeLaria GA, Hunter JA. Deep venous thrombosis. Implications after open heart surgery. Chest. 1991 Feb;99(2):284-8

High Incidence of Venous Thrombosis following Cardiac Surgery l November 7, 2007 l 4

Deep venous thrombosis following hospital discharge:

270 patientsentering cardiac rehabilitation

after CABG

47 (17.4%) patientshad DVT

2 (0.7%) patients with DVT had PE

Excluded patients with prior DVT, Concomitant non

coronary or valve surgery

171 (63%) were on heparin prophylaxis

Ambrosetti M, Salerno M, Zambelli M, Mastropasqua F, Tramarin R, Pedretti RF. Deep vein thrombosis among patients entering cardiac rehabilitation after coronary artery bypass surgery. Chest 2004;125:191-6

High Incidence of Venous Thrombosis following Cardiac Surgery l November 7, 2007 l 5

Aim of the study:

• To evaluate incidence of symptomatic venous thrombosis after contemporary open heart surgery

• To evaluate the relative time course and presenting locations of venous thrombosis

High Incidence of Venous Thrombosis following Cardiac Surgery l November 7, 2007 l 6

Inclusion criteria:

• All patients who underwent cardiac surgery (emergent and non emergent) during the year 01/2004 to 12/2006

• Patients evaluated with imaging studies for clinical suspicion of venous thrombosis

- Swelling, warmth, redness, pain related to the extremity

- Heparin induced thrombocytopenia

Exclusion criteria:

• Patients with known venous thrombosis prior to the surgery

High Incidence of Venous Thrombosis following Cardiac Surgery l November 7, 2007 l 7

Methods:

• Detailed post-operative data prospectively collected via Cleveland Clinic Cardiovascular Information Registry database (CVIR)

• Vascular study information up to 30 days post-op reviewed

• Stratified according to location of venous thrombosis; superficial venous thrombosis or deep venous thrombosis

High Incidence of Venous Thrombosis following Cardiac Surgery l November 7, 2007 l 8

Definitions:

• Early venous thrombosis was defined as positive results between 0-15 days from the surgery

• Late venous thrombosis was defined as positive results between 16-30 days after the surgery

High Incidence of Venous Thrombosis following Cardiac Surgery l November 7, 2007 l 9

Results:

10,588(01/2004-12/2006)

1,667 (15.7%) Underwent imaging studies

1,272 (12.0%)

All positive venous thrombosis

870 (8.2%)DVT positive

152Excluded for known venous thrombosis

prior to surgery

High Incidence of Venous Thrombosis following Cardiac Surgery l November 7, 2007 l 10

Site of venous thrombosis:

870 DVT positive

428 (49.2%)Positive LE DVT

442 (50.8%)Positive UE DVT

304 (34.9%)Calf vein DVT

396 (45.5%)IJ vein DVT

High Incidence of Venous Thrombosis following Cardiac Surgery l November 7, 2007 l 11

Time to thrombosis (Deep venous thrombosis):

0

10

20

30

40

0 7 14 21 28

LE DVT

UE DVT

Time in Days

High Incidence of Venous Thrombosis following Cardiac Surgery l November 7, 2007 l 12

Time to thrombosis (superficial and deep venous thrombosis):

0

10

20

30

40

50

1 8 15 22 29

Unilateral LE

Bilateral LE

Unilateral UE

Bilateral UE

Time in days

High Incidence of Venous Thrombosis following Cardiac Surgery l November 7, 2007 l 13

Deep venous thrombosis in CABG and valve surgery only:

0

2

4

6

8

10

12

14

16

18

Lower Ext. Upper Ext.

CABGValve

14.9%14%

9.7%

16.3%

High Incidence of Venous Thrombosis following Cardiac Surgery l November 7, 2007 l 14

Limitation:

• Single center, registry based study

• May not include the studies performed outside the central vascular lab

• Details of venous access site were not available

• Selection bias of clinically indicated vascular studies

High Incidence of Venous Thrombosis following Cardiac Surgery l November 7, 2007 l 15

Conclusion:

• Symptomatic venous thrombosis was found in 12% of patients undergoing open heart surgery in the contemporary era

• Incidence of deep venous thrombosis was 8.2%

• Over 3/4th of venous thrombosis were detected within 15 days post-operatively

• Internal jugular (45.5%) and calf vein thromboses (34.9%) being the most common sites.