AAOS Now

Published 1/1/2010
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Mary Ann Porucznik

Is DVT a valid proxy measure for PE?

Study raises questions about assumed connection

“If we assume that deep venous thrombosis (DVT) is a proxy for pulmonary embolism (PE), a reduction in DVT should, by definition, lead to a reduction in PE,” proposed Javad Parvizi, MD, FRCS. That hypothesis triggered research into the potential link between DVT and PE, the results of which Dr. Parvizi presented at the 2009 annual meeting of the American Association of Hip and Knee Surgeons (AAHKS).

A review of 31,000 patients who had total joint arthroplasty (hip or knee) at a single institution between 2004 and 2008 identified 1,698 patients who had undergone evaluation for DVT (1,016 patients), PE (867 patients), or both DVT and PE (320 patients). The evaluation included lower extremity ultrasound, chest computed tomography (CT), ventilation perfusion (VQ) scans, pulmonary angiographs, and, in some cases, lower extremity venography.

“The incidence of DVT among the 1,016 patients scanned for DVT was 15.9 percent; the incidence of PE among the 867 patients evaluated for PE was 20.6 percent. But the really interesting cohort was the 320 patients who had been scanned for both DVT and PE,” said Dr. Parvizi. “Of those patients, only 26 (8.1 percent) had both DVT and PE. This amounted to only 1.5 percent of the total cohort of 1,698 patients who were screened.”

Fact or just a theory?
“Although some papers related to the development of PE from distal DVT might be found in the medical literature, this fact has not been proven in orthopaedic patients,” Dr. Parvizi pointed out. “Little evidence exists to support the premise that DVT is a good proxy for PE.”

No one disputes the fact that venous thromboembolism (VTE) creates a huge social and healthcare burden or that it is also associated with catastrophic sequelae. The administration of anticoagulation drugs as a preventive for the development of VTE after orthopaedic surgery, however, is associated with its own risks, including bleeding, periprosthetic infection, transfusion requirements, and, based on a recent study, an increase in the all-time mortality rate following total joint replacement.

“The guidelines from the American College of Chest Physicians (ACCP),” noted Dr. Parvizi, “are based on the fact that the efficacy of the recommended drugs was measured by the prevention of asymptomatic DVT as diagnosed by venography. If PE is arising from lower extremity DVT, we should be seeing a much higher correlation.”

He cited a 2003 study of 135 patients suspected of having PE. After undergoing duplex ultrasonography, only 35 patients were identified with PE, and of these, only two had DVT. Another study cited looked at the natural history of distal DVT following total knee arthroplasty. Half of the patients were symptomatic and the other half were asymptomatic. At a mean of 3 years, repeat venography showed that most distal DVTs had resolved and that PE based on DVT had not developed in any of the patients.

Different etiologies?
“We know, based on registry data, as well as institutional experiences, that there has been no change in the incidence of symptomatic or fatal PE, despite the implementation of aggressive anticoagulation protocols, including those mandated by the ACCP,” said Dr. Parvizi.

“Our analysis found no correlation between distal DVT and PE in this patient cohort. It’s possible that DVT and PE arise from different etiologies, and recent studies have shown that the genetic mutations specific for DVT and PE appear to be different,” he continued. “Based on our data, no correlation exists between symptomatic DVT and PE in orthopaedic patients undergoing total joint arthroplasty, and it is possible that the PE may not arise from limb DVT at this point. We believe that further studies are likely to shed some light on these findings.”

Dr. Parvizi’s co-authors include Christina Jacovides, BS; James J. Purtill, MD; and Richard H. Rothman, MD. Drs. Parvizi and Rothman reported ties to Stryker Orthopaedics; the other authors reported no conflicts.

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org

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