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D e e p Ve n o u s T h ro m b o s i s

Prevention and Management

Ronald E. Iverson, MDa,b,*, Janet L. Gomez, RN, BA, RNFAc

 Deep vein thrombosis  Patient safety  Postoperative complications
 Postoperative risk assessment  Pulmonary emboli  Venous thromboembolism

 Deep vein thrombosis and its possible sequela of pulmonary embolism are a major risk for plastic
surgery patients.
 Patients undergoing an abdominoplasty are at a significant risk of death due to pulmonary emboli.
 Risk assessment is the basis for prevention of thromboembolic phenomena.
 Measures to prevent deep venous thrombosis must be taken based on risk stratification.
 Early diagnosis and treatment of deep venous thrombosis or pulmonary emboli are essential to
decrease the risks of these serious sequelae.

The incidence of thromboembolic phenomena, executive committee of the American Society

including deep venous thrombosis (DVT) and its of Plastic Surgeons (ASPS)approved Venous
feared sequela of pulmonary embolism (PE), are Thromboembolism Task Force Report identified
major health care issues and known postoperative the best practices for DVT/PE prevention and
risks of lengthy surgical procedures.1,2 The Sur- treatment.6 The ASPS Task Force on Patient
geon Generals Call to Action to Prevent Deep Safety has also published articles offering recom-
Vein Thrombosis and Pulmonary Embolism, 2008 mendations for DVT prophylaxis based on levels of
estimated that 350,000 to 600,000 Americans suf- risk in ambulatory surgery settings.79 The need for
fer annually from DVT and PE and that at least awareness of DVT/PE prophylaxis in plastic sur-
100,000 deaths per year may be related to these gery, and specifically in liposuction and abdomi-
diseases.3 In 2009, the National Quality Forum noplasty procedures, has been the basis for
had even more impressive statistics4: each year numerous articles.918 The correlation of DVT/PE
more than 900,000 Americans form DVTs, of which and body-contouring surgery after massive weight
500,000 experience a PE, resulting in roughly loss was addressed by Kenkel,19 for abdominal
300,000 deaths. Surgeons who operate in ambula- contouring by Hatef and colleagues,20,21 and is still
tory facilities must become aware of these health receiving attention as documented by Egrari21 in
risks for their patients. 2012. The risk of DVT is even greater in patients
receiving orthopedic care and in certain categories
of trauma and general surgery than in plastic
surgery. There is extensive published literature to
An historical review of the plastic surgery literature support this conclusion.2229
reveals studies that offer recommendations for Facelifts and their association with DVT/PE were

both DVT prophylaxis and risk management, start- documented by Rigg30 and by Reinisch and col-
ing with a 1999 article by Noel McDevitt.5 The leagues31 in 1998, and still remain an important

Stanford University Medical School, Palo Alto, CA, USA; b American Association for the Accreditation of
Surgical Facilities, IL, USA; c Ronald E. Iverson, MD, FACS, The Plastic Surgery Center, 1387 Santa Rita Road,
Pleasanton, CA 94566, USA
* Corresponding author. The Plastic Surgery Center, 1387 Santa Rita Road, Pleasanton, CA 94566, USA.
E-mail address: reiversonmd@sbcglobal.net

Clin Plastic Surg 40 (2013) 389398

0094-1298/13/$ see front matter 2013 Elsevier Inc. All rights reserved.
390 Iverson & Gomez

topic, as pointed out in the article by Abboushi and with a significant number of other procedures; 5 in
colleagues32 in 2012. The facelift procedures that facelift and blepharoplasty, 5 with liposuction, 2
were complicated by postoperative DVT were per- with buttocks/thigh extremity lift, and 2 with breast
formed under both local anesthesia with sedation surgery.
and general anesthesia, continuing a long discus-
sion as to whether avoidance of general anes- Risk Assessment
thesia can decrease or eliminate DVT/PE.3337
Plastic surgery continues to emphasize risk
Hoefflin38 countered by reporting no major compli-
assessment and risk-stratifying models for DVT
cations in 23,000 cases under general anesthesia.
as a basis for prevention and avoidance.2,5,7
Many patient characteristics, behaviors, and
AMERICAN ASSOCIATION FOR THE medical histories identify increased risks for post-
ACCREDITATION OF SURGICAL FACILITIES operative DVT. Obstetric history is important and
Peer Review Data: September 2012 frequently overlooked.23 Past obstetric complica-
tions including a still birth, miscarriage, or prema-
The American Association for the Accreditation of
ture birth with toxemia may indicate a serious
Surgical Facilities (AAAASF), through its quality
thrombophilia defect. Postmenopausal hormone
assurance and peer review process, has previ-
therapy and selective estrogen-receptor modula-
ously reported on significant issues in ambulatory
tors (tamoxifen and raloxifene) are associated
surgery.14,15 The latest data are shown in Table 1
with 2-fold to 3-fold increased risk of venous
and confirm the many reports that DVT/PE is a
thrombosis.39 The factors that predisposed a pa-
major problem for patients having plastic surgery.
tient to thrombosis or embolism in 2002 formed a
Of the 3,922,202 plastic surgery cases, there were
limited list.7 It has not only been expanded but
215 DVTs and 264 PEs for a total of 479. This is an
better defined by Caprini and others.2224,40
incidence by case of 0.01222% or 1 in every 8188
The 2005 Caprini Risk Assessment Model
cases. The largest number of venous thromboem-
(Fig. 1) and its subsequent, more developed,
bolism (VTE), 308, occurred with abdominoplas-
version, the 2010 Caprini Risk Assessment Model
ties. The abdominoplasty procedures performed
(Fig. 2), are thorough, noting common risk factors
alone were 98; abdominoplasties plus 1 additional
for DVT and PE. Each factor is weighted 1, 2, 3, or
procedure were 137; plus 2 additional procedures,
5 points, depending on its significance for risk. An
58; and plus 3 additional procedures, 15, which is
overall total risk category score is then assigned
an incidence of 0.0666% or 1 in every 1502 cases.
(Table 2). A correlation between the total risk
Total abdominoplasties that were associated with
score and proven VTE incidents in surgical pa-
a PE were 185, with an incidence of 0.04% or 1 in
tients has been reported.24,41,42
every 2500 cases. The distribution of PE cases
The assessment of postoperative VTE risk in
associated with abdominoplasty alone or abdom-
patients having plastic surgery, using both the
inoplasties with multiple procedures is similar to
2005 and 2010 Caprini Risk Assessment Models,
the data for patients having VTE/PE. There is no
was studied by Pannucci and colleagues.43 Their
significant statistical difference for VTE or PE
conclusion identified the 2005 Caprini model as a
whether the abdominoplasty is performed alone
more appropriate method for risk stratification of
or with multiple other procedures. It has been re-
patients having plastic surgery than the 2010
ported in the literature that performing multiple
procedures at the same time increases the risk
Although the Caprini assessment models do not
of complications, such as VTE. These peer-
include smoking as a risk factor, the presence of
reviewed data do not support that conclusion.
coagulation abnormalities associated with smok-
There were 94 deaths associated with plastic
ing44 may further increase the risk for DVT/PE. To-
surgery, or an incidence of 0.0024% or 1 in every
bacco smoking has been associated with
41,726 cases. The incidence of death in plastic sur-
increased serum homocysteine, representing a
gery procedures is 0.0017% or 1 in every 58,779
3-point risk factor in the model. The interrelation-
procedures. The death rate in plastic surgery by
ship between smoking, its procoagulant mech-
case or procedure is less than when all specialties
anisms, and VTE awaits further therapeutic
are combined; the number of deaths related to PE
studies. The importance of evidence-based medi-
in the plastic surgery cases was 40 of 94, or 43%. It
cine in these areas mandates further research.4547
is significant that, of the 40 deaths in plastic surgery
procedures, an incidence of 0.0010% or 1 in every
98,055 cases, 26 occurred with abdominoplasties
for an incidence of 0.0056% or 1 in every 17,791 The strategies for prevention of DVT/PE are exten-
cases. The data also reveal that PEs have occurred sive and most often based on preoperative risk
Deep Venous Thrombosis 391

Table 1
American association for the accreditation of surgical facilities, plastic surgery data for VTE, PE, and
deaths (September 2012)

Total Cases all 5,416,071

AAAASF Specialties
Total Procedures all 7,629,686 1.41 Procedures
AAAASF Specialties per Case
Plastic Surgery Cases 3,922,202
Plastic Surgery 5,525,255 1.41 Procedures
Procedures per Case
Incidence % 1 in # Case Incidence % 1 in #
by Case by Procedure Procedure
All Deaths all Specialties 184 0.0034% 29,435 0.0024% 41,466
Incidence % 1 in # Plastic Incidence % 1 in # Plastic
by Plastic Surgery Case by Plastic Surgery
Surgery Case Surgery Procedure
All Plastic Surgery 94 0.0024% 41,726 0.0017% 58,779
Total Abdominoplasties 462,564
Abdominoplasty Alone 176,092
Abdominoplasty 1 1 187,847
other procedure
Abdominoplasty 1 2 73,869
other procedures
Abdominoplasty 1 3 24,756
other procedures
Incidence % 1 in # Case Incidence % by 1 in #
by Case Procedure Procedure
Total Plastic Surgery VTE 479 0.0122% 8188 0.0087% 11,535
Plastic Surgery DVT 215 0.0055% 18,243 0.0039% 25,699
Plastic Surgery PE 264 0.0048% 20,929 0.0048% 20,929
Incidence % 1 in # Case
by Case
Abdominoplasty 1 VTE 308 0.0666% 1502
VTE Abdominoplasty 98 0.0557% 1797
VTE Abdominoplasty 1 1 137 0.0729% 1371
other procedure
VTE Abdominoplasty 1 2 58 0.0785% 1274
other procedures
VTE Abdominoplasty 1 3 15 0.0606% 1650
other procedures
Incidence % 1 in # Case
by Case
Abdominoplasty 1 PE 185 0.0400% 2500
PE Abdominoplasty 60 0.0341% 2935
PE Abdominoplasty 1 1 81 0.0431% 2319
other procedure
PE Abdominoplasty 1 2 37 0.0501% 1996
other procedures
(continued on next page)
Table 1

PE Abdominoplasty 1 3 7 0.0283% 3537

other procedures
Incidence % 1 in # Case Incidence % by 1 in #
by Case Procedure Procedure
Deaths PE All Plastic 40 0.0010% 98,055 0.0007% 138,131
Surgery Procedures
Deaths PE 6 0.0034% 29,349
Deaths PE 10 0.0053% 18,785
Abdominoplasty 1 1
other procedure
Deaths PE 9 0.0122% 8208
Abdominoplasty 1 2
other procedure
Deaths PE 1 0.0040% 24,756
Abdominoplasty 1 3
other procedure
Total Deaths PE 26 0.0056% 17,791
Deaths Facelift and 5
Deaths PE Liposuction 5
Death PE Buttocks 2
Thigh Extremity Lift
Deaths PE Breast 2
Augmentation or Lift
Data from American Association for Ambulatory Surgical Facilities, Inc. Internet Based Quality Assurance and Peer Review
Program. Available at: http://www.aaaasf.org.

Fig. 1. The 2005 Caprini Risk Assessment Model. COPD, chronic obstructive pulmonary disease. (Adapted from
Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon 2005;51:708; with permission.)
Deep Venous Thrombosis 393

Fig. 2. The 2010 Caprini Risk Assessment Model. BMI, body mass index; DVT/PE, deep venous thrombosis/pulmo-
nary embolus; SVT, superficial venous thrombophlebitis. (Adapted from Caprini JA. Risk assessment as a guide to
thrombosis prophylaxis. Curr Opin Pulm Med 2010;16:44852; with permission.)

assessment for DVT.11,2325,40 For instance, the

Table 2
patients risk factors for increased bleeding are
Risk assessment categories. The 2005 Caprini
Risk Assessment Model
critical to evaluate because the presence of these
factors may rule out the use of chemoprophylaxis.
Risk Factor Score Risk Level Risk factors for increased bleeding are listed in
Box 1.
01 Low risk
It is also important to identify and appraise any
2 Moderate risk relevant findings before intermittent pneumatic
34 High risk compression (IPC) devices are automatically
5 or more Highest risk used. Peripheral arterial disease, congestive heart
Adapted from Caprini JA. Thrombosis risk assessment as a
failure, acute superficial venous thrombophlebitis,
guide to quality patient care. Dis Mon 2005;51:708; with or DVT are known diseases and conditions that are
permission. contraindicated for IPC therapy.
394 Iverson & Gomez

Box 1 be (1) celecoxib (Celebrex) 200 mg, taken 1 hour

Risk factors for increased bleeding before surgery, (2) use of graded compression
stockings beginning 24 hours before surgery, (3)
 Current medications such as aspirin or IPC devices in place before surgery and main-
Coumadin tained until discharge from the postanesthesia
 Family history of bleeding disorder care unit, (4) maintenance of normothermia, and
 History of heparin-induced thrombocytopenia (5) encouraging ambulation as early as possible.
Surgical time was minimized by their technique
 Known acquired bleeding disorder and staff training. These suggestions are reason-
 Patient bruises or swells easily able and should be proactively considered to
 Platelet count less than 100,000/mm3 improve patient safety.
The authors use and recommend the strategies
 Previous bleeding issues during surgery or
dental procedures listed in Box 2 for postoperative management of
surgical patients.
The current standard for IPC devices from the
AAAASF, Version 13 200.017.030, states that
sequential compression devices are used for sur-
The prophylaxis regime,1,2325 based on the gical procedures of 1 hour or longer, except for
Caprini Risk Assessment Model, is shown in procedures performed under local anesthesia.50
Table 3. The basic recommendations in this table This reasonable recommendation should be
should be augmented with a comprehensive peri- adhered to no matter what level of risk is identified
operative and intraoperative approach.1,10,20,48,49 for the patient, unless the contraindications previ-
The use of chemoprophylaxis as part of the ously discussed are present.
approach to prevention is explained in the article Seruya and colleagues1 found that the incidence
by Alan Gold, MD, elsewhere in this issue. of treated patients who present with high-risk fac-
Somogyi and colleagues49 thought that their tors for DVT are sizable and comprise 15% of the
preventative approach lowered the risk of VTE in population of patients having plastic surgery. His
abdominoplasties to a level that made chemopro- studies suggest that thromboprophylaxis is more
phylaxis unnecessary. They made numerous rec- effective in this highest risk factor group than
ommendations, but the most significant seem to mechanical prophylaxis alone. All these risk fac-
tors and risk levels must be discussed with individ-
ual patients before the determination of their
Table 3 candidacy for surgery; this discussion is an essen-
Prophylaxis regime. The 2010 Caprini Risk tial part of an adequate informed consent. The
Assessment Model patients decision to have surgery and the sur-
geons decision to perform surgery hinge on those
Total Risk factors and levels of risks. Patients who are in the
Factor Risk Prophylaxis
highest risk category, especially if that risk is dou-
Scores Level Regime
ble digit, may need to forego elective quality-of-life
01 Low Early ambulation procedures given that their total risk factor score
2 Moderate ES or IPC or LDUH indicates an extremely high risk of DVT/PE.
34 High IPC or LDUH or
LMWH alone or in
with ES or IPC Box 2
Prevention through postoperative patient
5 or more Highest Pharmacologic: LDUH, management
LMWH, warfarin or
FAC Xa alone or in  Ambulation every hour
combination with
ES or IPC  Avoid popliteal pressure while sitting
 Foot elevation and flexion exercises at rest
Abbreviations: ES, elastic stocking; FAC Xa, factor, X inhib-
itor; IPC, pneumatic impression device; LDUH, low-dose  Graded compression elastic stockings for
unfractionated heparin; LMWH, low-molecular-weight 7 days
Adapted from Caprini JA. Risk assessment as a guide
to thrombosis prophylaxis. Curr Opin Pulm Med  Smoking cessation
2010;16:44852; with permission.
Deep Venous Thrombosis 395

Diagnosis emergency room for a physicians evaluation.

These symptoms are listed in Box 4.
DVT, in itself, is not likely to be fatal. One-half of
The ninth edition of The American College of
affected patients have an asymptomatic presenta-
Chest Physicians Evidence-based Clinical Practice
tion so that its diagnosis requires confirmatory lab-
Guidelines on thrombotic therapy and prevention
oratory tests such as duplex ultrasound (US)
of thrombosis provides multiple levels of evalua-
imaging or contrast phlebography.24 However,
tion for patients at risk for DVT.51 In the patient
the frequently associated sequela of a PE has a
with low pretest probability of first lower extremity
high mortality. DVT is historically associated with
DVT, the following tests are recommended: (1) a
the Virchow triad of venous stasis, vascular injury,
moderately sensitive D-dimer, (2) a highly sensitive
and hypercoagulability. DVT can present with the
D-dimer, or (3) compression US (CUS) of the prox-
vague symptoms of feeling dizzy and faint or pre-
imal veins. If the D-dimer is positive, further testing
sent dramatically with a severely swollen leg,
with CUS of the proximal veins rather than whole-
sometimes discolored white or blue.
leg US or venography is advised. If the CUS of the
The early diagnosis of DVT is vital to prevent un-
proximal veins is positive, it is recommended that
toward sequelae from the thrombosis in the leg
confirmatory venography is performed instead of
and to prevent a possible resulting PE. DVT most
instituting treatment of DVT.
commonly develops in the veins of the calf muscle
For the patient with high pretest probability of
and has a low incidence of clinically significant
first lower extremity DVT, proximal CUS or
emboli if it remains within the calf area. However,
whole-leg US is recommended. If the proximal
without appropriate treatment, 20% of venous
CUS or whole-leg US is positive for DVT, treatment
thrombi in the calf propagate and pose a serious
is recommended rather than confirmatory venog-
threat. At least 50% of proximal deep venous
raphy. In patients with high pretest probability,
thrombi are associated with PE or recurrent DVT.10
the moderately or highly sensitive D-dimer should
Awareness and knowledge of the symptoms of
not be used as a stand-alone test to rule out
DVT and associated VTE are critical for all individ-
DVT. The whole-leg US may be preferred to prox-
uals involved in postoperative communications
imal CUS in patients unable to return for serial
and care with the ambulatory surgical patient.
testing and in those with severe symptoms consis-
Every office staff member, from the secretary
tent with calf DVT or risk factors for extensive
answering the patients calls to the nursing staff
distal DVT.
providing postoperative advice and care, must
In patients with suspected lower extremity DVT
be trained to recognize the sometimes vague
in whom US is impractical, for example in a case
complaints that may indicate the presence of the
in which there is excessive fluid or subcutaneous
disease. These complaints are listed in Box 3.
tissue to prevent adequate assessment of com-
When in doubt, and in the absence of the
pressibility or diagnosis, computed tomography
surgeon, staff members should instruct any post-
venography is suggested. Magnetic resonance
operative patient, even those who present with
(MR) venography or MR direct thrombus imaging
symptoms 3 to 6 months after the procedure, to
seek medical care immediately. Any patient con-
tacting the office with complaints of cardiac or res-
piratory distress should be directed to contact Box 4
emergency medical services for transport to the Manifestations of DVT or PE requiring a
physicians evaluation

Box 3  Transient or orthostatic hypotension
Manifestations of DVT or PE that may elicit calls
to the office  Transient hypoxemia
 Unexplained decrease in level of
 Chest pain consciousness
 Fainting  Suspected postoperative myocardial
 Feeling dizzy, or faint leg color change infarction
 Leg pain  Postoperative nonhemorrhagic stroke
 Leg swelling  Postoperative pneumonia
 Leg tenderness  Unexplained sudden death
 Shortness of breath or tachypnea  Venous engorgement of the leg
396 Iverson & Gomez

can be used as an alternative to venography. problem. It seems from all current information
Patients suspected of DVT may choose treatment that DVT/PE problems will never be eliminated.
rather than venography. The level of awareness of DVT/PE as a major
cause of mortality in ambulatory surgery has
Treatment dramatically increased over the past 10 years.
There are many strategies for the prevention and
Once the diagnosis of DVT is made, the surgeon
treatment of DVT/PE. It is only through both
must immediately consider a consultation with
patients and surgeons being informed about the
the appropriate medical physician specialist and
dangers and realities of DVT that the incidence of
possibly a vascular surgeon. Without appropriate
the problem can be decreased. It is imperative
treatment, 20% of calf vein thrombi propagate
that plastic surgeons continue their efforts for
proximately to where they pose a serious threat.
increased public awareness and patient education
At least 50% of proximal DVTs are associated
related to the risk factors and symptoms of DVT.
with a PE or recurrent DVT, 10% were immediately
Plastic surgeons must routinely incorporate pre-
fatal with PE, and 5% caused death later as a
operative DVT risk assessment models for all pa-
result of right ventricular dysfunction and/or pul-
tients who are to undergo surgery as well as
monary hypertension.10 The other major problem
apply a renewed vigilance on patient selection.
following a DVT is postthrombotic syndrome
The prevention protocol should be based on risk
(PTS).25,26 PTS is clinically associated with leg
assessment and all appropriate recommended
pain, swelling of the leg, and varicose veins.
perioperative and postoperative modalities for
The protocol for antithrombotic therapy is
prevention must be used. Surgeon and their staff
covered in the 2012 The American College of
must be trained to identify and diagnose a DVT
Chest Physicians Evidence-based Clinical Practice
for when prevention fails. If a DVT is suspected,
Guidelines,51 summarizing bodies of evidence to
appropriate treatment using a specialist medical
offer 600 recommendations for diagnosing, pre-
consultation is a necessity and should be insti-
venting, and treating DVT. The guidelines suggest
tuted immediately.
that the initial anticoagulation for acute DVT be a
When these approaches are used by all plastics
parenteral anticoagulation low-molecular-weight
surgeons, a significant improvement in patient
heparin (Enoxaparin), fondaparinux (Arixtra), intra-
safety and surgical outcomes should be seen.
venous unfractionated heparin, or subcutaneous
The overall safety of performing surgery in an
heparin. This protocol is also indicated for patients
ambulatory setting is well documented. Continued
with a high suspicion of acute VTE. Any patient
vigilance is essential for all safety issues in the
who has been identified as high risk for bleeding
surgery suite, but those precautions for DVT/PE
dyscrasias requires special evaluation before insti-
prevention should be foremost because those dis-
tuting initial anticoagulation.
eases are frequently associated with a patients
Catheter-directed thrombolysis must be consid-
disability and even death.
ered because of the benefit for the prevention of
the PTS. Catheter-assisted thrombus removal is
also a consideration as a method of decreasing
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