PersonalIntroduction
Medical Background
1970 Medical Faculty, UII, Solo
1975 MD , Justus Liebig University, Giessen
1982 General Surgeon, JW Goethe University, Frankfurt
1986 Cardiac and Vascular Surgeon , Ph.D, JLU, Giessen
1989 T.C.V-Surgeon WWU Muenster, Germany
1997 Awarded Venia Legendi
Associate Professor for Thoracic and Cardiovascular Surgery
(T.C.V) ,WWU Muenster
2000-2006 Visiting Professor , UI, UGM, UMY
2007 Professor for T.C.V Surgery,
WWU Muenster ,Germany
2009 Academic Professor, Medical School University of
Indonesia
2012 Academic Professor, UMY
PersonalIntroduction
Institutional Affiliation
Cardiovascular Center, International Wing KENCANA,
Div. of Vascular and Endovascular Surgery, Dept.of
Surgery
University Hospital/ RSCM, University of Indonesia
Department of Thoracic and Cardiovascular
Surgery, University Hospital, Muenster-Germany
(former)
Specialty
Adult Cardiac Surgery
Peripheral Vascular Surgery
General Thoracic Surgery
D VT
D EEP V EIN TR O M B O S IS
Prof. Dr. Med. dr. H. Rasjid Soeparwata
Cardiovascular and Thoracic Surgeon
Vascular and Endovascular Division Consultant
FKUI/RSCM
CO N TEN T
Definition and Anatomy
Epidemiology
Algorithm
Risk Factors
Prophylaxis Options
Recommendations in specific populations
Surgical inpatients
Medical inpatients
Cancer Patients
O U R V EIN S Y S TEM
Epidem iology
Incidence - USA/Europe
DVT: 160 per 100,000
Symptomatic non-fatal PE: 20
per 100,000
Fatal PE: 50 per 100,000
80 cases per 100,000 population/years
1 person in 20 develops a DVT in the course
of his or her lifetime.
600,000 hospitalizations /year in USA.
Elderly incidence 4X.
Hospital VTE death 12%, rising to 21% in
elderly persons.
Incidence in hospitalized patients 20-70%.
Venous ulceration and venous insufficiency of
the lower leg 0.5% of the entire population.
5 mio. people venous stasis and venous
insufficiency.
M edicalInpatients:Evidence
50-70% of symptomatic VTE & 80%
of fatal PE in non-surgical patients
Average general medical patient is
low-moderate risk of VTE
5-7% rate of DVT on U/S screening
0.6% rate of hospital-acquired
symptomatic VTE
Highest risk illnesses: cancer, stroke,
COPD, sepsis, anything that leads to
bedrest
D VT Clin.M anifestation
10
To understand the abnormalities of veins
we must understand normal veins and
their function
2. Perforating Vein
3. Deep vein
Virchow Triad
Hypercoagulability
high fibrinogen, d-Dimer
Hemodynamic
changes (stasis, turbulence)
Endothelial
Injury (dysfunction)
EndotelFunction
Antithrombotic
Producing:
prostaglandin I2
Thrombomudulin
tissue-type plasminogen activator (t-PA)
glycosaminoglycan co faktor antithrobin
14
Throm bogenic Risk Factors
1. Age
2. Malignancy
3. Surgical Procedure/Trauma
4. Primary Hipercoagulability state
5. Pregnancy
6. Oral Contraception
O ralContraception & H orm onalTherapy
Estrogen > 50 g increase
in VIIa-Factor & reduce
antithrombin dan protein S
activity.
Hormonal therapy increase
thrombotic risk
Throm bogenesis in Pregnancy
VTE second cause of
abortion.
Post partum DVT risk 2 - 3 x
higher in pregnancy.
Increase in thrombotic risk and
prethrombotic state.
VTE Prevalence
Prevalence of asymptomatic DVT in
patients not receiving prophylaxis
(Geerts, Chest 2008)
Medical: 10-20%
Stroke 20-50%, Critical care 10-80%
General Surgery: 15-40%
THR, TKR: 40-60%
VTE/D VT O utcom es
17% 2-year risk of recurrence
25% 2-year risk of PTS
17% at 3-months PE mortality
21% in-hospital & 39% 1-year
mortality for PE in elderly
Klinis dan G ejala
Gejala :
1. Pembesaran
satu kaki
2. Asymptommatic
Klinis :
3. Odema
4. Nyeri
5. Selulitis
6. Ulkus hingga
gangren
20
LA B EX A M IN ATIO N
1. Complete Blood Count
2. Erythrocyte Sedimentation Rate
3. PT/APTT
4. Fibrinogen
5. D- Dimer
21
Color duplex scan of D VT
Venogram
show s D VT
Patient with suspect symptomatic
Acute lower extremity DVT
Venous duplex scan
negative
Low clinical probability observe
High
positive
clinical probability
aluate coagulogram /thrombophilia/ malignancy
Anticoagulant therapy
contraindication
yes
negative
Repeat scan /
Venography
IVC filter
No
pregnancy
OPD
hospitalisation
LMWH
LMWH
UFH
warfarin
Compression treatment
Absolute Risk of DVT in Hospitalized Patients
Patient Group DVT Prevalence, %
Medical patients
1020
General surgery
1540
Major gynecologic surgery 1540
Major urologic surgery 1540
Neurosurgery 1540
Stroke 2050
Hip or knee arthroplasty, hip fracture surgery
Major trauma 4080
Spinal cord injury 6080
Critical care patients
1080
Chest. 2004;126:338S-400S. PMID: 15383478.
4060
Risk Stratifi
cation
Risk
Low
Moderate
High
Type
Minor surgery
& medical,
mobile
Most general
surgery &
medical
patients
Ortho & major
trauma
Rx
Early
ambulation
Medical +/mechanical
Medical +/mechanical
O ptions for prophylaxis
The Virchow triad
Endothelial insult
(lesion or change of
the inner venous
wall)
Increased
coagulation
(fibrinolytic
abnormalities)
Reduced venous
flow
Option
None
Daily intake of
anticoagulants
Elastic compression,
pneumatic compression or
continuous passive motion
27
Prophylaxis Choices
Early & frequent ambulation ( The
Most Important)
Mechanical
Graduated compression stockings (GCS)
Intermittent pneumatic compression
(IPC)
Medical
Aspirin
Low-dose Unfractionated Heparin (LDUH)
Low Molecular Weight Heparin (LMWH)
Fondaparinux (Arixtra )
Warfarin (Coumadin )
Elastic Com pression
Conclusion
1
The number of VTE/cardiovascular disease is increasing
worldwide unexceptionally Indonesia.
1/3 among VTE manifests as PE, 2/3 manifests as DVT
Various risk factors that can cause VTE. Knowledge in
recognizing the risk factors is very important in order to
prevent VTE/DVT/PE.
Treating cardiovascular diseases should be done by
specifically trained expert team using interdisciplinary
approach in center of excellence.
The implementation of technological transfer in
cardiovascular disease from abroad is possible when we have
established a center of excellence with Governmental
support and Willingness.
TH A N K YO U
