Prevention of Deep Vein Thrombosis and Pulmonary Embolism

  • J. G. Sharnoff

Abstract

Ever since Crafoord15 recommended the use of postoperative intravenous heparin in the prevention of thrombosis, many routines have been tried. The methods of prevention of deep vein thrombosis has had two main attacks based on two of the postulates of Virchow’s original triad. The first attack was based on the assumption that slowing of the blood flow in the leg veins was the chief cause of deep vein thrombosis. This prompted the trial of early mobilization and ambulation following surgery. Then followed leg elevation, the wearing of elastic stockings89, massage of the lower limbs, electrical stimulation of the calf muscles during surgery and the application of pneumatic boots81 during surgery. These methods appeared to have had some beneficial effect in reducing the incidence of deep vein thrombosis but to a limited extent. Another method believed to improve blood flow was the use of the plasma expander dextran. More recently it has been shown that dextran7,10,29,33 may also impair platelet aggregation and adhesiveness, an important cause of intravascular thrombosis. In addition, it has been described as a thrombolytic agent in the dissolution of already formed thrombi. Reports with the use of dextran 40 and 70 are contradictory, however. They also have adverse effects such as the overloading of the circulation and the necessity of repeated venous injections29,30,82.

Keywords

Aspirin Nicotinate Heparin Immobilization Coumadin 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Abernethy, E. E. and Hartsuck, J. M. (1974). Postoperative pulmonary embolism. A prospective study utilizing low-dose heparin. Am. J. Surg., 128, 739PubMedCrossRefGoogle Scholar
  2. 2.
    Abdou-Abdallah, E., Rausis, C., Loup, P. and Mosimann, R. (1975). Etude comparative heparinate de sodium et de calcium dans la prophylazie des maladies thrombo-emboliques en chirurgie. Helv. Chir. Acta, 42, 691Google Scholar
  3. 3.
    Allen, N. H., Jenkins, J. D. and Smart, C. J. (1978). Surgical haemorrhage in patients given subcutaneous heparin as prophylaxis against thrombo-embolism. Br. Med. J., 1, 326Google Scholar
  4. 4.
    Baskin, H. E., Murray, J. M. and Harris, R. E. (1977). Low-dose heparin for prevention of thromboembolic disease in pregnancy. Am. J. Obstet. Gyne-col., 129, 590Google Scholar
  5. 5.
    Bauer, G. (1954). Thirteen years experience with heparin therapy. In Koller, T. and Merz, W. (eds.). Proceedings of the 1st Conference on Thrombosis and Embolism, Basel, p. 721Google Scholar
  6. 6.
    Bauer, G. (1955). Prophylaxis and therapy of thrombosis of legs. Nord. Med., 53, 779PubMedGoogle Scholar
  7. 7.
    Bergentz, S. E. (1978). Dextran in prophylaxis of pulmonary embolism. World J. Surg., 2, 19PubMedCrossRefGoogle Scholar
  8. 8.
    Berquist, D. and Hallbrook, T. (1977). Are there any differences in thrombosis, prophylaxis and the side effects between sodium and calcium heparin? Proceedings of the 6th International Congress on Thrombosis and Hemostasis, p. 106Google Scholar
  9. 9.
    Bern, M. M. (1975). Variable response of activated partial thromboplastin time in heparin therapy during hemodialysis. Am. J. Clin. Pathol., 64, 602PubMedGoogle Scholar
  10. 10.
    Browse, N. L., Clemenson, G., Bateman, N. T., Gaunt, J. I. and Croft, D. N. (1976). Effect of intravenous dextran 70 and pneumatic leg compression on incidence of postoperative pulmonary embolism. Br. Med. J., 2, 1281PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Canadian Cooperative Study Group (1978). A randomized trial of aspirin and sulfinpyrazone in threatened stroke. N. Engl. J. Med., 299, 53CrossRefGoogle Scholar
  12. 12.
    Charnley, J. (1972). Prophylaxis of postoperative thromboembolism. Lancet, 2, 134PubMedCrossRefGoogle Scholar
  13. 13.
    Cooke, E. D., Lloyd, M. J., Bowcock, S. A. and Pilcher, M. F. (1976). Monitoring during low-dose heparin prophylaxis. N. Engl.J. Med., 294, 1066PubMedGoogle Scholar
  14. 14.
    Council on Thrombosis of the American Heart Association (1977). Prevention of venous thromboembolism in surgical patients by low dose heparin. Circulation, 55, 423ACrossRefGoogle Scholar
  15. 15.
    Crafoord, C. (1936). Preliminary report on post-operative treatment with heparin as a preventative of thrombosis. Acta Chir. Scand., 77, 407Google Scholar
  16. 16.
    Dechavanne, M., Ville, D., Viala, J. J., Kher, A., Faivre, J., Pousset, M. B. and Dejour, H. (1975). Controlled trial of platelet anti-aggregating agents and subcutaneous heparin in prevention of postoperative deep vein thrombosis in high risk patients. Hemostasis, 4, 94Google Scholar
  17. 17.
    Dechavanne, M., Soudin, F., Viala, J. J., Kher, A., Bertrix, L. and deMourgues, G. (1974). Prevention des thromboses veineuses. Succès de l’heparin a fortes doses des coxarthroses. Nouv. Presse Med., 3, 1317PubMedGoogle Scholar
  18. 18.
    deTakats, G. (1950). Anticoagulation in surgery. J. Am. Med. Assoc., 142, 507CrossRefGoogle Scholar
  19. 19.
    deTakats, G. (1977). Small-dose prophylactic heparin. Mod. Med., Oct., 38Google Scholar
  20. 20.
    Duckert, F., Gruber, U. F., Fridrich, R., Torhorst, J. and Rem, J. (1977). Low-dose heparin. Lancet, 2, 1163CrossRefGoogle Scholar
  21. 21.
    Editorial (1975). Low-dose heparin and the prevention of venous thrombo-embolic disease. Br. Med. J., 2, 447Google Scholar
  22. 22.
    Editorial (1975). Prevention of fatal post-operative pulmonary embolism by low doses of heparin. Lancet, 1, 145Google Scholar
  23. 23.
    Freiman, D. G., Syemoto, J. and Wessler, S. (1965). Frequency of pulmonary thromboembolism in man. N. Engl. J. Med., 272, 1278PubMedCrossRefGoogle Scholar
  24. 24.
    Galasko, C. S., Edwards, D. H., Fearn, C. B. D. and Barker, H. M. (1976). The value of low dosage heparin for the prophylaxis of thromboembolism in patients with transcervical and intertrochanteric femoral fractures. Acta Orthop. Scand., 47, 276PubMedCrossRefGoogle Scholar
  25. 25.
    Gallus, A. S., Hirsh, J., Tuttle, R. J., Trebilcock, R., O’Brien, S. E., Carroll, J. J., Minden, J. H. and Hudecki, S. M. (1973). Small subcutaneous doses of heparin in prevention of venous thrombosis. N. Engl. J. Med., 288, 545PubMedCrossRefGoogle Scholar
  26. 26.
    Gallus, A. S., Hirsh, J., O’Brien, S. E., McBride, J. A., Tuttle, R. J. and Gent, M. (1976). Prevention of venous thrombosis with small subcutaneous doses of heparin. J. Am. Med. Assoc., 235, 1980CrossRefGoogle Scholar
  27. 27.
    Gordon-Smith, I. C., Grundy, D. J., LeQuesne, L. P. and Newcombe, J. F. (1972). Controlled trial of two regimens of subcutaneous heparin in prevention of post-operative deep vein thrombosis. Lancet, 1, 1132Google Scholar
  28. 28.
    Gordon-Smith, I. C., LeQuesne, L. P. and Newcombe, J. F. (1974). Subcutaneous heparin and postoperative venous thrombosis. Lancet, 2, 286CrossRefGoogle Scholar
  29. 29.
    Gruber, U. F., Duckert, F., Fridrich, R., Torhorst, J. and Rem, J. (1977). Prevention of postoperative thromboembolism by dextran 40, low doses of heparin or xantinol nicotinate. Lancet, 1, 207PubMedCrossRefGoogle Scholar
  30. 30.
    Gruber, U. F., Rem, J., Altorfer, R., Schaub, N., Freddie, K. E., Fridrich, R. and Duckert, F. (1973). Efficacy of dextran 40 or heparin in prevention of deep vein thrombosis after major surgery. Eur. Surg. Res. (Suppl. 2), 5, 15Google Scholar
  31. 31.
    Harris, W. H. (1976). Low-dose heparin in total hip replacement. Lancet, 2, 423CrossRefGoogle Scholar
  32. 32.
    Harris, W. A., Salzman, E. W., Athanasoulis, C. A., Waltman, A. C., and DeSanctis, R. W. (1977). Aspirin prophylaxis of venous thromboembolism after total hip replacement. N. Engl. J. Med., 297, 1246PubMedCrossRefGoogle Scholar
  33. 33.
    Harris, W. H., Salzman, E. W., Athanasoulis, C. A., Waltman, A. C., Baum, S. and DeSanctis, R. W. (1974). Comparison of warfarin, low-molecular weight dextran, aspirin, and subcutaneous heparin in prevention of venous thromboembolism following total hip replacement. J. Bone Jt. Surg., 56A, 1552Google Scholar
  34. 34.
    Hume, M. (1978). Aspirin for prophylaxis of venous thromboembolism. N. Engl. J. Med., 298, 1091Google Scholar
  35. 35.
    Jaques, L. B., Mahados, J. and Kavanaugh, L. W. (1976). Intrapulmonary heparin. Lancet, 2, 1157PubMedCrossRefGoogle Scholar
  36. 36.
    Jennings, J. J., Harris, W. H. and Sarmiento, A. (1976). A clinical evaluation of aspirin prophylaxis after total hip arthroplasty. J. Bone Jt. Surg., 58A, 926Google Scholar
  37. 37.
    Kakkar, V. V., Field, E. S., Nicolaides, A. N., Flute, P. T., Wessler, S. and Yin, E. T. (1971). Low doses of heparin in the prevention of deep vein thrombosis. Lancet, 2, 669PubMedCrossRefGoogle Scholar
  38. 38.
    Kakkar, V. V., Corrigan, T. P., Spindler, J., Fossard, D. P., Flute, P. T., Crellin, R. Q., Wessler, S. and Yin, E. T. (1972). Efficacy of low doses of heparin in prevention of deep vein thrombosis after major surgery. A double blind randomized trial. Lancet, 2, 101PubMedCrossRefGoogle Scholar
  39. 39.
    Kakkar, V. V. (1978). The current status of low-dose heparin prophylaxis of thrombophlebitis and pulmonary embolism. World J. Surg., 2, 3PubMedCrossRefGoogle Scholar
  40. 40.
    Lenggenhager, K. (1957). Genese und prophylaxes der postoperatiren fern-thrombose. Helv. Chir. Acta, 24, 316PubMedGoogle Scholar
  41. 41.
    Mannucci, P. M., Citterio, L. E. and Panjotopoulous, N. (1976). Low-dose heparin and deep vein thrombosis after total hip replacement. Thromb. Hemo-stas., 36, 167Google Scholar
  42. 42.
    Medical Research Council (1972). Effect of aspirin on postoperative venous thrombosis. Lancet, 2, 441Google Scholar
  43. 43.
    Morris, G. K. and Mitchell, J. R. A. (1977). Preventing venous thromboembolism in elderly patients with hip fractures: studies of low dose heparin, dipyridamole, aspirin and flurbiprofen. Br. Med. J., 1, 535PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Multicentre Trial (1975). Prevention of fatal postoperative pulmonary embolism by low doses of heparin. Lancet, 2, 45Google Scholar
  45. 45.
    Nicolaides, A. N., Dupont, P. A., Desai, S., Lewis, J. D., Douglas, J. N., Dodsworth, H., Fourides, G., Luck, R. J. and Jamieson, C. W. (1972). Small doses of subcutaneous sodium heparin in preventing deep venous thrombosis after major surgery. Lancet, 2, 890PubMedCrossRefGoogle Scholar
  46. 46.
    Nicolaides, A. N., Dupont, P., Parsons, D., Appleberg, M., Horan, F. T., Esah, K. M. and Walker, C. J. (1974). Small dose subcutaneous sodium heparin in preventing deep venous thrombosis after elective hip surgery. Br. J. Surg., 61, 320PubMedGoogle Scholar
  47. 47.
    Nicolaides, A. N. (1978). Invited commentary to V. V. Kakkar — Heparin prophylaxis of thromboembolism. World J. Surg., 2, 13CrossRefGoogle Scholar
  48. 48.
    Pachter, H. L. and Riles, T. S. (1977). Low dose heparin: bleeding and wound complications in the surgical patient, a prospective randomized study. Ann. Surg., 186, 669PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Poller, L., Thomson, J. M. and Yee, K. F. (1977). Stability studies on lyophilized reference thromboplastins for standardization of prothrombin times. Lancet, 2, 1019PubMedCrossRefGoogle Scholar
  50. 50.
    Reappraisal of results of international multicentre trial. Prevention of fatal postoperative pulmonary embolism by low doses of heparin. (1977). Lancet, 1, 567Google Scholar
  51. 51.
    Roberts, V. C. and Cotter, L. T. (1975). Failure of low dose heparin to improve efficacy of preoperative intermittent calf compression in preventing deep vein thrombosis. Br. Med. J., 3, 458PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Rocko, J. M., Mikhail, F., Trilles, F. and Timmes, J. J. (1978). The safety of low dose heparin prophylaxis. Am. J. Surg., 135, 798PubMedCrossRefGoogle Scholar
  53. 53.
    Rosenberg, R. D. (1974). Heparin action. Circulation, 49, 603PubMedCrossRefGoogle Scholar
  54. 54.
    Rubin, R. N. (1978). Aspirin and post surgery bleeding. Ann. Intern. Med., 89, 1006PubMedCrossRefGoogle Scholar
  55. 55.
    Sagar, S., Massey, J. and Sanderson, J. M. (1975). Low dose heparin prophylaxis against fatal pulmonary embolism. Br. Med. J., 4, 257PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Sagar, S., Nairn, D., Stamatakis, J. D., Maffei, F. H., Higgins, A. F., Thomas, D. P. and Kakkar, V. V. (1976). Efficacy of low-dose heparin in prevention of extensive deep vein thrombosis in patients undergoing total hip replacement. Lancet, 1, 1151PubMedCrossRefGoogle Scholar
  57. 57.
    Salzman, E. W., Deykin, D., Shapiro, R. M. and Rosenberg, R. (1975). Management of heparin therapy controlled prospective study. New. Engl. J. Med., 292, 1046PubMedCrossRefGoogle Scholar
  58. 58.
    Sevitt, S. and Gallager, N. G. (1959). Prevention of venous thrombosis and pulmonary embolism in injured patients. Lancet, 2, 981PubMedCrossRefGoogle Scholar
  59. 59.
    Sevitt, S. (1970). In Hume, M., Sevitt, S. and Thomas, D. P. (eds.). Venous Thrombosis and Pulmonary Embolism, p. 380. (Cambridge: Harvard University Press)Google Scholar
  60. 60.
    Sharnoff, J. G. (1957). Thrombotic thrombocytopenic purpura. Am. J. Med., 23, 740PubMedCrossRefGoogle Scholar
  61. 61.
    Sharnoff, J. G. and Kim, E. S. (1958). Evaluation of pulmonary megakaryo-cytes. Arch. Pathol., 66, 176Google Scholar
  62. 62.
    Sharnoff, J. G. and Kim, E. S. (1958). Pulmonary megakaryocyte studies in rabbits. Arch. Pathol., 66, 340Google Scholar
  63. 63.
    Sharnoff, J. G. (1959). Increased pulmonary megakaryocytes — probable role in postoperative thromboembolism. J. Am. Med. Assoc., 169, 688PubMedCrossRefGoogle Scholar
  64. 64.
    Sharnoff, J. G. (1959). A possible explanation of the formation of long platelets from pulmonary megakaryocytes. Nature (London), 184, 75CrossRefGoogle Scholar
  65. 65.
    Sharnoff, J. G. and Scardino, V. (1959). Pulmonary megakaryocytes in human fetuses and premature and full-term infants. Arch. Pathol., 69, 139Google Scholar
  66. 66.
    Sharnoff, J. G. and Scardino, V. (1960). Platelet count differences in blood of rabbit right and left heart ventricles. Nature (London), 187, 334CrossRefGoogle Scholar
  67. 67.
    Sharnoff, J. G. Bagg, J. F., Breen, S. R., Rogliano, A. G., Walsh, A. R. and Scardino, V. (1960). The possible indication of postoperative thromboembolism by platelet counts and blood coagulation studies in the patient undergoing extensive surgery. Surg. Gynecol. Obstet., 111, 469Google Scholar
  68. 68.
    Sharnoff, J. G. Kass, H. H. and Mistica, B. A. (1962). A plan of heparinization of the surgical patient to prevent postoperative thromboembolism. Surg. Gynecol. Obstet., 115, 75PubMedGoogle Scholar
  69. 69.
    Sharnoff, J. G. (1963). An evaluation of the Dale and Laidlaw coagulometer in the heparin control of thromboembolism. Proc. NY State Assoc. Pub. Hlth. Labs., 43, 10Google Scholar
  70. 70.
    Sharnoff, J. G. and Rosenberg, M. (1964). Effects of age and immobilization on the incidence of postoperative thromboembolism. Lancet, 1, 845PubMedCrossRefGoogle Scholar
  71. 71.
    Sharnoff, J. G. (1966). Results in the prophylaxis of postoperative thromboembolism. Surg. Gynecol. Obstet., 123, 303PubMedGoogle Scholar
  72. 72.
    Sharnoff, J. G. (1966). Post mortem findings in 25 cases of sudden heart arrest in the perioperative period. Lancet, 2, 876PubMedGoogle Scholar
  73. 73.
    Sharnoff, J. G. (1969). Prevention of sudden cardio-pulmonary arrest in the perioperative period with prophylactic heparin. Lancet, 2, 292PubMedCrossRefGoogle Scholar
  74. 74.
    Sharnoff, J. G. and DeBlasio, G. (1970). Prevention of fatal post-operative thromboembolism by heparin prophylaxis. Lancet, 2, 1006PubMedCrossRefGoogle Scholar
  75. 75.
    Sharnoff, J. G. and DeBlasio, G. (1970). Some implications in the successful heparin prophylaxis of sudden cardio-pulmonary arrest by thrombosis and embolism. Am. Heart J., 80, 848PubMedCrossRefGoogle Scholar
  76. 76.
    Sharnoff, J. G. (1973). Prevention of thromboembolism. Bull NY Acad. Med., 49, 655Google Scholar
  77. 77.
    Sharnoff, J. G., Rosen, R. L., Sadler, A. H. and Ibarra-Isunza, G. C. (1976). Prevention of pulmonary thromboembolism by heparin prophylaxis after surgery for hip fractures. J. Bone Jt. Surg., 58A, 913Google Scholar
  78. 78.
    Sharnoff, J. G. (1975). Prevention of postoperative thromboembolism. Lancet, 2, 361PubMedCrossRefGoogle Scholar
  79. 79.
    Sharnoff, J. G. (1977). Low dose or small dose heparin. Lancet, 2, 1087PubMedCrossRefGoogle Scholar
  80. 80.
    Sherry, S. (1975). Low-dose heparin prophylaxis for postoperative venous thromboembolism. N. Engl. J. Med., 273, 300CrossRefGoogle Scholar
  81. 81.
    Skillman, J. J., Collins, R. E., Coe, N. P., Goldstein, B. S., Shapiro, R. M., Zervas, N. T., Bettman, M. A. and Salzman, E. W. (1978). Prevention of deep vein thrombosis in neurosurgical patients: a controlled randomized trial of external pneumatic compression boots. Surgery, 83, 354PubMedGoogle Scholar
  82. 82.
    Smith, R. C., Elton, P. A., Orr, J. D., Hart, A. J. L., Graham, D. F., Fuller, G. A. G., Rundle, J. S. H., McPherson, A. I. S. and Ruckley, C. V. (1978). Dextran and intermittent pneumatic compression in prevention of deep vein thrombosis: multicentre trial. Br. Med. J., 1, 1031CrossRefGoogle Scholar
  83. 83.
    Stamatakis, J. D., Kakkar, V. V., Lawrence, D., Bentley, P. G., Nairn, D. and Ward, V. (1978). Failure of aspirin to prevent post-operative deep vein thrombosis in patients undergoing total hip replacement. Br. Med.J., 1, 1031PubMedCrossRefPubMedCentralGoogle Scholar
  84. 84.
    Strandness, D. E. Jr. (1978). Invited commentary to Kakkar, V. V. — Heparin prophylaxis of thromboembolism. World J. Surg., 2, 17CrossRefGoogle Scholar
  85. 85.
    Thomas, D. P. (1978). Heparin in prophylaxis and treatment of venous thromboembolism. Semin. Hematol., 15, 1PubMedGoogle Scholar
  86. 86.
    Thomas, D. P., Lane, D. A., Michalski, P., Johnson, E. M. and Kakkar, V. V. (1977). A heparin analogue with specific action on antithrombin III. Lancet, 1, 120PubMedCrossRefGoogle Scholar
  87. 87.
    Wallace, W. A. and Evans, C. M. (1976). Venous thromboembolism: a cost evaluation of prophylaxis, investigation and treatment. J. R. Coll. Surg. Edinburgh, 2, 218Google Scholar
  88. 88.
    Wessler, S. (1977). The anticoagulant dilemma — a prescription for its resolution. Am. J. Med. Sci., 274, 107Google Scholar
  89. 89.
    Wilkens, R. W., Mixter, Jr. G., Stanton, J. R. and Litter, J. (1952). Elastic stockings in the prevention of pulmonary embolism: a preliminary report. N. Engl. J. Med., 246, 360CrossRefGoogle Scholar
  90. 90.
    Williams, H. T. (1971). Prevention of postoperative deep vein thrombosis with perioperative subcutaneous heparin. Lancet, 2, 950PubMedCrossRefGoogle Scholar
  91. 91.
    Chrisman, O. D., Snook, E. A., Wilson, T. C. and Short, J. Y. (1976). Prevention of venous thrombo bolism by administration of hydrochloroquine. A preliminary report. J. Bone Jt. Surg., 58, 918Google Scholar

Copyright information

© J. G. Sharnoff 1980

Authors and Affiliations

  • J. G. Sharnoff
    • 1
  1. 1.The Mount Vernon HospitalMount VernonUSA

Personalised recommendations