From the Guidelines
For extensive great saphenous vein (GSV) thrombosis following open reduction internal fixation (ORIF) of the left femur two weeks ago, I recommend immediate anticoagulation therapy with low molecular weight heparin (LMWH) such as enoxaparin 1 mg/kg twice daily or 1.5 mg/kg once daily, transitioning to oral anticoagulation with a direct oral anticoagulant (DOAC) like rivaroxaban 15 mg twice daily for 21 days followed by 20 mg once daily. Treatment should continue for at least 3 months. Elevate the affected leg above heart level when resting, apply warm compresses to reduce discomfort, and encourage gentle ambulation as tolerated within post-surgical restrictions.
Key Considerations
- Compression stockings (20-30 mmHg) should be worn during the day once acute pain subsides.
- Close monitoring for extension of thrombosis into the deep venous system is essential, with follow-up ultrasound recommended at 1-2 weeks.
- This approach addresses the superficial venous thrombosis while preventing progression to deep vein thrombosis or pulmonary embolism. The thrombosis likely developed due to a combination of surgical trauma, immobility, and venous stasis during the postoperative period, which activated the coagulation cascade and led to clot formation in the great saphenous vein, as discussed in the American Heart Association scientific statement 1.
Rationale for Anticoagulation
- The use of anticoagulation therapy is supported by guidelines from the American College of Chest Physicians, which recommend prophylaxis with a pharmacologic agent or intermittent pneumatic compression devices (IPCD) for a minimum of 10 to 14 days, and suggest extending prophylaxis for up to 35 days 1.
- The choice of anticoagulant, such as LMWH or DOAC, depends on the patient's individual risk factors and clinical circumstances, with consideration of the benefits and risks of each option, as outlined in the Circulation journal 1.
Monitoring and Follow-up
- Regular follow-up with ultrasound is crucial to monitor the resolution of the thrombosis and to detect any potential complications, such as extension of the thrombosis into the deep venous system.
- The patient should be educated on the signs and symptoms of deep vein thrombosis and pulmonary embolism, and instructed to seek immediate medical attention if they experience any of these symptoms.
From the Research
Extensive GSV Thrombosis Post ORIF of Left Femur
- Extensive great saphenous vein (GSV) thrombosis is a serious condition that can lead to venous thromboembolism (VTE) and pulmonary embolism (PE) 2, 3.
- The risk of propagation to deep vein thrombosis (DVT) or PE is higher in patients with isolated proximal GSV thrombosis, especially if left untreated 4.
- Anticoagulation therapy is the mainstay treatment for extensive GSV thrombosis, with low-molecular-weight heparin (LMWH) and factor Xa inhibitors being commonly used options 2, 3.
- The optimal dose and duration of anticoagulation therapy for extensive GSV thrombosis are still unclear and require further studies 2, 3.
- Postoperative VTE prophylaxis is crucial in patients undergoing high ligation and stripping of the GSV, with LMWH and unfractionated heparin being effective options 5.
- Inferior vena cava filters (IVCFs) may be used in patients with contraindications to anticoagulation therapy or those who have failed anticoagulation therapy, with retrievable IVCFs being preferred over permanent ones 6.
Treatment Options
- Anticoagulation therapy: LMWH, factor Xa inhibitors, and unfractionated heparin are commonly used options 2, 3, 5.
- IVCFs: retrievable IVCFs are preferred over permanent ones, with a removal rate of 72% 6.
- Catheter-directed thrombolysis: may be used in patients with extensive GSV thrombosis, with urokinase being the main thrombolytic drug used 6.