Is there an increased risk of developing a Deep Vein Thrombosis (DVT) in the lower leg without a DVT after a corticosteroid (e.g. Cortizone, containing corticosteroids such as prednisone or triamcinolone) knee injection, in a patient with a contralateral DVT managed with an Inferior Vena Cava (IVC) filter due to contraindications to anticoagulation?

Risk of DVT After Corticosteroid Knee Injection in a Patient with Contralateral DVT and IVC Filter

There is an increased risk of developing a DVT in the lower leg following a corticosteroid knee injection in a patient with a contralateral DVT managed with an IVC filter due to contraindications to anticoagulation. This procedure should be avoided or approached with extreme caution.

Risk Assessment and Rationale

• Thrombogenic Potential: IVC filters themselves increase the risk of DVT recurrence. In the PREPIC randomized trial, at 2 years, recurrence of DVT was significantly more frequent with filters (21%) compared to conventional treatment without filters (12%) 1.

• Contralateral DVT Impact: The presence of a DVT on one side is a strong risk factor for developing DVT on the contralateral side, as it indicates an underlying prothrombotic state.

• Absence of Anticoagulation: The patient's contraindication to anticoagulation significantly increases their risk profile, as anticoagulation is the primary preventive measure against DVT formation 1.

• Procedural Risk: Corticosteroid injections can potentially increase thrombotic risk through:

  • Local tissue trauma during injection
  • Systemic absorption of corticosteroids, which may have prothrombotic effects
  • Reduced mobility following the procedure due to pain or discomfort

Management Algorithm

1. Avoid Injection If Possible:

   • According to the American College of Chest Physicians guidelines, procedures that could potentially disrupt existing thrombi or increase thrombotic risk should be avoided in patients with DVT, especially those not on anticoagulation 2.

2. If Injection Is Deemed Necessary:

   • Consider temporary anticoagulation if contraindications are relative rather than absolute
   • Use ultrasound guidance to minimize tissue trauma
   • Use the smallest effective dose of corticosteroid
   • Implement aggressive post-procedure mobilization protocols

3. Post-Injection Monitoring:

   • Implement vigilant monitoring for signs of DVT (pain, swelling, warmth in the leg)
   • Consider baseline and follow-up Doppler ultrasound of the lower extremity
   • Educate patient on DVT symptoms and when to seek immediate medical attention

Alternative Management Options

• Non-invasive OA Management: During this high-risk period, manage knee osteoarthritis non-invasively with oral analgesics (if not contraindicated), physical therapy focusing on non-weight bearing exercises, topical analgesics, and assistive devices to reduce weight bearing 2.

• Consider Retrievable IVC Filter: If the contraindication to anticoagulation is temporary, consider a retrievable IVC filter that can be removed once anticoagulation becomes possible 3.

Important Caveats

• The presence of an IVC filter without anticoagulation is associated with a higher rate of filter occlusion (15%) compared to patients with filters who receive anticoagulation (8%) 1.

• If the patient's contraindication to anticoagulation resolves, anticoagulation should be resumed as soon as possible, as recommended by the American Heart Association 1.

• Patients with IVC filters who are not anticoagulated should be monitored closely for development of new DVT, as the filter itself may serve as a nidus for thrombus formation 4.