Deep vein thrombosis: beyond the operating table

Deep vein thrombosis (DVT) is of clinical importance and carries the short-term risk of pulmonary embolism. Patients undergoing orthopedic surgery are at particular risk of DVT. Pharmacological prophylaxis to prevent thromboembolic events has become standard practice in this patient group. However, DVT may also lead to long-term venous insufficiency, causing disabling symptoms of swelling, chronic pain, and skin ulceration, imposing substantial health-care costs. Prevention of these long-term sequelae of DVT, termed post-thrombotic syndrome (PTS), may be of equal or even greater clinical, economic, and medicolegal significance than avoidance of the short-term effects. Surveys suggest that PTS is present in 30%-70% of patients, 5 years after an initial symptomatic or asymptomatic, proximal or distal DVT. Post-thrombotic syndrome is not reliably prevented by treatment of the initial DVT with anticoagulant therapy or thrombolysis. Therefore, prevention of DVT is the only effective approach to PTS prevention. Pharmacological thromboprophylaxis prevents venographically proven DVT in patients following orthopedic surgery, and is now recommended by North American and European consensus statements. Uncertainties remain, however, regarding the optimal duration of postsurgical prophylaxis.