How to manage RI venography in pre-orthopedic surgery patients

The preoperative evaluation of venous thromboembolism (VTE) is important to avoid complications, because VTE is often induced by orthopedic surgery. We focused on radioisotope venography (RIV) using 99mTc-macroaggregated human serum albumin, examining orthopedic patients.

We conducted 34 examinations in 33 patients who were referred for RIV and lung perfusion scintigraphy for the pre-orthopedic operative evaluation of VTE. Two board-certified (one nuclear medicine board-certified) radiologists interpreted the images based on the following: (1) flow defect of the lower extremities; (2) interruption of flow; (3) irregular or asymmetric filling of the deep vein (low flow); (4) presence of collateral vessels; and (5) abnormal RI retention on delayed-phase images. Scoring was based on a 5-point scale, and more than 2 points was considered VTE positive.

Abnormal findings were noted in 27 of the 34 examinations performed in the 33 patients and normal findings in the other 7 examinations. According to the RI score, 21 patients were classified into the VTE-positive group and 12 into the VTE-negative group. Surgery was canceled because of advanced age and respiratory dysfunction in 2 of the 21 patients in the VTE-positive group. Of the 19 patients who underwent surgery, an IVH filter was placed before surgery in 2 and anticoagulant treatment with heparin and warfarin was initiated on the day of surgery in 12 to prevent postoperative VTE, and only one of the patients receiving anticoagulant treatment developed PTE after surgery. Surgery was canceled due to advanced age and at patient's request in 2 of 12 patients in the VTE-negative group. Anticoagulant treatment with heparin/ warfarin was performed to prevent postoperative VTE in only 3 patients: one with a past medical history of pulmonary infarction, one with atrial fibrillation, and one suspected of having antiphospholipid antibody syndrome. No patient in the VTE-negative group developed VTE after surgery.

The preoperative identification of patients with VTE by RIV might be useful for perioperative management and the evaluation of preventive measures against postoperative VTE.