Diagnosis and management of venous thrombosis in the surgical patient

Deep venous thrombosis (DVT) continues to be a source of major morbidity and mortality for surgical patients. The incidence of postoperative DVT is as high as 28% in some series. Risk factors include immobility, venous endothelial injury, stasis, and advanced age, all of which are highly prevalent in many populations of surgical patients. Diagnosis is generally confirmed by using duplex ultrasound to examine the legs. This modality has largely replaced contrast venography as the gold standard imaging test for DVT. Treatment begins with heparin and warfarin. Recently, low-molecular-weight heparin (LMWH) has been shown to be a suitable alternative to conventional, unfractionated heparin as the initial anticoagulant treatment of DVT. This change permits outpatient treatment of DVT in suitable patients. However, anticoagulation is contraindicated in many postoperative patients, who may then require an inferior vena caval filter. Iliofemoral venous thrombectomy should be considered when postoperative patients present with phlegmasia cerulea dolens. Long-term management of these patients focuses on measures to prevent clinical manifestations of chronic venous insufficiency.