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Vein Facts - Present 10x persons suffer from venous insufficiency vs. PAD All age groups may be affected Stasis Ulcers affect 500,000 persons 20,000 new stasis ulcers/year
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Three Phases of Thrombotic Events of the Lower Extremity
Phase 1 Prevention Marlin W. Schul, MD, RVT, FACPh Medical
Director, Owner Lafayette Regional Vein & Laser Center Vein
Facts - Present 10x persons suffer from venousinsufficiency vs. PAD
All age groups may be affected Stasis Ulcers affect 500,000persons
20,000 new stasis ulcers/year Vein Facts - Present VTE occurs in
1/20 persons over lifetime
>500,000 are hospitalized forDVT/PE each year Fatal PE
represents the 3rd mostcommon cause of death amonghospitalized
patients. Vein Facts - Present DVT and PE are preventable!
Studies have shown >40% of cases failed toreceive prophylaxis.*
Patients surviving VTE +/- PE areplagued with chronic pain
andswelling *Spyropoulos A.Emerging Strategies in the Prevention of
Venous Thromboembolism in Hospitalized Medical Patients.Chest 2005;
128: Vein Facts - Present REITE Registry over 30,000 DVT JAMA
Oct/2013
77% occur following hosp. D/C 55% happen after proph. D/C DVT risk
rises over 100 days after ortho surgery Median time to VTE event 74
days after hospitalization JAMA Oct/2013 Paradoxical findings
Increased prophylaxis/Inc. incidence Increased surveillance/Inc.
incidence Vein Facts - Present In 2005, US Senate passed
aresolution declaring the month ofMarch as National DVT
AwarenessMonth Joint Commission and CMS havedeclared VTE as a area
of concern NEVER EVENTS! The Burden of DVT Population-Based
Studies: High Incidence of VTE VTE: An Important Problem Among
Hospital Patients Percentage of Patients at Risk for VTE by Country
Percentage of At-Risk Patients Receiving Recommended Prophylaxis
Pulmonary Embolism Carries a High Mortality Rate Poor Clinical
Outcomes After VTE Treatment The Natural History of Acute DVT
DVT is a chronic disease of coagulation Early natural history is a
dynamic balance between Recanalization Greatest change in thrombus
burden occurs over first 3-6 months 55% with complete
recanalization at 6 months Recurrent thrombotic events Late natural
history dominated by recurrent VTE Underlying thrombotic risk
factors Extent of recanalization Degree of active coagulation
Long-term outcomes related to natural history Rapid recanalization
protects valve function Recurrent DVT predicts reflux & PTS
Pre-test Question 1 The three tenets of Virchow's triad carry equal
weight. A) True B) False Pathophysiology of VTE
Vessel Injury Stasis Virchows Triad Hypercoagulability Congenital
Acquired Situational Combined FVL APL Antibodies Surgery Elev.
Homocys. C20210A Malignancy Trauma Elev. F VIII Protein C & S
Adv. Age Pregnancy AT III OCP/HRT Venous Thrombosis: a multi-causal
disease Rosendaal FR, Lancet 1999
Risk Factors are SYNERGISTIC NOT ADDITIVE Oral contraceptives + FVL
= X risk Surgery (1.6%) + ATIII (0.8%) = 12.7%/yr Risk Curve Age
Thrombotic Potential FVL OCP Time Background Use slide with
Virchow's triadand assymmetry of effect Case #1 47YOWM has left
lower extremityarthroscopy because of knee painand inability to
competitively playbasketball with his sons. What VTE risk factors
does thispatient possess? Case #1 3 days after scope procedure
limbis swollen and painful.He visitshis ortho doc three times over
a 9month period and was toldeveryone has swelling and it willjust
take time. LLE Duplex Exam: Noncompressible FV fromproximal FV to
POPV; No evidence of superficial ordeep vein reflux; High antegrade
flow of the greatsaphenous vein Could this have been prevented?
Case #1 LLE Duplex Exam: Noncompressible FV from proximal FV to
POPV;
No evidence of superficial ordeep vein reflux; High antegrade flow
of the greatsaphenous vein Text box. Could this event have possibly
been prevented? Background Epidemic Most preventable cause of
hospital death
Surgeon General Focus CMS Focus 'Never Events' Hospitalized
subjects vs.outpatient risk assessment Is risk the same? Medical
patients vs. Surgicalpatients? Risk to whom? Fatal PE image
Pre-test Question 2 Which of the following statements of
compression therapy is true? A) Compression increases flow rates of
the deep venous system; B) Compression is proven to reduce
occupational edema; C) Calf high mmHg stockings are proven to
reduce the incidence of post-thrombotic syndrome by 50%; D) TED
stockings have proven benefit in nonambulatory subjects; E) All of
the above Start with Healthy Vein Habits
Ambulation/Active Lifestyle Avoid prolonged sitting or standing
Target 10k steps per day Compression Therapy Increase flow
velocities of DVS Minimize occupational hazards Maintaining Normal
Weight BMI 40+ increases VTE Risk 3-fold Role of Compression
Therapy
Reduce complication rates andsymptoms following acute DVT Reduce
the incidence of PTS by50% when worn in acute DVT fortwo years
(article image) Reduces occupational edema Enhances ulcer healing
rates Primary treatment forlymphedema subjects Individualized Risk
Assessment: Caprini Score Risk Assessment In Practice?
Outpatient Medical/Surgical Inpatient Considerations Primary care
tool for patientsconcerned with this risk; Pre-surgical risk
assessmenttool, and guide to safepropylaxis. All patients carry
risk, yet riskvaries and cannot be seen by thenaked eye; Risk
Assessment in Practice Risk Assessment in Practice Overall
Risk/Benefit Analysis
Risks without individual assessment Benefits of individual
assessment Subjects with risk fail to be identified life/limb
threatening events occur Subjects without risk may be at riskwith
prophylactic doses of LMWH Medicolegal consequences Failure to
treat Economic consequences Never events, etc. Appropriate risk
stratification protectspatients without risk, and
identifiessubjects with risk that need extra carebecause of risk
Recongized as a best practice CMS Measures are met PQRS credits are
met Lower event rates/Lower readmissionrates Value of
Individualized Risk Stratification
Identify At-Risk Individuals Protect based upon risk Ambulation
Compression Anticoagulation Recognize events will still occur
Frequency of events will decline Boston University U of Michigan
Texas Health Resources Risk Stratification? Early Ambulation SCD's
Either
Low Risk Priorities Caprini RiskAssessment Score