PersonalIntroduction

Medical Background
1970 Medical Faculty, UII, Solo
1975 MD , Justus Liebig University, Giessen
1982 General Surgeon, JW Goethe University, Frankfurt
1986 Cardiac and Vascular Surgeon , Ph.D, JLU, Giessen
1989 T.C.V-Surgeon WWU Muenster, Germany
1997 Awarded Venia Legendi
Associate Professor for Thoracic and Cardiovascular Surgery

(T.C.V) ,WWU Muenster

2000-2006 Visiting Professor , UI, UGM, UMY
2007 Professor for T.C.V Surgery,
WWU Muenster ,Germany
2009 Academic Professor, Medical School University of
Indonesia
2012 Academic Professor, UMY

PersonalIntroduction
Institutional Affiliation
Cardiovascular Center, International Wing KENCANA,
Div. of Vascular and Endovascular Surgery, Dept.of

Surgery
University Hospital/ RSCM, University of Indonesia
Department of Thoracic and Cardiovascular
Surgery, University Hospital, Muenster-Germany
(former)

Specialty
Adult Cardiac Surgery
Peripheral Vascular Surgery
General Thoracic Surgery

D VT
D EEP V EIN TR O M B O S IS

Prof. Dr. Med. dr. H. Rasjid Soeparwata

Cardiovascular and Thoracic Surgeon
Vascular and Endovascular Division Consultant
FKUI/RSCM

CO N TEN T
Definition and Anatomy
Epidemiology
Algorithm
Risk Factors
Prophylaxis Options
Recommendations in specific populations
Surgical inpatients
Medical inpatients
Cancer Patients

O U R V EIN S Y S TEM

Epidem iology

Incidence - USA/Europe
DVT: 160 per 100,000
Symptomatic non-fatal PE: 20
per 100,000
Fatal PE: 50 per 100,000

80 cases per 100,000 population/years

1 person in 20 develops a DVT in the course

of his or her lifetime.

600,000 hospitalizations /year in USA.
Elderly incidence 4X.
Hospital VTE death 12%, rising to 21% in
elderly persons.
Incidence in hospitalized patients 20-70%.
Venous ulceration and venous insufficiency of
the lower leg 0.5% of the entire population.
5 mio. people venous stasis and venous
insufficiency.

M edicalInpatients:Evidence
50-70% of symptomatic VTE & 80%

of fatal PE in non-surgical patients

Average general medical patient is
low-moderate risk of VTE
5-7% rate of DVT on U/S screening
0.6% rate of hospital-acquired

symptomatic VTE

Highest risk illnesses: cancer, stroke,

COPD, sepsis, anything that leads to

bedrest

D VT Clin.M anifestation

10

To understand the abnormalities of veins

we must understand normal veins and
their function

2. Perforating Vein
3. Deep vein

Virchow Triad
Hypercoagulability
high fibrinogen, d-Dimer

Hemodynamic
changes (stasis, turbulence)

Endothelial
Injury (dysfunction)

EndotelFunction
Antithrombotic
Producing:
prostaglandin I2
Thrombomudulin
tissue-type plasminogen activator (t-PA)
glycosaminoglycan co faktor antithrobin

14

Throm bogenic Risk Factors

1. Age
2. Malignancy
3. Surgical Procedure/Trauma
4. Primary Hipercoagulability state
5. Pregnancy
6. Oral Contraception

O ralContraception & H orm onalTherapy

Estrogen > 50 g increase

in VIIa-Factor & reduce

antithrombin dan protein S
activity.
Hormonal therapy increase
thrombotic risk

Throm bogenesis in Pregnancy

VTE second cause of

abortion.
Post partum DVT risk 2 - 3 x
higher in pregnancy.
Increase in thrombotic risk and
prethrombotic state.

VTE Prevalence
Prevalence of asymptomatic DVT in

patients not receiving prophylaxis

(Geerts, Chest 2008)

Medical: 10-20%
Stroke 20-50%, Critical care 10-80%

General Surgery: 15-40%

THR, TKR: 40-60%

VTE/D VT O utcom es

17% 2-year risk of recurrence

25% 2-year risk of PTS
17% at 3-months PE mortality
21% in-hospital & 39% 1-year
mortality for PE in elderly

Klinis dan G ejala

Gejala :
1. Pembesaran

satu kaki
2. Asymptommatic

Klinis :
3. Odema
4. Nyeri
5. Selulitis
6. Ulkus hingga

gangren

20

LA B EX A M IN ATIO N
1. Complete Blood Count
2. Erythrocyte Sedimentation Rate
3. PT/APTT
4. Fibrinogen
5. D- Dimer

21

Color duplex scan of D VT

Venogram
show s D VT

Patient with suspect symptomatic

Acute lower extremity DVT

Venous duplex scan

negative

Low clinical probability observe

High

positive

clinical probability

aluate coagulogram /thrombophilia/ malignancy

Anticoagulant therapy
contraindication

yes

negative

Repeat scan /
Venography

IVC filter

No

pregnancy
OPD
hospitalisation

LMWH
LMWH
UFH

warfarin

Compression treatment

Absolute Risk of DVT in Hospitalized Patients

Patient Group DVT Prevalence, %
Medical patients
1020
General surgery
1540
Major gynecologic surgery 1540
Major urologic surgery 1540
Neurosurgery 1540
Stroke 2050
Hip or knee arthroplasty, hip fracture surgery
Major trauma 4080
Spinal cord injury 6080
Critical care patients
1080
Chest. 2004;126:338S-400S. PMID: 15383478.

4060

Risk Stratifi
cation
Risk
Low

Moderate

High

Type
Minor surgery
& medical,
mobile
Most general
surgery &
medical
patients
Ortho & major
trauma

Rx
Early
ambulation
Medical +/mechanical
Medical +/mechanical

O ptions for prophylaxis

The Virchow triad
Endothelial insult

(lesion or change of
the inner venous
wall)
Increased

coagulation
(fibrinolytic
abnormalities)
Reduced venous

flow

Option
None

Daily intake of

anticoagulants
Elastic compression,

pneumatic compression or
continuous passive motion
27

Prophylaxis Choices
Early & frequent ambulation ( The

Most Important)
Mechanical

Graduated compression stockings (GCS)

Intermittent pneumatic compression

(IPC)

Medical

Aspirin
Low-dose Unfractionated Heparin (LDUH)
Low Molecular Weight Heparin (LMWH)
Fondaparinux (Arixtra )
Warfarin (Coumadin )

Elastic Com pression

Conclusion
1

The number of VTE/cardiovascular disease is increasing

worldwide unexceptionally Indonesia.

1/3 among VTE manifests as PE, 2/3 manifests as DVT

Various risk factors that can cause VTE. Knowledge in

recognizing the risk factors is very important in order to
prevent VTE/DVT/PE.

Treating cardiovascular diseases should be done by

specifically trained expert team using interdisciplinary
approach in center of excellence.

The implementation of technological transfer in

cardiovascular disease from abroad is possible when we have
established a center of excellence with Governmental
support and Willingness.

TH A N K YO U