|Year : 2020 | Volume
| Issue : 1 | Page : 29-33
Analysis of patients with venous thromboembolism in a multi-specialty tertiary hospital in South India
Pranay Pawar, MK Ayyappan, Jithin Jagan, Naveen Rajendra, Kapil Mathur, Radhakrishnan Raju
Department of Vascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
|Date of Submission||12-May-2019|
|Date of Decision||03-Jun-2019|
|Date of Acceptance||31-Jul-2019|
|Date of Web Publication||16-Mar-2020|
Dr. M K Ayyappan
Department of Vascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Objectives: The objective of this study is to ascertain the incidence of venous thromboembolism (VTE) in Indian patients at a tertiary care center with emphasis on the data pertaining to demographics, management, and temporal trends. Materials and Methods: This was a retrospective cross-sectional Level II audit study carried out in the Department of Vascular Surgery at our institute from January 2012 to December 2017. The patients were identified from the electronic medical records by the International Classification of Diseases code. Consecutive patients were identified from the above-mentioned time period, and data on demographics, presentation, site, predisposing factors, etiology, primary referring specialty, and management were recorded. Results: This was a 6-year retrospective study and a total number of 1010 patients were included in the study that presented primarily with VTE. There were a total of 518,111 admissions in this period with a VTE incidence of 19.49/10,000 cases. Males contributed to 55% of patients in this study. Acute deep-vein thrombosis (DVT) (<14 days of presentation) contributed to 66% of the patients. The age group between 41 and 60 years had the maximum incidence of DVT of 43.9%. Provoking factors were found in 48.8% (493) of the cases. Conclusions: VTE is a common disease and is associated with reduced survival and significant morbidity. More locoregional registries like ours are the need of the hour and will help large institutions identify their lacunae and address areas, which need attention, like thromboprophylaxis and uniform management.
Keywords: Deep-vein thrombosis, Indian population, tertiary hospital, venous thromboembolism
|How to cite this article:|
Pawar P, Ayyappan M K, Jagan J, Rajendra N, Mathur K, Raju R. Analysis of patients with venous thromboembolism in a multi-specialty tertiary hospital in South India. Indian J Vasc Endovasc Surg 2020;7:29-33
|How to cite this URL:|
Pawar P, Ayyappan M K, Jagan J, Rajendra N, Mathur K, Raju R. Analysis of patients with venous thromboembolism in a multi-specialty tertiary hospital in South India. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Jul 10];7:29-33. Available from: http://www.indjvascsurg.org/text.asp?2020/7/1/29/280664
| Introduction|| |
Venous thromboembolism (VTE) is a global health concern with substantial mortality and morbidity. Approximately 70% of patients with symptomatic VTE manifest as deep-vein thrombosis (DVT). Contrary to earlier belief, the incidence of VTE in India is comparable to the Western population. Earlier studies from India ascertain the incidence to be 22/10,000 admissions. The risk of VTE is especially high in the hospitalized patients, especially in the immediate postoperative period, the majority of which can be prevented by appropriate thromboprophylaxis. As very few studies on DVT are present of the Indian population, we aim to publish the results of our registry with respect to demographics, management, and clinical outcomes.
| Materials and Methods|| |
The Institutional ethics committee approval was obtained before the initiation of the study. This was a retrospective cross-sectional Level II audit study carried out in the Department of Vascular Surgery at a multi-specialty tertiary hospital in South India from January 2012 to December 2017. The patients were identified from the electronic medical records by the International Classification of Diseases code. Consecutive patients were identified from the above-mentioned time period, and data on demographics, presentation, site, predisposing factors, etiology, primary referring specialty, and management were recorded. DVT was identified by duplex ultrasonography and computed tomography (CT) venogram wherever required. PTE was identified by CT angiogram. The level of DVT was classified as iliofemoral, femoropopliteal, and tibial. Thrombophilia workup was not routinely done and was ordered at the treating physician's discretion.
| Results|| |
This was a 6-year retrospective study and a total number of 1010 patients were included in the study that presented primarily with VTE. The yearly distribution of cases was fairly constant with a peak of 192 cases in 2015. There were a total of 518,111 admissions in this period with a VTE incidence of 19.49/10,000 cases [Figure 1].
Males constituted 55% (551) and females 45% (459) in this study. Acute DVT (<14 days of presentation) contributed to 66% (665) of the patients. Pulmonary embolism (PE) was present in 170 of the patients. The age group between 41 and 60 years had a maximum incidence of DVT of 43.9%, i.e., 444 [Figure 2].
There was a preponderance of the left lower limb DVT in both males (56%) and females (67%). The femoropopliteal level of DVT constituted 51.9% (364) of acute DVT cases [Figure 3]a, [Figure 3]b and [Figure 4]a, [Figure 4]b.
|Figure 3: (a) Side of deep-vein thrombosis (male) (b) Side of deep-vein thrombosis (female)|
Click here to view
|Figure 4: (a) Site of deep-vein thrombosis (male)(b) Site of deep-vein thrombosis (female)|
Click here to view
Provoking factors were found in 48.8% (493) of the cases. In male patients, the major provoking factors were medical patients with stroke, heart failure, sepsis, chronic obstructive pulmonary disease (COPD) on ventilator support (39%), recent surgery (26%), neurosurgical patients (19%), and malignancy (13%) [Figure 5]. In females, the major provoking factors were medical patients with stroke, sepsis, heart failure, COPD, nephrotic syndrome (31%), malignancy (29%), and recent surgery (23%) [Figure 6].
The most common malignancies associated with DVT in our female population were carcinoma ovary, cervix, and breast (80%). DVT associated with pregnancy contributed to 6% of cases among female DVT.
The referring specialties for male patients were mainly the surgical specialties (47%), neurosurgery (19%), orthopedics (17%) and general surgery (13%), followed by the medical specialties (40%). For female patients, the referrals were from medical specialties (29%), oncology (29%), obstetrics and gynecology (13%), neurosurgery (12%), and general surgery and orthopedics (17%) [Figure 7] and [Figure 8].
There were 51 cases of DVT after orthopedic procedures, and femur fracture surgeries were the main cause of postoperative DVT, and there were 53 cases of DVT after general surgical procedures and laparotomies were the major contributing factor [Figure 9] and [Figure 10].
|Figure 10: Postoperative deep-vein thrombosis general surgical procedures|
Click here to view
Obstetrics and gynecological cases contributed to 13 cases with hysterectomy contributing to the majority of postoperative DVT (53%).
Unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) followed by an oral anticoagulant, i.e., acitrom/warfarin constituted a majority of our treatment protocol.
From January 2016, 38 patients underwent catheter-directed thrombolysis (CDT) of iliofemoral DVT with good results. The mean duration of symptoms before CDT was 7.47 days. Left leg CDT was done in 24 and right in 14 patients. The mean dose of reteplase used was 38 mg and the mean duration of infusion was 40 h. Twenty-eight patients achieved a lysis grade of >50% and the 1 year Villalta score of them was an average of 4, whereas 10 patients had a lysis grade of <50% and of them the average Villalta score was 11.
Inferior vena cava (IVC) filters were inserted in 61 patients. Significantly, there were a total of 117 patients who developed DVT postsurgery and only 12 of them had received any sort of thromboprophylaxis, and were not based on any risk assessment score.
| Discussion|| |
In this study, we have retrospectively analyzed data about general patient population demographics and management of DVT of 1010 patients at our center. We had an incidence rate of 19.49/10,000 hospital admissions over 6 years, which is similar to the Vellore study of 22/10,000 admissions. We have looked primarily at symptomatic DVT with lower/upper limb pain and swelling with PE as the main presenting feature and not isolated PE.
Males contributed to 55% of the patients in our cohort while in the CMC Vellore, Indian subgroup of ENDORSE and the ARRIVE study they contributed to 48%, 69%, and 70% of the patient load.,, A reason for this disparity could be that there has been reported a higher level of homocysteine in males than in females in the Indian population. A study by Chandrakumar et al. conducted in general surgical patients also echoed a similar male preponderance as our data. However, Naqvi et al. showed a marked female preponderance. This may be due to the fact that the majority of patients with DVT in their study were postpartum.,
The age group between 41 and 60 years contributed the maximum cases of DVT in our study 43.9% and the mean age was 49 years and it correlated with the data from the Vellore and the ARRIVE study. These data are in stark contrast to a population-based study conducted by the Mayo clinic in which the mean age was 61.7 years which suggests that DVT occurs in much younger age groups in the Indian population as compared to our Western counterparts.
Acute DVT (<14 days) contributed to 66% of our patient load and we report a preponderance of left lower limb DVT contributing to 61.7% of cases. This could be due to the course of the left common iliac vein which is compressed by the right common iliac artery, a syndrome which is known as May–Thurner syndrome and is not infrequent.,
Proximal DVT, which includes the iliofemoral and femoropopliteal segment, contributed to 82.7% of the acute DVT cases in our study, which is similar to the results, echoed by other studies. We analyzed provoking causes of DVT separately for both sexes, with 48.8% of cases eliciting a cause. Other studies from India found provoking causes in 55%–80.6%., The reasons for the lower percentage of provoked DVT in our study may be due to the retrospective nature of the study, the number of specialties involved, and the lack of awareness/management protocol. The Indian subset of the ENDORSE study found 53.6% of patients to be at risk as per the ACCP risk criteria, while the global ENDORSE data placed the risk at 51.8%, which again highlights the fact that VTE may be more prevalent in the Indian population.,
In this study, the provoking causes for males were mainly medical patients (39%) with stroke, bedridden in intensive care unit with COPD, sepsis, postoperative surgical and orthopedic patients (26%), and neurosurgical patients (19%) who are bedridden. The provoking causes for female include medical causes, malignancies (29%) with carcinomas of ovary, cervix, and breast contributing to almost 80% of cases and postoperative patients (23%). Postpartum and pregnancy-induced DVT comprised 6% of our cases among females. The Vellore study reported malignancy (31%) and postoperative status (30%) to be the major predisposing conditions to DVT.
A study by Dhillon et al. in Asian patients undergoing orthopedic surgery without thromboprophylaxis showed a 62.5% rate of postoperative DVT. Studies in Indian patients undergoing major lower limb orthopedic procedures report DVT incidence rates ranging from 8% to 20%., Similar epidemiological studies from the Western countries by Anderson et al., Cushman et al., Heit et al., and White showed the 15%–25% of cases had cancer and 23%–25% had undergone recent surgery. Interestingly, 26%–47% of first time DVT was idiopathic or unprovoked.,,, The risk of VTE in patients undergoing surgery is stratified on the basis of patient age, BMI, type of surgery, smoking status, presence of active cancer, and physical status of the patient. The surgical procedures associated with a high risk of VTE include neurosurgery, major lower limb orthopedic procedures, renal transplantation, cardiovascular surgery, and thoracic, abdominal, or pelvic surgery for cancer.
The majority of admissions/referrals in males were from surgical specialties, including general surgery, orthopedics, and neurosurgery (47%), whereas in females, it was oncology (29%) and medical specialties (29%). The Vellore study had almost 75% of its cases from surgical fields, while the ARRIVE study had quite the opposite data, with 82% of cases from medical specialties. The Indian subset of ENDORSE put 61.3% of surgical patients at risk, while the global data of ENDORSE puts it at 64.4%. The conspicuous differences in the distribution of the cases can be attributed to the varying patterns of referrals and management in different institutions.,,
The treatment protocol followed by us used UFH/LMWH followed by oral anticoagulation in the cases. LMWH is the preferred mode of initiating therapy and thromboprophylaxis, probably due to its dosage protocol and ease of administration. We maintain the INR at a range of 2–3 once starting on oral anticoagulants and monitor them regularly in the outpatient department. For proximal DVT/PE, we like to continue the treatment for 6 months and then reevaluate with duplex and D-dimer levels, whereas for distal DVT were evaluate at 3 months. The use of new oral anticoagulants has been the exception rather than the norm in our practice due to the financial constraints of our population.
We had 170 patients with PE, of which 96 were confirmed diagnosis by CT angiogram. We had total mortality of 50 patients in our cohort, of which 20 deaths were attributed to confirmed cases of PE. This rate could be higher if all the patients suspected of PE had CT angiograms to confirm the diagnosis. Our mortality rate of PE is considerably lower as compared to other studies, but this may be due to the lack of confirmation scans, silent PEs and mortalities being attributed to other causes. The study from CMC Vellore reports 49.5% mortality with PE, while studies from western countries report a rate of 23%–32.5%., The International Cooperative PE registry was established to determine mortality rates of PE and other baseline factors, and they concluded that the 3-month crude mortality rate was 17.4% with 45.1% of the deaths being attributed to PE. The risk of early mortality in patients with PE is 18-fold as compared to patients with DVT without PE, and for almost 25% of patients, the initial presentation of PE is sudden death. The mortality due to PE in India will always be under-reported due to the lack of autopsies being performed for all mortalities.
Sixty-one patients underwent IVC filter insertions, and these insertions were split among the vascular surgeons, cardiologists, and the interventional radiologists. The indications for insertions by vascular surgeons were a transient contraindication to anticoagulation in massive trauma with DVT and recurrent PEs. During the latter part of the study period from January 2017 onward, 38 catheter-directed thrombolysis procedures were performed for iliofemoral DVT to prevent postthrombotic syndrome and immediate thrombus load reduction with favorable results.
There were 117 cases of DVT that developed after recent surgery by the general surgeons and the orthopedic surgeons, and only 10.7% of these patients had received any thromboprophylaxis. These data emphasize the fact that increased awareness and proper protocols have to be initiated in surgical patients to prevent postsurgical venous thrombosis.
Since this is a retrospective study and involves data from many specialties, it does have its share of lacunae such as uniformity in management protocol, lack of long-term follow-up data, mortality confirmation data, and lack of autopsies performed at our center. However, it does give a fair amount of information regarding the epidemiology and temporal profile of VTE in a large tertiary institute, and it reiterates the pressing need for proper implementation of VTE prophylaxis and treatment in India.
| Conclusions|| |
VTE is a fairly common disease and is associated with reduced survival and significant morbidity. As we and other studies have shown, the incidence is rising in India and Asia. More registries like ours are the need of the hour and will only help large institutions identify their lacunae and address areas, which need attention, such as thromboprophylaxis and uniform management. Awareness of the substantial problem of VTE and proper protocols modified to the loco-regional pattern can go a long way in the reduction of VTE.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG, et al.
Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007;98:756-64.
Lee AD, Stephen E, Agarwal S, Premkumar P. Venous thrombo-embolism in India. Eur J Vasc Endovasc Surg 2009;37:482-5.
Pinjala R; ENDORSE-India Investigators. Venous thromboembolism risk & prophylaxis in the acute hospital care setting (ENDORSE), a multinational cross-sectional study: Results from the Indian subset data. Indian J Med Res 2012;136:60-7. [Full text]
Kamerkar DR, John MJ, Desai SC, Dsilva LC, Joglekar SJ. Arrive: A retrospective registry of Indian patients with venous thromboembolism. Indian J Crit Care Med 2016;20:150-8.
] [Full text]
Pai N, Ghosh K, Shetty S. Cause of deep venous thrombosis and pulmonary embolism in young patients from India as compared with other ethnic groups. Blood Coagul Fibrinolysis 2012;23:257-61.
Chandrakumar A, Sajid AM, Suriyaprakash TN, Ajmal KK. Prevalence of venous thromboembolism risk factors and prophylactic adequacy among general surgical patients in a tertiary care hospital. Indian Heart J 2016;68:513-8.
Naqvi SE, Haseen MA, Beg MH, Ali E, Khan T. Deep vein thrombosis: An experience of 25 years from North India. Indian J Vasc Endovasc Surg 2016;3:2-6. [Full text]
Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ 3rd
. Trends in the incidence of deep vein thrombosis and pulmonary embolism: A 25-year population-based study. Arch Intern Med 1998;158:585-93.
Heniford BT, Senler SO, Olsofka JM, Carrillo EH, Bergamini TM. May-Thurner syndrome: Management by endovascular surgical techniques. Ann Vasc Surg 1998;12:482-6.
Patel NH, Stookey KR, Ketcham DB, Cragg AH. Endovascular management of acute extensive iliofemoral deep venous thrombosis caused by May-Thurner syndrome. J Vasc Interv Radiol 2000;11:1297-302.
Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al.
Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th
edition). Chest 2008;133:381S-453S.
Cohen AT, Tapson VF, Bergmann JF, Goldhaber SZ, Kakkar AK, Deslandes B, et al.
Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): A multinational cross-sectional study. Lancet 2008;371:387-94.
Dhillon KS, Askander A, Doraismay S. Postoperative deep-vein thrombosis in Asian patients is not a rarity: A prospective study of 88 patients with no prophylaxis. J Bone Joint Surg Br 1996;78:427-30.
Nagi ON, Dhillon MS, Katariya S, Mujeeb MS. Deep vein thrombosis after major surgery-evaluation by compression ultrasonography. Indian J Orthop 1999;33:200. [Full text]
Sharma H, Maini L, Agrawal N, Upadhyay A, Vishwanath J, Dhaon BK. Incidence of deep vein thrombosis in patients with fractures around hip joint: A prospective study. Indian J Orthop 2002;36:5.
Anderson FA Jr., Wheeler HB, Goldberg RJ, Hosmer DW, Patwardhan NA, Jovanovic B, et al.
A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT study. Arch Intern Med 1991;151:933-8.
Cushman M, Tsai A, Heckbert SR, White R, Rosamund W, Enright P. Incidence rates, case fatality, and recurrence rates of deep vein thrombosis and pulmonary embolus: The Longitudinal Investigation of Thromboembolism Etiology (LITE). Thromb Haemost 2001;86:1.
Heit JA, O'Fallon WM, Petterson TM, Lohse CM, Silverstein MD, Mohr DN, et al.
Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: A population-based study. Arch Intern Med 2002;162:1245-8.
White RH. The epidemiology of venous thromboembolism. Circulation 2003;107:I4-8.
Heit JA. Epidemiology of venous thromboembolism. Nat Rev Cardiol 2015;12:464-74.
Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ 3rd
. Predictors of survival after deep vein thrombosis and pulmonary embolism: A population-based, cohort study. Arch Intern Med 1999;159:445-53.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]