Which mechanical methods are used for deep venous thrombosis (DVT) prophylaxis in patients undergoing orthopedic surgery?

Updated: Jul 25, 2019
  • Author: David A Forsh, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
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Answer

Answer

Mechanical methods have been shown to be a useful adjunct to anticoagulation therapy in reducing the incidence of DVT. Modalities include passive devices, such as knee- or thigh-high graduated compression (elastic) stockings (GCS) [11] ; active (external pneumatic compress or intermittent pneumatic compression [IPC]) devices [12] ; or venous foot pumps (VFP). [13]

A 2012 systematic review of randomized, controlled trials found that knee- and thigh-high GCS do not significantly differ in their effectiveness in reducing the incidence of DVT in hospitalized patients. Ease of use, patient compliance, and cost influence which type of stocking is used in clinical practice. [14]

In a study of the efficacy of IPC in multiple postoperative patient groups versus no use of prophylaxis, Urbankova et al reported that the incidence of DVT was reduced by 60%. [15] However, the use of mechanical means of prophylaxis alone is not effective in moderate or high-risk cases.

IPC devices are designed to decrease venous stasis, improve blood flow velocity, and increase the level of circulating fibrinolysins. IPC devices have the advantage of requiring no monitoring, with no increase in bleeding. Generally, they are well tolerated. There are a wide variety of these devices, and they can be applied to the foot, calf, or thigh. A study comparing asymmetrical with circumferential intermittent compression devices following total knee replacement (TKR) seemed to support the asymmetrical device. [16]

Patient compliance is an issue with IPC devices, and efficacy is dependent on the time of use. Evidence from clinical trials has shown that although the rate of distal thrombi is reduced significantly, that of proximal thrombi is not. This finding may lead to a false sense of security because although the total number of deep venous thrombi may be similar to the numbers observed with pharmacologic prophylaxis, the proportion of the relatively more dangerous proximal clots is increased (see Table 1 below).

Table 1. Frequency of Thrombi at Different Sites With Intermittent Pneumatic Compression vs Warfarin (Open Table in a new window)

Thrombi

Warfarin (n = 72) 

IPC (n = 67) 

Iliac and femoral

5

14

Calf, popliteal, plantar

10

2

Total

15

16

Although all three types of mechanical compression reduce the incidence of DVT to less than that found when prophylaxis is absent, these modalities are generally less effective at producing such reductions than pharmacologic methods are. Shorter hospital stays make the use of mechanical methods alone ineffective in preventing DVT in the critical weeks after joint replacement. No mechanical prophylaxis method has been shown to reduce the risk of PE or death. The use of IPC devices is therefore recommended primarily as an adjunct to anticoagulant-based prophylaxis or in patients who are at high risk of bleeding.


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