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Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St, Pomona, CA |
One of the very important skills many of us are taught in school and residency is how to find the answers to our clinical questions. At Western University, we teach our students to use search engines such as PubMed to find the answers to clinical questions they create as a result of patient care encounters. As a medical provider, I also try to stay as current as I can, reading various journal articles, attending workshops and conferences, to give me new perspectives.
 This is one of the wonderful things about being a teacher for both students and residents. It's also beneficial being part of a teaching hospital. I live in a bubble of trainees questioning the status quo at so many different levels, from basic questions like how does that test work to more advanced issues such as the post-test probability of diagnosis with a certain laboratory test. I constantly need to re-evaluate what I know and read to find the best answers. Sometimes, though, I get caught by surprise, and my interactions with the medical community force me to realize the limits of my knowledge (and the fact that no one can know everything about everything).
Recently, while rounding at the hospital, I was contacted about a new consultation on a patient from my own clinic. This patient was admitted for acute lower extremity edema and inguinal pain, which on ultrasound was diagnosed as a saphenous vein thrombosis.
This situation brought me way back to my general surgery rotation as a resident in which we had a patient that had been diagnosed with a venous thrombosis in the arm. The medical service was very worried at the time, but when the vascular surgeon saw the patient, he took maybe 60 seconds to tell everyone to calm down. This was a superficial thrombophlebitis (SVT) that did not require anticoagulation, but rather moist warm heat and anti-inflammatories. Having forgotten their anatomy, the medical service was slightly embarrassed.
Recalling the anatomy of my patient, I knew that the great saphenous vein was superficial. The patient was on a heparin drip by the time I saw him, and I recommended to the medicine team that anticoagulation was not necessary. The medical staff, though, kept him on heparin, arguing that the thrombus was too close to the saphenous vein junction with the femoral vein to be safe, and they would treat the patient as if he had a deep venous thrombosis. Since this is clearly not my area of expertise, I did not push the issue.
Instead, I did what I've been taught and have been teaching others to do: I looked it up. I rarely believe anything at face value anyway, so I wanted to be sure the medicine team was correct, and I was wrong. The first thing I did was create a clinical question using the PICO method (Patient Intervention Comparison Outcome). Here's my version of the question:
QUESTION:
In a patient with thrombosis of the saphenous vein near the saphenofemoral junction (Patient) does heparin (Intervention) compared with no treatment (Comparison) reduce the risk of deep venous thrombosis and/or pulmonary embolism (Outcome)?
Using this question as a guide, a PubMed search found two articles that I could quickly read and evaluate. The first was a retrospective study looking at 2,646 lower extremity venous ultrasounds performed in a level one-trauma hospital during a one-year period. Of the total group 388 (14.5%) were positive for a DVT. Of these, there were 30 patients (1.1%) with a thrombus of the greater saphenous vein. In these, 22 (73%) showed an extension of the thrombus into the common femoral vein or shortness of breath. The authors recommended that thomboses of the greater saphenous vein close to the saphenofemoral junction be treated like a DVT.1
Part of the evidence-based practice system is to evaluate the journal articles we read for validity. In light of that standard, I'll mention that the study by Hill and associates does have methodological weaknesses such as the retrospective nature of the study, the level one trauma hospital location (causing a bias toward potentially worse situations like polytrauma patients and hence decreased generalizability), and a weak statistical analysis. Something as basic as a relative risk analysis would have been an improvement over the simple descriptive statistics.
So, not completely trusting the results of this study, I turned to my second article, which was a review.2 Now, a review is a lower level of medical evidence (lower than the clinical study). However, I wanted to see what the general consensus was, if any, in the medical community. I also wanted to see if other studies existed that might be future references, if necessary. After looking at the known literature, the review stated the following recommendations:
- SVT of the greater saphenous vein has generally been considered equivalent to a DVT regarding its risk of progression.
- A distance of less than 3 cm from the saphenofemoral junction (and possibly the saphanopopliteal junction) is an indication for aggressive treatment (anticoagulation, anti-inflammatories, and sometimes surgery).
- In these cases, anticoagulation should be considered for at least three months (optimal duration unknown).
- Repeat ultrasound should be performed at 48-72 hours after start of treatment to determine if propagation, resolution, or stabilization have occurred.1
- Surgical thrombectomy should be considered in cases of progression of the clot despite antithrombotic therapy.
The medical team had been right and I, in fact, was wrong. They were treating the patient correctly. I noted during my reading that over the past 10 years, much work has been done to demonstrate the increased risk of deep venous extension in SVT close to the saphenofemoral junction. Interestingly, this time period corresponds loosely with the time I have been in clinical practice after graduating from residency. The time we spend in residency makes us sharp and knowledgeable, and it is easy for us to become less up-to-date the further we are from training. Continuing to remain interested and engaged, while taking the time to read about new changes in medicine, will help each of us stay as on top of the current knowledge as we were as residents.
Best wishes,
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
References:
- Hill SL, Hancock DH, Webb TL. Thrombosis of the great saphenous vein – recommendations for treatment, Phlebology, 2008;23:35-39..
- Cosmi B. Management of superficial vein thrombosis. J Thtomb Haemost. 2015;13:1-9.
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