**6. Treatment of DVT/PE**

The goals of treatment of patients with DVT and PE are to prevent local growth of the thrombus, prevent the thrombus from breaking down into small pieces (emboli) and traveling to other places, prevent complications of DVT, prevent recurrence of the thrombus and in some clinical situations accelerate fibrinolysis (Hirsh & Hoak, 1996).

DVT is treated by immediate institution of anticoagulant therapy. Treatment is given as either unfractionated heparin or low molecular weight heparins, followed by few weeks to 6 months of oral anticoagulant therapy (Clarke-Pearson & Abaid, 2008). However, life-long anticoagulation has been recommended in some patients with active cancers after partial improvement or failure of treatment, because they remain at very high risk to recurrent DVT (Clarke-Pearson & Abaid, 2008).Low concentrations of heparin can inhibit the early stages of blood coagulation. However, higher concentrations are needed to inhibit the much higher concentrations of thrombin that are formed if the DVT process is not modulated (Hirsh & Hoak, 1996).

Deep Venous Thrombosis After Radical Pelvic Surgery 181

Deep venous thrombosis and pulmonary embolism are among the major post-operative complications that develop after radical pelvic surgeries. Pulmonary embolism is one of the leading causes of post-operative mortality in these patients. Most of the cases are asymptomatic and in the majority of patients dying from pulmonary embolism the embolism is diagnosed at autopsy. Treatment is essentially prophylactic and the primary treatment objectives are to prevent PE, decrease morbidity and to prevent the risk of developing the post-thrombotic syndrome (PTS). High-risk patients may be subject for dual mechanical and pharmacologic prophylaxis with good results. Anticoagulation provides the main stay of treatment. Thrombolytic therapy is currently used for massive pulmonary embolism and some selected cases of deep venous thrombosis. Surgical (thrombectomy or

embolectomy) or endovascular techniques have been tried with promising results.

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**7. Conclusion** 

**8. References** 

When unfractionated heparin is used, we usually start by a bolus injection followed by continuos infusion and the dose is then adjusted to maintain the level of activated partial thromboplastin time (APTT) at 1.5–2.5 times the control value (Clarke-Pearson & Abaid, 2008). Oral anticoagulation (warfarin) should be started on the first day of the heparin infusion aiming to achieve an international normalized ratio (INR) of 2.0-3.0. IV heparin may be discontinued in 5 days if an adequate INR level has been established (Clarke-Pearson & Abaid, 2008). Studies have demonstrated that some of the new anticoagulants, such as hirudin and its fragments, are effective inhibitors of clot-bound thrombin and therefore, they may provide a better efficacy than heparin in neutralizing the procoagulant effects of the fibrin-bound thrombin (Weitz et al., 1990).

Low molecular weight heparins such as enoxaparin and dalteparin have been proved to be as effective and safe as unfactionated heparin in the treatment and recurrence prophylaxis of DVT/PE (Quinlan et al., 2004). They have the advantage of the possibility to be given in the outpatient setting (Clarke-Pearson & Abaid, 2008).

Fibrinolysis can be performed by one of the fibrinolytic enzymes, such as streptokinase, urokinase and TPA, all of them can increase the dissolution rate of the thromus or embolus (Hirsh & Hoak, 1996). They are not routinely recommended in the treatment of DVT/PE, because of their cost and the high risk of bleeding (Hirsh & Hoak, 1996). Thrombolytic therapy is indicated in all patients with massive pulmonary embolism and in some selected cases of proximal DVT or with severe obstruction (Hirsh & Hoak, 1996). Thrombolytic therapy has the advantage of preserving the pulmonary microcirculation after PE and decreasing the possibility of post-thrombotic syndrome (PTS) following DVT (Linn et al., 1988). Intrapulmonary artery infusion of urokinase in extensive PE has been found to be safe and effective in treatment of patients with and without contraindication to the use of systemic thrombolytic therapy (McCotter et al., 1999). With the recommended dose, thrombolytic therapy produces significant and rapid resolution of pulmonary emboli with a low morbidity and mortality rate. However, in lower extremity DVT, therapeutic thrombolysis is still controversial.

In PE immediate anticoagulant therapy is given and respiratory support is maintained. In addition, pulmonary artery catheterization with the administration of thrombolytic agents has been tried as previously mentioned (McCotter et al., 1999).

Surgical intervention of the thrombus or embolus is rarely indicated. However, surgical extirpation of the thrombus (venous thrombectomy), of the embolus (pulmonary embolectomy) and endovascular therapies to treat DVT have been reported with promising results (Lindow et al., 2010; Jenkins, 2011).

Long-term results after transfemoral venous thrombectomy for iliofemoral DVT has shown that the technique is safe and effective and can prevent the development of severe postthrombotic syndrome in the long term (Lindow et al., 2010).

Inferior vena cava filters have been introduced to prevent PE in patients in whom anticoagulation therapy is contraindicated, has failed or has been associated with complications and in patients with extensive free-floating thrombi or residual thrombi following massive PE (Chung et al., 2008; Kalva et al., 2008).

#### **7. Conclusion**

180 Deep Vein Thrombosis

When unfractionated heparin is used, we usually start by a bolus injection followed by continuos infusion and the dose is then adjusted to maintain the level of activated partial thromboplastin time (APTT) at 1.5–2.5 times the control value (Clarke-Pearson & Abaid, 2008). Oral anticoagulation (warfarin) should be started on the first day of the heparin infusion aiming to achieve an international normalized ratio (INR) of 2.0-3.0. IV heparin may be discontinued in 5 days if an adequate INR level has been established (Clarke-Pearson & Abaid, 2008). Studies have demonstrated that some of the new anticoagulants, such as hirudin and its fragments, are effective inhibitors of clot-bound thrombin and therefore, they may provide a better efficacy than heparin in neutralizing the procoagulant

Low molecular weight heparins such as enoxaparin and dalteparin have been proved to be as effective and safe as unfactionated heparin in the treatment and recurrence prophylaxis of DVT/PE (Quinlan et al., 2004). They have the advantage of the possibility to be given in the

Fibrinolysis can be performed by one of the fibrinolytic enzymes, such as streptokinase, urokinase and TPA, all of them can increase the dissolution rate of the thromus or embolus (Hirsh & Hoak, 1996). They are not routinely recommended in the treatment of DVT/PE, because of their cost and the high risk of bleeding (Hirsh & Hoak, 1996). Thrombolytic therapy is indicated in all patients with massive pulmonary embolism and in some selected cases of proximal DVT or with severe obstruction (Hirsh & Hoak, 1996). Thrombolytic therapy has the advantage of preserving the pulmonary microcirculation after PE and decreasing the possibility of post-thrombotic syndrome (PTS) following DVT (Linn et al., 1988). Intrapulmonary artery infusion of urokinase in extensive PE has been found to be safe and effective in treatment of patients with and without contraindication to the use of systemic thrombolytic therapy (McCotter et al., 1999). With the recommended dose, thrombolytic therapy produces significant and rapid resolution of pulmonary emboli with a low morbidity and mortality rate. However, in lower extremity DVT, therapeutic

In PE immediate anticoagulant therapy is given and respiratory support is maintained. In addition, pulmonary artery catheterization with the administration of thrombolytic agents

Surgical intervention of the thrombus or embolus is rarely indicated. However, surgical extirpation of the thrombus (venous thrombectomy), of the embolus (pulmonary embolectomy) and endovascular therapies to treat DVT have been reported with promising

Long-term results after transfemoral venous thrombectomy for iliofemoral DVT has shown that the technique is safe and effective and can prevent the development of severe post-

Inferior vena cava filters have been introduced to prevent PE in patients in whom anticoagulation therapy is contraindicated, has failed or has been associated with complications and in patients with extensive free-floating thrombi or residual thrombi

has been tried as previously mentioned (McCotter et al., 1999).

thrombotic syndrome in the long term (Lindow et al., 2010).

following massive PE (Chung et al., 2008; Kalva et al., 2008).

effects of the fibrin-bound thrombin (Weitz et al., 1990).

outpatient setting (Clarke-Pearson & Abaid, 2008).

thrombolysis is still controversial.

results (Lindow et al., 2010; Jenkins, 2011).

Deep venous thrombosis and pulmonary embolism are among the major post-operative complications that develop after radical pelvic surgeries. Pulmonary embolism is one of the leading causes of post-operative mortality in these patients. Most of the cases are asymptomatic and in the majority of patients dying from pulmonary embolism the embolism is diagnosed at autopsy. Treatment is essentially prophylactic and the primary treatment objectives are to prevent PE, decrease morbidity and to prevent the risk of developing the post-thrombotic syndrome (PTS). High-risk patients may be subject for dual mechanical and pharmacologic prophylaxis with good results. Anticoagulation provides the main stay of treatment. Thrombolytic therapy is currently used for massive pulmonary embolism and some selected cases of deep venous thrombosis. Surgical (thrombectomy or embolectomy) or endovascular techniques have been tried with promising results.

#### **8. References**


print][http://www.ncbi.nlm.nih.gov/pubmed/21812019]


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