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Imaging Modalities for Detecting Deep Venous Thrombosis After Bariatric Surgery

  • Bariatric Surgery (A. Ghaferi, Section Editor)
  • Published:
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Abstract

Purpose of Review

Deep venous thrombosis (DVT) remains a leading cause of morbidity and mortality in the bariatric patient. We review the current non-invasive modalities—Doppler ultrasound (DUS), computed tomographic venography (CTV) and magnetic resonance venography (MRV)—for the detection of DVT in the post-bariatric surgical patient.

Recent Findings

CTV and MRV are highly sensitive non-invasive imaging modalities with improved capability over DUS of detecting proximal, especially pelvic, DVT. MRV has recently been shown to be capable of detecting asymptomatic pelvic DVT in post-bariatric surgical patients. The clinical significance of these findings remains uncertain.

Summary

Invasive contrast venography, while remaining the gold standard, has been supplanted by DUS in routine clinical use. However, DUS has technical limitations in the morbidly obese patient. CTV and MRV remain highly accurate in this population and warrant further investigation for routine clinical use.

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References

Papers of particular interest published recently or of strong relevance to this review, are highlighted as: • Of importance •• Of major importance

  1. Marks JB. Obesity in America: it’s getting worse. Clin Diabetes. 2004;22:1–2.

    Article  Google Scholar 

  2. An R. Prevalence and trends of adult obesity in the US, 1999–2012. ISRN Obes. 2014;2014:185132.

    PubMed  PubMed Central  Google Scholar 

  3. Hofso D, Nordstrand N, Johnson LK, et al. Obesity-related cardiovascular risk factors after weight loss: a clinical trial comparing gastric bypass surgery and intensive lifestyle intervention. Eur J Endocrinol. 2010;163:735–45.

    Article  CAS  Google Scholar 

  4. Vest AR, Heneghan HM, Schauer PR, et al. Surgical management of obesity and the relationship to cardiovascular disease. Circulation. 2013;127:945–59.

    Article  Google Scholar 

  5. Ashrafian H, le Roux CW, Darzi A, et al. Effects of bariatric surgery on cardiovascular function. Circulation. 2008;118:2091–102.

    Article  Google Scholar 

  6. Stein PD, Matta F. Pulmonary embolism and deep venous thrombosis following bariatric surgery. Obes Surg. 2013;23:663–8.

    Article  Google Scholar 

  7. Becattini C, Agnelli G, Manina G, et al. Venous thromboembolism after laparoscopic bariatric surgery for morbid obesity: clinical burden and prevention. Surg Obes Relat Dis. 2012;8:108–15.

    Article  Google Scholar 

  8. Morino M, Toppino M, Forestieri P, et al. Mortality after bariatric surgery: analysis of 13,871 morbidly obese patients from a national registry. Ann Surg. 2007;246:9.

    Article  Google Scholar 

  9. • Cramer SC, Rordorf G, Kaufman JA, et al. Clinically occult pelvic-vein thrombosis in cryptogenic stroke. Lancet. 1998;351:1927–8. In an attempt to elucidate the source of thrombi in cryptogenic strokes, Cramer et al carried out MRV on patients diagnosed with cryptogenic strokes. These patients had undergone ultrasound of bilateral lower extremities which was negative for DVT pathology. MRV detected thrombi which had gone undetected by ultrasound. Although this study was not carried out in the bariatric cohort. The author’s findings further support our position in this review.

    Article  CAS  Google Scholar 

  10. Yuan K, Kasner SE. Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention. Stroke Vasc Neurol. 2018;3:84–91.

    Article  Google Scholar 

  11. Dhakal P, Verma V, Bhatt VR. Cryptogenic stroke. N Engl J Med. 2016;375:e26.

    Article  Google Scholar 

  12. Harris LM, Curl GR, Booth FV, et al. Screening for asymptomatic deep vein thrombosis in surgical intensive care patients. J Vasc Surg. 1997;26:764–9.

    Article  CAS  Google Scholar 

  13. •• American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. ASMBS updated position statement on prophylactic measures to reduce the risk of venous thromboembolism in bariatric surgery patients. Surg Obes Relat Dis. 2013;9:493–7. The most up to date position statement/guidelines regarding venous thromboembolism prophylaxis in the bariatric surgical patient.

  14. • Carpenter JP, Holland GA, Baum RA, et al. Magnetic resonance venography for the detection of deep venous thrombosis: comparison with contrast venography and duplex Doppler ultrasonography. J Vasc Surg. 1993;18:734–41. Carpenter et all explored the advantages and drawbacks to three imaging modalities for DVT, Contrast Venography, MRV and DUS. They sought to compare the efficacy and accuracy of MRV to that of Contrast Venography and DUS. They were able to conclude from their results that MRV is an accurate method of detecting DVTs. Importantly, the patient cohort was not an obese bariatric surgery cohort and hence would not accurately highlight the difficulties of imaging with DUS in this patient population.

    Article  CAS  Google Scholar 

  15. Hallett JW. Comprehensive vascular and endovascular surgery. Philadelphia: Mosby/Elsevier; 2009. p. 807–41.

    Google Scholar 

  16. Bates SM, Jaeschke R, Stevens SM, et al. Diagnosis of DVT: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141:e418S.

    Google Scholar 

  17. Goodacre S, Sampson F, Thomas S, et al. Systematic review and meta-analysis of the diagnostic accuracy of ultrasonography for deep vein thrombosis. BMC Med Imaging. 2005;5:6.

    Article  Google Scholar 

  18. Divittorio R, Bluth EI, Sullivan MA. Deep vein thrombosis: diagnosis of a comon clinical problem. Ochsner J. 2002;4:14–7.

    PubMed  PubMed Central  Google Scholar 

  19. Sica GT, Pugach ME, Koniaris LS, et al. Isolated calf vein thrombosis: comparison of MR venography and conventional venography after initial sonography in symptomatic patients. Acad Radiol. 2001;8:856–63.

    Article  CAS  Google Scholar 

  20. Katz DS, Fruauff K, Kranz AO, Hon M. Imaging of deep venous thrombosis: a multimodality overview. Appl Radiol. 2014;43:6.

    Google Scholar 

  21. Lockhart ME, Sheldon HI, Robbin ML. Augmentation in lower extremity sonography for the detection of deep venous thrombosis. Am J Roentgenol. 2005;184:419–22.

    Article  Google Scholar 

  22. Elfandi A, Anghel S, Sales C. Current management of isolated soleal and gastrocnemius vein thrombosis. J Vasc Surg Venous Lymphat Disord. 2015;3:341–4.

    Article  Google Scholar 

  23. •• Abdalla G, Fawzi Matuk R, Venugopal V, et al. The diagnostic accuracy of magnetic resonance venography in the detection of deep venous thrombosis: a systematic review and meta-analysis. Clin Radiol. 2015;70:858–71. The study is a systematic review and meta-analysis of the diagnostic accuracy of MRV for the detection of DVT which showed a high sensitivity and specificity when MRV was used as a diagnostic tool. Although there was no evidence to support the replacement of DUS with MRV, MRV was suggested as an alternative when DUS was not feasible.

    Article  CAS  Google Scholar 

  24. Modica MJ, Kanal KM, Gunn ML. The obese emergency patient: imaging challenges and solutions. Radiographics. 2011;31:811–23.

    Article  Google Scholar 

  25. Chen D, Zhou J, Wang P, et al. Low-tube-voltage combined with adaptive statistical iterative reconstruction-V technique in CT venography of lower limb deep vein thrombosis. Sci Rep. 2018. https://doi.org/10.1038/s41598-018-29519-y.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Mattos MA, Melendres G, Sumner DS, et al. Prevalence and distribution of calf vein thrombosis in patients with symptomatic deep venous thrombosis: a color-flow duplex study. J Vasc Surg. 1996;24:738–44.

    Article  CAS  Google Scholar 

  27. Hartung MP, Grist TM, Francois CJ. Magnetic resonance angiography: current status and future directions. J Cardiovasc Magn Reson. 2011;13:19.

    Article  Google Scholar 

  28. •• Steele KE, Canner J, Prokopowicz G, et al. The EFFORT trial: preoperative enoxaparin versus postoperative fondaparinux for thromboprophylaxis in bariatric surgical patients: a randomized double-blind pilot trial. Surg Obes Relat Dis. 2015;11:672–83. This was the main study from which our motivation to write this review originated. This was a randomized double-blinded clinical trial/pharmacokinetic study evaluating the efficacy of two anticoagulants enoxaparin twice daily and fondaparinux once daily as perioperative VTE prophylaxis in the bariatric surgical patient. MRV was used as the primary detection tool for post-bariatric surgery asymptomatic DVT. MRV was chosen as the detection tool of choice for DVT instead of DUS due to the need for a high level of accuracy and the challenges in the obese patient.

    Article  Google Scholar 

  29. Daftari Besheli L, Aran S, Shaqdan K, et al. Current status of nephrogenic systemic fibrosis. Clin Radiol. 2014;69:661–8.

    Article  CAS  Google Scholar 

  30. Spritzer CE, Arata MA, Freed KS. Isolated pelvic deep venous thrombosis: relative frequency as detected with MR imaging. Radiology. 2001;219:521–5.

    Article  CAS  Google Scholar 

  31. Blackburn GL, Hutter MM, Harvey AM, et al. Expert Panel on Weight Loss Surgery: executive report update. Obesity (Silver Spring). 2009;17:842–62.

    Article  Google Scholar 

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Authors and Affiliations

  1. The Johns Hopkins University School of Medicine, Department of Radiology – Diagnostic Radiology, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave, Baltimore, MD, 21224, USA

    Franco Verde

  2. Royal College of Surgeons in Ireland, 123 St Stephen’s Green, Dublin 2, Dublin, Ireland

    Oludare Alabi

  3. The Johns Hopkins University School of Medicine, Department of General Internal Medicine, Johns Hopkins Hospital, 601 N. Caroline St., Suite 7157, Baltimore, MD, 21287, USA

    Gregory Prokopowicz

  4. The Johns Hopkins University School of Medicine, Department of Surgery, The Johns Hopkins Center for Bariatric Surgery, 4940 Eastern Ave, Baltimore, MD, 21224, USA

    Kimberley Eden Steele

Authors
  1. Franco Verde
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  2. Oludare Alabi
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  3. Gregory Prokopowicz
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  4. Kimberley Eden Steele
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Corresponding author

Correspondence to Kimberley Eden Steele.

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Conflict of interest

Franco Verde, Oludare Alabi, Gregory Prokopowicz, Kimberley Eden Steele declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical collection on Bariatric Surgery.

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Verde, F., Alabi, O., Prokopowicz, G. et al. Imaging Modalities for Detecting Deep Venous Thrombosis After Bariatric Surgery. Curr Surg Rep 6, 24 (2018). https://doi.org/10.1007/s40137-018-0219-4

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  • DOI: https://doi.org/10.1007/s40137-018-0219-4

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