Deep vein thrombosis after major lower extremity amputation – not such a rare complication, but rarely symptomatic

C. Geppert, T. Lattmann, L. Gürke, P. Stierli

Objective

We report two incidences of symptomatic deep vein thrombosis (DVT) after major lower extremity amputation (MLE) within 1 year in our institution.

Methods

A 73yr old male patient with known peripheral arterial disease (PAD) Rutherford V of the left leg underwent a below-knee amputation. Despite continued therapy with aspirin® and prophylactic intravenous heparin respectively low-molecular weight heparin (LMWH), the patient developed a painful swelling of the amputated limb after 10 days. Duplex sonography demonstrated an iliofemoral thrombosis. Due to the severe symptoms, we performed a venous thrombectomy. He was started on therapeutic anticoagulation. The recovery thereafter was uneventful.

In the second case, a 50yr old male patient with thrombotic thrombocytopenic purpura (TTP) underwent a below-knee amputation left for PAD Rutherford IV. His treatment with aspirin® was continued throughout the perioperative phase. In addition, he received prophylactic LMWH for 5 weeks. 10 days after discharge, he developed swelling of his left limb. Duplex sonography and CT scan revealed an extensive iliofemoral thrombosis protruding into the inferior vena cava. Therapeutic heparin and compression therapy of the left leg was successful within 24 hours. Treatment with rivaroxaban was started in addition to aspirin®. No surgery was performed in this case and further recovery was uneventful.

In both cases, there was no evidence of a May-Thurner syndrome.

CT scan case 1: Arrows pointing to thrombosis in inferior vena cava, common and external iliac vein left

Results

In the literature, the incidence of DVTs after MLE amputations varies from 12-26%. When consulting the Cochrane Database, there is insufficient evidence regarding the most effective thromboprophylaxis in patients with MLE amputations. Per annum, we perform 60-80 MLE amputations. All our patients receive prophylactic LMWH. These two cases within one year are the first symptomatic DVTs after MLE amputations in our institution in the past 10 years.

Conclusion

We are aware, that the incidence of DVTs may well be much higher than these two events, but we don’t routinely investigate patients for DVTs. This begs the question: Should we be investigating and treating our patients with MLE amputations differently, possibly with therapeutic anticoagulation?