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Research Fellow Christchurch Hospital Christchurch, New Zealand
To the Editor:
It was recently stated that the mortality of untreated deep venous thrombosis (DVT) is between 1 and 5%; because of this, anticoagulant therapy for this disorder is obligatory in all cases.1 Mortality is a fraction that requires a denominator (the incidence), and for DVT, this figure has been mostly unknown. To avoid generalizations, it is instructive to examine the problem in a specific context. Demers et al2 have recently provided a very accurate figure for the incidence of venographically proven DVT following knee arthroscopy. They found DVT in 17.9% of cases postoperatively, 4.9% of which represented proximal vein thrombosis. These data are concordant with the findings of another prospective study which, using compression ultrasound, found a 3.5% incidence of proximal DVT following the same type of surgery.3 According to Demers et al,2 20,000 arthroscopies are performed in Canada each year. Consequently, there must be approximately 980 cases of proximal DVT each year following such surgery, most of which are unrecognized and therefore untreated.
The incidence of such thrombosis is considerable, but what is the clinical significance? A study of 10,262 such procedures determined an overall complication rate of 1.68%, 6.9% of which were clinically recognized thromboembolic disease.4 This represents an incidence of recognized thromboembolic disease of approximately 0.0012%. There are a few reports of fatal pulmonary air embolism following arthroscopy, but compared to the incidence of proximal DVT, the mortality from pulmonary thromboembolism appears to be unmeasurably small.5 By comparison, the mortality associated with the treatment of thromboembolic disease with 3 months of warfarin is approximately 1 in 1,000, with a 1% incidence of major hemorrhage; the use of IV heparin in this situation causes approximately 5 in 1,000 deaths and major bleeding in 5% of cases.6
This is not to say that proximal DVT is unimportant. In the setting of diminished cardiopulmonary function, it may be life-threatening. But for proximal DVT following arthroscopic surgery, this is clearly not the case. In this case, the risks associated with treatment appear to be greater than those of the underlying condition.
Correspondence to: Paul Egermayer, MBChB, Hagley Building, Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand
References
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