Ultrasound Screening in the Office for Venous Thromboembolism Detection: A Major Step Forward for Patient Safety and Practice Growth

In order to learn about the natural history of venous thromboembolism (VTE) in plastic surgery outpatients, the author has evaluated over 200 consecutive patients before, the day after, and approximately 1 week after surgery using duplex ultrasound, a noninvasive method that is highly accurate.  All patients were treated using total intravenous anesthesia and SAFE principles (Spontaneous breathing, Avoid gas, Face up, and Extremities mobile).  No patient received chemoprophylaxis.  Only one thrombosis was detected on a scan, 8 days after surgery (Fig. 1).  The thrombosis was isolated to the calf and responded quickly to anticoagulation (Fig. 2). 

These findings suggest that the natural history of VTE in plastic surgery patients is quite different from orthopedic patients, in whom our present knowledge of VTE is based.  Thromboses form much less frequently (0.5%) and are likely to form after surgery rather than intraoperatively (all 1^st day postoperative scans were negative).  Deep venous thromboses are likely to be small and located in the calf veins, where they are less likely to cause pulmonary emboli.

Patient compliance with ultrasound screening examinations has been 100%.  Patients are already aware of the gravity of this complication.  This method represents a major change in management.  Rather than trying to identify individuals who will develop this complication (risk stratification has a sensitivity of only 52% and a false positive rate of 97%), all patients are screened and those who actually develop a thrombosis are treated.  Serious side effects of routine anticoagulation, such as bleeding, are avoided.

The cost of this equipment is approximately $30,000.  The prevention of even a single case of pulmonary embolism, which can be fatal, justifies its expense.  Ultrasound imaging has other applications in the plastic surgery office, such as ruling out undetected abdominal defects in patients undergoing liposuction and abdominoplasty (Fig. 3).  It can also assist in the diagnosis and management of breast implant ruptures and seromas.

Ultrasound screening facilitates a candid discussion of VTE risk with patients.  Prospective patients are relieved to know that, in addition to SAFE principles, they will be screened to rule out a thrombosis.  They (correctly) believe that their surgeon is genuinely interested in their safety and willing to provide this extra safety measure at no charge.  Internists involved in the care of affected patients are impressed that plastic surgeons are attuned to this problem and taking extra steps to defend against it.  Ultrasound screening serves as an early warning system.  Safety is good for business and can only improve medical malpractice liability.  It helps differentiate one's practice from the competition.  Any plastic surgeon who adopts this practice is likely to see an increase in patient volume, and a reduced (or no) advertising budget.  Increased patient referrals more than compensate for its cost.

Fig. 1   Doppler ultrasound image reveals no flow in the left posterior tibial veins. 

Fig. 2.  Doppler ultrasound image 5 weeks after surgery shows restoration of venous flow with no obstruction in the peroneal veins.

Fig. 3.  Abdominal ultrasound scan in a patient before abdominoplasty.