Clin Colon Rectal Surg 2003; 16(2): 109-118
DOI: 10.1055/s-2003-40661
Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Prophylaxis for Deep Vein Thrombosis

S. D. Ting, Francis Seow-Choen
  • Department of Colorectal Surgery, Singapore General Hospital, Singapore
Further Information

Publication History

Publication Date:
18 July 2003 (online)


Deep vein thrombosis (DVT) can result in significant morbidity and mortality if not recognized and treated effectively. It is a common but largely preventable perioperative complication. In addition to increasing the perioperative mortality rate, usually as a result of massive pulmonary embolism (PE), DVT also prolongs hospitalization and hence increases healthcare costs. Despite overwhelming evidence of the effectiveness of regimens for DVT prophylaxis, and well-documented risk factors for venous thromboembolism (VTE), many surgeons still do not routinely practice perioperative DVT prophylaxis. This article outlines the various aspects of DVT prophylaxis, and acts as a guide for perioperative DVT prophylaxis in general and colorectal surgery.


  • 1 Braunwald E, Fauci A S, Kasper D L, Hauser S L, Longo D L, Jameson J L. Harrison's Principles of Internal Medicine, International Edition, 15th ed.  New York: McGraw-Hill 2001 : 1440-1441
  • 2 Dalen J E, Alpert J S. Natural history of pulmonary embolism.  Prog Cardiovasc Dis . 1975;  17 257-270
  • 3 Alpert J S, Dalen J E. Epidemiology and natural history of venous thromboembolism.  Prog Cardiovasc Dis . 1994;  36 417-422
  • 4 Goldhaber S Z, Hennekens C H, Evans D A. et al . Factors associated with correct antemortem diagnosis of major pulmonary embolism.  Am J Med . 1982;  73 822-826
  • 5 Rubinstein I, Murray D, Hoffstein V. Fatal pulmonary emboli in hospitalised patients.  Arch Intern Med . 1988;  148 1425-1426
  • 6 Heit J A, Silverstein M D, Mohr D N, Petterson T M, O'Fallon W M, Melton L J. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study.  Arch Intern Med . 2000;  160 809-815
  • 7 Cogo A, Bernadi E, Prandoni P. et al . Acquired risk factors for deep vein thrombosis in symptomatic outpatients.  Arch Intern Med . 1994;  154 164-168
  • 8 Goldhaber S Z, Grodstein F, Stampfer M J. et al . A prospective study of risk factors for pulmonary embolism in women.  JAMA . 1997;  227 642-645
  • 9 Quinn D A, Thompson B T, Terrin M L. et al . A prospective investigation of pulmonary embolism in women and men.  JAMA . 1992;  268 1689-1696
  • 10 Chasan-Taber L, Stampfer M J. Epidemiology of oral contraceptives and cardiovascular disease.  Ann Intern Med . 1998;  128 467-477
  • 11 Daly E, Vessey M P, Hawkins M M. et al . Risk of venous thromboembolism in users of hormone replacement therapy.  Lancet . 1996;  348 977-980
  • 12 Jick H, Derby L, Wald M. et al . Risk of hospital admission for idiopathic venous thromboembolism among users of postmenopausal estrogens.  Lancet . 1996;  348 981-983
  • 13 Perez-Gutthann S, Garcia-Rodriguez L A, Castellsague-Pique J. et al . Hormonal replacement therapy and the risk of venous thromboembolic events: a population-based case-control study.  BMJ . 1997;  314 796-800
  • 14 Silverstein M D, Heit J A, Mohr D N, Petterson T M, O'Fallon W M, Melton L J. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study.  Arch Intern Med . 1998;  158 585-593
  • 15 Clagett G P, Anderson Jr A F, Heit J, Levine M N, Wheeler H B. Prevention of venous thromboembolism.  Chest . 1995;  108 (suppl 4) S312-S324
  • 16 Caprini J A, Arcelus J I, Hoffman K. et al . Prevention of VTE in North America: results of a survey among general surgeons.  J Vasc Surg . 1994;  20 751-758
  • 17 Janku G V, Paiement G D, Green H D. Prevention of VTE in orthopaedics in the United States.  Clin Orthop . 1996;  325 313-321
  • 18 Morris G K. Prevention of VTE: a survey of methods used by orthopaedic and general surgeons.  Lancet . 1980;  2(8194) 572-574
  • 19 Williams H R, MacDonald D A. Audit of thromboembolic prophylaxis in hip and knee surgery.  Ann R Coll Surg Engl . 1997;  79 55-57
  • 20 Bergqvist D. Prophylaxis against postoperative VTE-a survey of surveys.  Thromb Haemorrh Disorders . 1990;  2 69-73
  • 21 Fletcher J P, Koutts J, Ockelford P A. Deep vein thrombosis prophylaxis: a survey of current practice in Australia and New Zealand.  Aust N Z J Surg . 1992;  62 601-605
  • 22 Rodgers A, Gray H, MacMahon S. Pharmacological thromboprophylaxis in hip and knee surgery: a survey of New Zealand orthopaedic surgeons.  Aust N Z J Surg . 1994;  64 167-172
  • 23 Gillies T E, Ruckley C V, Nixon S J. Still missing the boat with fatal pulmonary embolism.  Br J Surg . 1996;  83 1394-1395
  • 24 Stratton M A, Anderson F A, Bussey H I. et al . Prevention of venous thromboembolism: adherence to the 1995 American College of Chest Physicians guidelines for surgical patients.  Arch Intern Med . 2000;  160 334-340
  • 25 Warkentin T E, Levine M N, Hirsh J. et al . Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin.  N Engl J Med . 1995;  332 1330-1335
  • 26 Oster G, Tuden R L, Colditz G A. Prevention of VTE after general surgery: cost-effectiveness analysis of alternative approaches to prophylaxis.  Am J Med . 1987;  82 889-899
  • 27 Hauch O, Khattar S C, Jorgensen L N. Cost-benefit analysis of prophylaxis against deep vein thrombosis in surgery.  Semin Thromb Hemost . 1991;  17 (suppl 3) 280-283
  • 28 Bergqvist D, Lindgren B, Matzsch T. Comparison of the cost of preventing postoperative deep vein thrombosis with either unfractionated or low molecular weight heparin.  Br J Surg . 1996;  83 1548-1552
  • 29 Hwang W S. The rarity of pulmonary thromboembolism in Asians.  Singapore Med J . 1968;  9 276-279
  • 30 Tinckler L F. Absence of pulmonary embolism in Asians [letter].  BMJ . 1964;  1 50
  • 31 Woo K S, Mak G Y, Sung J Y. et al . The incidence and clinical pattern of deep vein thrombosis in the Chinese in Hong Kong.  Singapore Med J . 1988;  29 357-359
  • 32 Liam C K, Ng S C. A review of patients with deep vein thrombosis diagnosed at University Hospital, Kuala Lumpur.  Ann Acad Med Singapore . 1990;  19 837-840
  • 33 Lee L H. Deep vein thrombosis in a single centre at Singapore General Hospital [abstract].  Haematol J . 2000;  1 (suppl 1) S103
  • 34 Teo C ES. A study of coroner's cases from hospitals: a comparison of autopsy and clinical diagnosis.  Ann Acad Med Singapore . 1993;  22 3-7
  • 35 Lau G. Pulmonary thromboembolism is not uncommon: results and implications of a five-year study of 116 necropsies.  Ann Acad Med Singapore . 1995;  24 356-365
  • 36 Ho Y H, Seow-Choen F, Leong A, Eu K W, Nyam D, Teoh M K. Randomised, controlled trial of low molecular weight heparin vs no deep vein thrombosis prophylaxis for major colon and rectal surgery in Asian patients.  Dis Colon Rectum . 1999;  42 196-202
  • 37 Inada K, Shirai N, Hayashi M, Matsumoto K, Hirose M. Postoperative deep venous thrombosis in Japan. Incidence and prophylaxis.  Am J Surg . 1983;  145 775-779
  • 38 Nandi P, Wong K P, Wei W I, Ngan H, Ong G B. Incidence of postoperative deep vein thrombosis in Hong Kong Chinese.  Br J Surg . 1980;  6 251-253
  • 39 Cunningham I GE, Yong N K. The incidence of postoperative deep vein thrombosis in Malaysia.  Br J Surg . 1974;  61 482-483
  • 40 Cheng K K, Lai S T, Yu T J, Kuo S M. Postoperative deep vein thrombosis in the Taiwanese Chinese population.  Am J Surg . 1987;  153 302-305
  • 41 Geerts W H, Heit J A, Clagget G P. et al . Sixth ACCP Consensus Conference on Antithrombotic Therapy. Prevention of venous thromboembolism.  Chest . 2001;  119(suppl) S132-S175
  • 42 Rodgers A, Walker N, Schug S. et al . Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials.  BMJ . 2000;  321 1493-1497
  • 43 Modig J, Hjelmstedt A, Sahlstedt B, Maripuu E. Comparative influences of epidural and general anaesthesia on deep vein thrombosis and pulmonary embolism after total hip replacement.  Acta Chir Scand . 1981;  147 125-130
  • 44 Agu O, Hamilton G, Baker D. Graduated compression stockings in the prevention of venous thromboembolism.  Br J Surg . 1999;  86 992-1004
  • 45 Sarin S, Scurr J H, Coleridge Smith D P. Mechanism of action of external compression on venous function.  Br J Surg . 1992;  79 499-502
  • 46 Jeffery P C, Nicolaides A N. Graduated compression stockings in the prevention of postoperative deep vein thrombosis.  Br J Surg . 1990;  77 380-383
  • 47 Willie-Jorgensen P, Thorup J, Fischer A. et al . Heparin with and without graded compression stockings in the prevention of thromboembolic complications of major abdominal surgery: a randomised trial.  Br J Surg . 1985;  72 579-581
  • 48 Porteous L MJ, Nicholson E A, Morris L T, James R, Negus D. Thigh length versus knee length stockings in the prevention of deep vein thrombosis.  Br J Surg . 1989;  76 296-297
  • 49 Byrne B. Deep vein thrombosis prophylaxis: the effectiveness and implications of using below-knee or thigh-length graduated compression stockings.  Heart Lung . 2001;  30 277-284
  • 50 Williams A M, Davies P R, Sweetnam D IS, Harper G, Pusey R, Lightowler C DR. Short note: knee-length versus thigh-length graduated compression stockings in the prevention of deep vein thrombosis.  Br J Surg . 1996;  83 1553
  • 51 Schwenk W, Bohm B, Junghans T, Hofmann H, Muller J M. Intermittent sequential compression of the lower limbs prevents venous stasis in laparoscopic and conventional colorectal surgery.  Dis Colon Rectum . 1997;  40 1056-1062
  • 52 Comerota A J, Chouhan V, Harada R N. et al . The fibrinolytic effects of intermittent pneumatic compression: mechanism of enhanced fibrinolysis.  Ann Surg . 1997;  226 306-314
  • 53 Westrich G H, Haas S B, Mosca P, Peterson M. Meta-analysis of thromboembolic prophylaxis after total knee arthroplasty.  J Bone Joint Surg . 2000;  82B 795-800
  • 54 Hull R D, Pineo G F. Intermittent pneumatic compression for the prevention of venous thromboembolism.  Chest . 1996;  109 6-9
  • 55 James K V, Sovolewski A B, Lohr J M, Welling R E. Tricuspid insufficiency after intracardiac migration of a Greenfield filter: case report and review of literature.  J Vasc Surg . 1996;  24 494-498
  • 56 Clagget G P, Brier D F, Roscoff C B, Schneider P B, Salzman E W. The effect of aspirin on postoperative platelet kinetics and venous thrombosis.  Surg Forum . 1974;  25 473-476
  • 57 Haas S B, Insall J N, Scuderi G R, Windsor R E, Ghelman B. Pneumatic sequential-compression boots compared with aspirin prophylaxis of deep vein thrombosis after total knee arthroplasty.  J Bone Joint Surg Am . 1989;  72 27-31
  • 58 Imperiale T F, Spenhoff T. A meta-analysis of methods to prevent venous-thromboembolism following total hip arthroplasty.  JAMA . 1994;  271 1780-1785
  • 59 Clagget G P, Reisch J S. Prevention of venous thromboembolism in general surgical patients. Results of meta-analysis.  Ann Surg . 1988;  208 227-240
  • 60 Hohl M K, Luscher K P, Tichy J. et al . Prevention of postoperative thromboembolism by dextran 70 or low-dose heparin.  Obstet Gynecol . 1980;  55 497-500
  • 61 Oertli D, Hess P, Durig M. et al . Prevention of deep vein thrombosis in patients with hip fractures: low molecular weight heparin versus dextran.  World J Surg . 1992;  16 980-984
  • 62 Brookenthal K L, Freedman K B, Lotke P A, Fitzgerald R H, Lonner J H. A meta-analysis of thromboembolic prophylaxis in total knee arthroplasty.  J Arthroplasty . 2001;  16 293-300
  • 63 Hirsh J, Warkentin T E, Raschke R. et al . Heparin and low-molecular-weight-heparin: mechanisms of action, pharmacokinetics, dosing consideration, monitoring, efficacy and safety.  Chest . 1998;  114(suppl) S489-S510
  • 64 Kakkar V V, Corrigan T P, Fossard D P. et al . Prevention of fatal postoperative pulmonary embolism by low doses of heparin: an international multicentre trial.  Lancet . 1975;  2 45-51
  • 65 Sagar S, Massey J, Sanderson J M. Low-dose heparin prophylaxis against fatal pulmonary embolism.  BMJ . 1975;  4 257-259
  • 66 Kiil J, Kiil J, Axelsen F. et al . Prophylaxis against postoperative pulmonary embolism and deep-vein thrombosis by low-dose heparin.  Lancet . 1978;  1(8074) 1115-1116
  • 67 Warkentin T E. Heparin induced skin lesions.  Br J Haematol . 1996;  92 494-497
  • 68 Litin S C, Heit J A, Mees K A. Use of low-molecular-weight heparin in the treatment of venous thromboembolic disease: answers to frequently asked questions.  Mayo Clin Proc . 1998;  73 545-551
  • 69 Kakkar V V, Boeckl O, Boneu B. et al . Efficacy and safety of a low-molecular weight heparin and standard unfractionated heparin for prophylaxis of postoperative venous thromboembolism: <~>European multicenter trial.  World J Surg . 1997;  21 2-8
  • 70 Kakkar V V, Cohen A T, Edmonson R A. et al . Low molecular weight versus standard heparin for prevention of venous thromboembolism after major abdominal surgery. The Thromboprophylaxis Collaborative Group.  Lancet . 1993;  341 259-265
  • 71 Mismetti P, Laporte S, Darmon J-Y, Buchmuller A, Decousus H. Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery.  Br J Surg . 2001;  88 913-930
  • 72 Koch A, Bouges S, Ziegler S, Dinkel H, Daures J P, Victor N. Low molecular weight heparin and unfractionated heparin in thrombosis prophylaxis after major surgical intervention: update of previous meta-analyses.  Br J Surg . 1997;  84 750-759
  • 73 McLeod R S, Geerts W H, Sniderman K W. et al . Subcutaneous heparin versus low-molecular-weight heparin as thromboprophylaxis in patients undergoing colorectal surgery. Results of the Canadian colorectal DVT prophylaxis trial: a randomised, double-blind trial.  Ann Surg . 2001;  233 438-444
  • 74 Bergqvist D, Matzsch T, Burmark U S. et al . Low molecular weight heparin given the evening before surgery compared with conventional low-dose heparin in prevention of thrombosis.  Br J Surg . 1988;  75 888-891
  • 75 Etchells E, McLeod R S, Geerts W, Barton P, Detsky A S. Economic analysis of low-dose heparin vs the low-molecular-weight heparin enoxaparin for prevention of VTE after colorectal surgery.  Arch Intern Med . 1999;  159 1221-1228
  • 76 Bergqvist D, Burmark U S, Flordal P A. et al . Low molecular weight heparin started before surgery as prophylaxis against deep vein thrombosis: 2500 versus 5000 Xal units in 2070 patients.  Br J Surg . 1995;  82 496-501
  • 77 Mamdani M M, Weingarten C M, Stevenson J G. Thromboembolic prophylaxis in moderate-risk patients undergoing elective abdominal surgery: decision and cost-effectiveness analyses.  Pharmacotherapy . 1996;  16 1111-1127
  • 78 Hull R D, Brant R F, Pineo G F, Stein P D, Raskob G E, Valentine K A. Preoperative vs postoperative initiation of low-molecular-weight heparin prophylaxis against venous thromboembolism in patients undergoing elective hip replacement.  Arch Intern Med . 1999;  159 137-141
  • 79 Lausen I, Jensen R, Jorgensen L N. et al . Incidence and prevention of deep venous thrombosis occurring late after general surgery: randomised controlled study of prolonged thromboprophylaxis.  Eur J Surg . 1998;  164 657-663
  • 80 Bergqvist D, Giancarlo A, Alexander T. et al . Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer.  N Eng J Med . 2002;  346 975-980