Thrombosis, one of the biggest risks in surgery. Do you know what thrombosis is? I am Dr. Fernando Amato, I am a plastic surgeon here at Instituto
Amato and today I'm going to talk about deep vein thrombosis. Many people talk about the risks of plastic surgery, some people don't have surgery because they are afraid something might happen during the surgery, but one of the biggest risks, one of the biggest problems that can happen in surgery is not during the surgery, it's afterwards in the postoperative period, how this postoperative period is managed is thrombosis. What is thrombosis? And why is it so risky?

Why is it so feared by patients and doctors, by surgeons?

Thrombosis is a blockage of a vessel, that is, the vessel that circulates blood, right? The vein brings blood back to the heart, and a vein can become blocked, forming a clot, right? And this clot will hinder blood drainage, right? Blood won't circulate as well, and this clot can break off and go to the lung, causing a pulmonary embolism. In the case of a pulmonary embolism, the vessel blockage prevents blood circulation in the lung, which compromises oxygenation. The body cannot survive without oxygen, and that is why thrombosis is so feared, due to the risk of pulmonary embolism, when the clot detaches and goes to the vessels that carry blood to the lung.

So this is the big risk of surgery or it can even happen without surgery, some people have risk factors. Some people travel by plane and can get thrombosis, but in surgery, which is what we want to talk about now, about surgery, what I fear most in surgery is thrombosis, because it doesn't happen during surgery, the problem is not intraoperatively, the problem is postoperatively. Clot formation usually begins to manifest around one week, ten days.

What can be done to prevent thrombosis?

This is the goal of this video, this serious problem that can compromise surgery, especially plastic surgery. Undoubtedly, many things intraoperatively make a difference. It starts with surgical planning. 

So, surgical time is one of the main factors in the risk of developing thrombosis. Why time? Because the patient remains immobile when anesthetized and blood doesn't circulate, so the fact that blood remains stagnant increases the chance of thrombosis forming and evolving into thrombosis. So this surgical time is very important. The extent of the surgery, right? 

How much area we are operating on in liposuction, abdominoplasty, breast surgery, is also important because it increases the patient's inflammatory state during and after surgery, also favoring thrombus formation and also making early ambulation difficult for the patient. What is ambulation, right? To ambulate is for the patient to simply walk, and why is this important in a postoperative period? A patient who can walk, can move their foot, right? In a way that there is something called a plantar pump, that is, the foot makes this movement on the ground, facilitating the blood to return, for the blood to circulate in the leg, preventing thrombus formation, right? Early ambulation is very important. 

High risk of thrombosis

So, patients undergoing medical surgeries, for example, and who have limited mobility, are also at high risk of thrombosis, therefore, doctors perform prophylaxis to prevent thrombosis. So, we have already talked about surgical time, surgical extent, and the need for early ambulation. Intraoperatively, we can use compression stockings and leave them on postoperatively, because compression stockings prevent blood from stagnating, so the patient lying down with an anti-thrombus stocking, right? They even have this name: anti-thrombus, they make it difficult for blood to stagnate and form a thrombus. 

So, anti-thrombus stockings are a simple and fundamental measure in surgery that has a higher risk of thrombus formation. Also in surgery, it is possible, when we foresee, when we plan and know that the surgery will take longer, we can use a pneumatic boot. And what is this pneumatic boot?

Pneumatic boot

The pneumatic boot, it is a boot that inflates and deflates to make this movement in the leg, so this facilitates blood circulation in the leg while the patient is still during surgery and sometimes it is even possible to leave this pneumatic boot in the postoperative period when the patient is in the room, when she has not started walking, precisely to keep the blood moving. Many times the patient can even do physical therapy in the postoperative period precisely to move the foot, some movements with the foot even if the patient cannot walk help and facilitate blood circulation. So we have already mentioned some very important measures and there are the pharmacological measures, right? There are heparins, right?

Which have been used for a long time, low molecular weight heparin is widely known, with the trade name Clexane, but there are others, aren't there? 

And their advantage is that they have an effect, leaving the blood with less chance of forming clots, there is also the disadvantage of heparin that it needs to be injectable, patients have a lot of difficulty with this because sometimes they are afraid to give the injection at home, they don't have help, they are afraid, this is a patient difficulty, but it is important.

Advantages of using Clexane

I personally prefer Clexane over oral medications, because heparins have an anti-inflammatory effect on the vessel, I believe they have a greater advantage, but there are super modern medications that can be used orally, but they are not well approved for prophylaxis, they are often for anticoagulation, or rather, someone who has already had thrombosis, they can use these oral medications, so there is a certain difficulty for us as plastic surgeons, right?

They are not approved for plastic procedures, because the cases that did studies had more complications such as hematoma, so it's a risk that when we start using these medications, we evaluate the risk of using this medication, so it doesn't apply to all patients and needs to be discussed with the doctor, to see if it's worth it in that case, if there will be a limitation of movement and how long this medication will be used. 

I think it's important that there are other measures that can be taken, I think hydration in the preoperative period is also important, which the anesthesiologist can also do intraoperatively, preoperatively when admitted, intraoperatively, this also makes the blood more fluid and has less chance of forming clots. So, these are the main ways to prevent thrombus formation. It's worth remembering that thrombosis is not only in the legs, it can happen in any vessel and therefore can be in the arm, so suddenly there is a local compression, someone leaning on the patient's arm, this would also be a risk. 

Who is at higher risk, right?

And we need to know this, if the patient has a personal history, has already had thrombosis, if this patient has a family history, sometimes there may be a genetic issue and a higher risk of thrombosis formation, there are patients who use hormones, some hormone replacement or even contraceptives can increase the risk of thrombosis, those who have some cancer, right? A neoplasm, obesity. So, there are several conditions that we can use as criteria to even indicate prophylaxis, right, prevention with the use of these medications or these other measures that I have already mentioned.

So, basically what I wanted to bring to you is exactly this, this topic of thrombosis, deep vein thrombosis, pulmonary thromboembolism. If something wasn't clear here, please leave a comment, you can ask your questions, you can tell your story if you want, but please like and subscribe to the channel and please share with someone who is going to have surgery and is afraid of surgery.

Thank you very much!