EXPERT OPINION
Meet the Expert Javad Parvizi MD FRCS
Hospital Pharmacy Europe had the pleasure of speaking with Dr Javad Parvizi , James Edward Professor of Orthopaedic Surgery at the Sidney Kimmel School of Medicine and Rothman Institute in Philadelphia , US . He shares his perceptions and thoughts on the recently published international consensus meeting recommendations on venous thromboembolism and how they could impact clinical care
Q Please tell us about your background and institution ?
A Dr Parvizi originally trained for four years to be cardiovascular surgeon before moving to the US to undertake research on blood flow based in an orthopaedics laboratory . He later took up a residency in orthopaedics at the Mayo Clinic before finally moving to Philadelphia , where he has been since 2003 . The Rothman Institute is part of Thomas Jefferson University and one of the largest orthopaedic practices in the world , employing over 300 physicians and surgeons . According to Dr Parvizi , this busy department ‘ performs approximately 20,000 joint replacements every year ’.
Q What exactly is a DVT and how common is it ?
A As Dr Parvizi explained , ‘ a DVT is a deep vein thrombosis and is a clotting problem that occurs in people ’ s veins and blocks the vein .’ He added that ‘ sometimes a clot in the lungs can stop people from breathing , leading to a fatal outcome ’. As he continued , ‘ both a DVT and pulmonary embolism or collectively , a venous thromboembolism ( VTE ), are potentially life-threatening conditions if not treated or prevented .’
Dr Parvizi discussed how ‘ most VTEs happen after surgical procedures but a VTE can be an unprovoked occurrence , for instance , through air travel , sitting for a long period of time or even out of the blue ’. Although there is always a risk of developing a DVT after a surgical procedure , Dr Parvizi added that current thinking suggested that some patients have a genetic predisposition to develop a VTE .
Q How high is the risk of developing a VTE among surgical patients ?
A According to Dr Parvizi , the risk of developing a VTE after an orthopaedic procedure ( even when accounting for other risk factors ) is variable . There are two types of VTE : one below the knee ( a distal DVT ); and a proximal DVT , which occurs above the knee , and which is associated with a greater risk to a patient . Dr Parvizi felt that distal DVTs are common , suggesting that these can occur ‘ in
The economic impact of a chronic DVT is significant , as patients require long-term treatment , which might include hospitalisation as well as chronic use of anticoagulants
10 % – 15 % of cases after a joint replacement ’ but , fortunately , as he explained , ‘ these are all self-limiting , non-significant events .’ In fact , Dr Parvizi noted how in many cases , both clinicians and patients would be unaware that a DVT occurred and that distal DVTs invariably resolve over time . Nevertheless , the development of a pulmonary embolism ( PE ) is a much more serious complication , but thankfully the rate at which these develop is much lower . Dr Parvizi estimated that a PE might occur at a rate of ‘ perhaps 0.5 % or even lower , although the rate of a fatal PE is even lower , perhaps 1 in 1000 , although the literature suggests that the actual incidence might be lower still , at 1 in 4000 ’.
Q What is the patient burden of a VTE ?
A In most cases where a patient develops a distal DVT after surgery , Dr Parvizi described this as a benign event that commonly resolves without any lasting problems . In contrast , a chronic VTE is more problematic and could lead to postphlebitic syndrome , where there is a blockage of the veins in the legs . As he explained , postphlebitic syndrome can result in ‘ chronic swelling , and chronic ulcerations for a patient .’ However , he ventured that perhaps the most important reason to assess whether a patient had a DVT was to prevent the formation of a PE . Although there is a widely held belief in the mechanical propagation theory , i . e ., where a DVT literally travels from distal veins to the pulmonary circulation , Dr Parvizi said that recent work has questioned this theory and that now ‘ we think that a DVT doesn ’ t really travel to the lungs but that a PE and DVT can develop at the same time , in a patient who is in a hypercoagulable state .’
Q What about the healthcare and economic burden of chronic DVT ?
A Dr Parvizi explained how the economic impact of a chronic DVT is significant , as patients require long-term treatment , which might include hospitalisation as well as chronic use of anticoagulants . As he explained , a DVT is more likely to become
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