DVT Deep venous thrombosis((

By

Dr- Hayam M. AL-moutary

Supervised by

Dr-Abdulla AL-goblain

Content Epidemiology Symptom& signRisk factorDeferential diagnosisDiagnosisManagement

DVT

• the formation of a thrombus in the deep veins of the leg

• Virchow triad venous stasisvessel wall injuryhypercoagulable state

Epidemiology DVTs occur in about 1 per 1000 persons per

year.100,000 deaths may be directly or indirectly

related to these diseases• In pregnant women, it has an incidence of 0.5

to 7 per 1,000 pregnancies, and is the second most common cause of maternal death in developed countries after bleeding

•Journal of Internal Medicine volume 232 Issue 2, Pages 155 - 160•

Risk factor

– General • Age • Immobilization longer

than 3 days • Pregnancy and the

postpartum period • Major surgery in previous

4 weeks • Long plane or car trips (>4

h) in previous 4 weeks

– Medical • Cancer • Previous DVT • Stroke• Sepsis • Nephrotic syndrome • Ulcerative colitis• SLE• Protein c & s deficiency• Obesity

Risk factor

– Trauma

Multiple trauma

– Drugs/medications

OCP

• In a five-year case-control study (1988 to 1993) at Assir Central Hospital (ACH), Abha (8,000 feet above sea level), Saudi Arabia, 92 of 129 patients suspected of deep venous thrombosis (DVT) were studied with ascending contrast venography (CV) (74 patients, 80.4%) or Doppler ultrasonography (DUS) (18 patients, 19.6%). Female-to-male ratio was 2.3 to 1. Age range of patients was twelve to ninety years; mean age was 44.45 yrs ±17.38

years. DVT hospital incidence was 18 per 10,000 admissions

Angiology, Vol. 46, No. 12, 1107-1113 (1995)

http://ang.sagepub.com/cgi/content/abstract/46/12/1107

Most risk factor

• chronic diseases (21.7%),

• trauma and surgery (19.6%),

• pregnancy and oral contraceptives usage (16.3%).

most symptom and sign

• tenderness (95.6%)• Limb swelling was noted

in 93.5% of patients.• Pulmonary embolism

was the greatest complication

clinical feature

swelling, principally unilateral, Leg pain occurs in 50% of patientsSOB Clinical signs and symptoms of PE as the

primary manifestation occur in 10% of patients with confirmed DVT

In patients with angiographically proven PE, DVT is found in 45-70%.

clinical feature

• Unilateral edema• Leg tenderness• Redness, hotness• Bluish discoloration• Absent or decrease pulse

Clinical feature Phlegmasia cerulea

dolens leg is cyanotic from

massive ileofemoral venous obstruction. The leg is usually

markedly edematous, painful, and cyanotic. Petechiae are often present.

Phlegmasia alba dolens Painful white inflammation

was originally used to describe massive ileofemoral venous thrombosis and associated arterial spasm. The affected extremity is often pale with poor or even absent distal pulses

Phlegmasia cerulea dolens

Clinical feature • Superficial thrombophlebitis is characterized by the

finding of a palpable, indurate, cordlike, tender, subcutaneous venous segment.

• 40% of patients with superficial thrombophlebitis without coexisting varicose veins and with no other obvious etiology (eg, intravenous catheters, intravenous drug abuse, soft tissue injury) have an associated DVT

DVT

Deferential diagnosis

• Cellulitis, lymphangitis• Lymphedema• Postphlebitic syndrome• Ruptured Baker cyst• Varicose veins• Superfical thrombophlibitis

)Diagnosis ( work upHistoryPhysical examination(work up)Probablity scoring (well score)Blood test D-dimarOther blood testImaging studyMRI , U/S , venography

Physical examination

• Homans' test Dorsiflexion of foot elicits pain in posterior calf. Warning: it must be noted that it is of little diagnostic value and is theoretically dangerous because of the possibility of dislodgement of loose clot.

• Pratt's sign: Squeezing of posterior calf elicits pain.

• back

)wells score) Clinical Parameter Score Score

Active cancer (treatment ongoing, or within 6 mo or palliative)

+1

Paralysis or recent plaster immobilization of the lower extremities

+1

Recently bedridden for >3 d or major surgery <4 wk +1

Localized tenderness along the distribution of the deep venous system

+1

Calf swelling >3 cm compared with the asymptomatic leg

+1

Pitting edema (greater in the symptomatic leg) +1

Previous DVT documented +1

Collateral superficial veins (nonvaricose) +1

Alternative diagnosis (as likely or greater than that of DVT)

-2

Total of Above Score

High probability <3

Moderate probability 1 or 2

Low probability >0

Wells score

case

35 year old female recently pregnant, now on OCP, complain of 1 week unilateral right leg swelling , no history of trauma, she has DVT history 2year ago

On P/E

her right calf is 5 cm greater in circumference than her left and there is tenderness when squeeze the gastroncemius muscle.

Blood test

• complete blood count• Primary coagulation studies: PT, APTT, INR• renal function test and electrolytes• liver function test

investigation

• D-dimer testing • D-dimer antibodies account for their high sensitivity for

venous thrombo embolism.

• D-dimer level may be elevated in any medical condition where clots form. D-dimer level is elevated in trauma, recent surgery, hemorrhage, cancer, and sepsis.

• The D-dimer assays have low specificity for DVT; therefore,

they should only be used to rule out DVT, not to confirm the diagnosis of DVT.

• D-dimer results should be used as follows:

– A negative D-dimer assay result rules out DVT in patients with low-to-moderate risk and a Wells DVT score less than 2.

– All patients with a positive D-dimer assay result and all patients with a moderate-to-high risk of DVT (Wells DVT score >2) require a diagnostic study (duplex ultrasonography).

Duplex ultrasonography

• Technological advances in ultrasonography have permitted the combination of real-time ultrasonographic imaging with Doppler flow studies (duplex ultrasonography).

• The absence of the normal phasic Doppler signals arising from the changes to venous flow provides indirect evidence of venous occlusion

Duplex ultrasonography

Duplex ultrasonography

A dvantage A dvantage

helpful to differentiate venous thrombosis from hematoma, Baker cyst, abscess, and other causes of leg pain and edema.

helpful to differentiate venous thrombosis from hematoma, Baker cyst, abscess, and other causes of leg pain and edema.

Disadvantage Disadvantage

Venous thrombi proximal to the inguinal ligament are also difficult to visualize

Nonoccluding thrombi not be able to differentiate

between old and new clots

Venous thrombi proximal to the inguinal ligament are also difficult to visualize

Nonoccluding thrombi not be able to differentiate

between old and new clots

MRI

– In the second and third trimester of pregnancy, MRI is more accurate than duplex ultrasonography because the gravid uterus alters Doppler venous flow characteristics.

– In suspected calf vein thrombosis, MRI is more sensitive than any other noninvasive study.

MRI

• Disadvantage Expansivelack of general availability technical issues limit its use

CT venography(gold stander(

• The gold standard is intravenous venography, which involves injecting a peripheral vein of the affected limb with a contrast agent and taking CT, to reveal whether the venous supply has been obstructed. Because of its invasiveness, this test is rarely performed

CT venography(gold stander(

• A number of small studies have compared CT venography alone to duplex ultrasonography alone for the diagnosis of lower extremity DVT.

• Similar high sensitivities for ultrasonography and CT have been reported, but no large trials comparing the two have yet been performed

CT venography(gold stander(• Disadvantage visualized veins, artifactual interference from metal

implants such as hip and knee arthroplasties . contraindications to the administration of contrast

dye.

Bilatral thrombosis

High clinical pretest probability- DVT likely

Doppler ultrasound

Ultrasound positive for DVTDiagnoses of DVT confirmed

Begin treatment

Ultrasound negative for DVT

D-Dmer test (if available and reliable(Otherwise skip

to repeat ultrasound

D-Dimer positive Repeatultrasound in 1 week

D-Dimer negativeDVT ruled out

Repeat ultrasound positive for DVTDiagnoses of DVT confirmed

Begin treatment

Suspect DVT

Low clinical pretest probability- DVT likely

Consider starting with D-dimer test first

(if available and reliable (Or skip to ultrasound

D-dimer positiveD-Dimer negative

DVT ruled out

Doppler ultrasound

Ultrasound positive for DVTDiagnose of DVT confirmed

Begin treatment

Ultrasound negative for DVT

DVT ruled out (consider repeat

ultrasound if D-dimer not available(

Complications of deep vein thrombosis

• There are two main complications of deep vein thrombosis (DVT):

• pulmonary embolism • post-thrombotic syndrome• occurs in 15% of patients with deep vein thrombosis

(DVT). It presents with leg oedema, pain, nocturnal cramping, venous claudication, skin pigmentation, dermatitis and ulceratiaion (usually on the medial aspect of the lower leg).

management

• Non-pharmcological • we can reduce risk of DVT by making changes to patient

lifestyle, such as:• avoid smoking • eating a healthy balanced diet • getting regular exercise and • maintaining a healthy weight or losing weight if patient obese• Rise leg , This reduces the pressure in the calf veins

Travelling

• drink enough amount of water • avoid taking sleeping pills as it can cause immobility• perform simple leg exercises, such as regularly

flexing ankles• take occasional short walks when possible• wear elastic compression stockings

Compression stockings • Elastic compression stockings should be routinely applied

"beginning within 1 month of diagnosis of proximal DVT and continuing for a minimum of 1 year after diagnosis

• Most trials used knee-high stockings. A meta-analysis of randomized controlled trials by the Cochrane Collaboration showed reduced incidence of post-phlebitic syndrome.

• •

Treatment The current guidelines recommend short-term

anticoagulation with LMWH SC , unfractionated heparin SC , (Grade 1A),

should continue for at least 5 days and until the INR is >2 for 24 hours (Grade 1C).

Warfarin 5 mg PO daily is overlapped with heparin for 4-5 days until the international normalized ratio (INR) is therapeutically elevated to 2-3.

For the first episode of DVT, patients should be treated for 3-6 months. Recurrent episodes should be treated for at least 1 year

[Guideline] American Academy of Family Physicians

The current guidelines recommend short-term anticoagulation with LMWH SC , unfractionated heparin SC , (Grade 1A),

should continue for at least 5 days and until the INR is >2 for 24 hours (Grade 1C).

Warfarin 5 mg PO daily is overlapped with heparin for 4-5 days until the international normalized ratio (INR) is therapeutically elevated to 2-3.

For the first episode of DVT, patients should be treated for 3-6 months. Recurrent episodes should be treated for at least 1 year

[Guideline] American Academy of Family Physicians

Treatment • A protocol for IV heparin use is as follows:

Give an initial bolus of 80 U/kgInitiate a constant maintenance infusion of 18

U/kg. Check the aPTT or Heparin Activity level 6

hours Continue to check the aPTT until 2 successive

values are therapeutic.

• A protocol for IV heparin use is as follows:

Give an initial bolus of 80 U/kgInitiate a constant maintenance infusion of 18

U/kg. Check the aPTT or Heparin Activity level 6

hours Continue to check the aPTT until 2 successive

values are therapeutic.

Mangment Heparin side effect

• heparin-induced thrombocytopenia (HIT).

• elevation of serum aminotransferase levels

• Hyperkalemia• alopecia and osteoporosis

can occur with chronic use.

Werfarin side effect

• Hemorrhage • Werfarin necrosis • Osteoporosis• Purple toe syndrome

Filters for DVT

• indications for filter placement are • (1) severe hemorrhagic complications on

anticoagulant therapy or other absolute contraindications to anticoagulation

• (2) failure of anticoagulant therapy, such as new or recurrent venous thrombosis

Surgery for DVT • Indication anticoagulant therapy is ineffectiveUnsafeContraindication The major surgical procedures for DVT are

clot removal and partial interruption of the inferior vena cava to prevent PE

Treatment in pregnancy

• The treatment of DVT in pregnancy is similar to the treatment of non pregnant.

• Heparin SC or small pump infusion • avoid warfarin in pregnancy If warfarin therapy is

essential, it should be avoided at least during the first trimester (because of teratogenicity) and from about 2 to 4 weeks before delivery to reduce risk of hemorrhagic complications

• Compression stockings

Prevention

• Prophylaxis for DVT is required in all patients with risk factors. DVT prophylaxis for patients scheduled to undergo major surgery is well recognized.

• Recently, a large multicenter double-blind placebo-controlled trial showed that a single subcutaneous 40-mg daily dose of enoxaparin achieved a 63% reduction in the incidence of DVT/PE in general medical patients admitted to the hospital.

Prevention

• In the Women's Health Study, supplementation with vitamin E (alpha-tocopherol, 600 IU every other day) reduced the risk of venous thrombo embolism in women, especially those with a prior history or genetic predisposition.

• High-risk patients should also be prescribed a single prophylactic subcutaneous 40 mg dose of enoxaparin prior to a long plane trip (>6 h).

Summary

• If deal with risk factor early can be prevent DVT• Early detect & diagnosis prevent fetal complication• DVT is 2nd cause of death in pregnancy• wells score& D-dimar and use of U/S can diagnosis

DVT• PE& post thrombatic syndrom most common

complication

Reference E medicineAmerican family physiciansCanadian family physiciansRakel essential family medicineOxford handbook of clinical medicineSwansons family medicine review

workshop

• CALCULATE:• Control events rate• Experimental event rate• RRR(Relative Risk Reduction)• ARR (Absolute Risk Reduction)• RR (Relative Risk)• NNT(Number needed to treatment)• Comments on the curves