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DEEP VEIN THROMBOSIS

FAIZAL DRISSA HASIBUAN

BAGIAN PENYAKIT DALAMFK UNIVERSITAS YARSI

JAKARTA 2011

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DEEP VEINTHROMBOSIS

(DVT):

Terminology andClinical Manifestation

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DVT (1)

Terminology:- thrombus which occurs in the deep vein system

- a part of venous thrombosis ( VT ) or venous

thromboembolism ( VTE ) Sites:- VT/VTE in all venous system: upper &

lower extremities, renal, mesenterical, splenchnic ,

portal, cerebral veins, etc

- DVT indicated to deep veins of the lowerextremities & pelvic vein

Superficial thrombophlebitis / superficial venous

thrombosis >< DVT

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DVT in the LEGS vs

Superficial VT

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DVT (2) In general:

- predilection sites : at the calf veins(posterior tibial vein / peroneus vein)

- rarely: anterior tibial vein

- extended to the proximal veins

ascending thrombosis

In certain cases(e.g. pregnancy, tumor)

- more proximal: external iliac veins

& common iliac veins

- more distal = descending thrombosis

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>>>

pos

ttib

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Symptoms or /

and signs (+)

=

SYMPTOMATIC

DVT

Symptoms or /

and signs (-)

=

ASYMPTOMATIC

DVT

ACUTE DVT

COMPLICATIONS of the LOWER

EXTREMITIES VEINS

Permanently venous damagesVenous valve insuficiency

Post-phlebitic / thrombotic

syndrome

COMPLICATIONS of the LUNG &

HEART VASCULARIZATIONS:

Pulmonary Embolism (PE)

Chronic Thromboembolic

Pulmonal Hypertension (CTEPH)

LOCAL CHRONIC

Consequences :

CHRONIC DVT

DVT

Distance Acute

/ ChronicConsequences:

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ACUTE DVT :

SYMPTOMATIC & ASYMPTOMATIC DVT

SYMPTOMATIC DVT:

- pain and edema in the upright position

> obvious than in the bedridden position

ASYMPTOMATIC:

- occurs more prominent in bedridden

patients:- especially post surgical period

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RECURRENT DVT

ASYMPTOMATIC DVT:recurrent DVT in week 1 no symptoms

or signs appear

SYMPTOMATIC DVT:

- recurrent DVT in patients on warfarin

- may be divided into two groups:

* those who are with non-adequate anti

coagulant dosages

* those who are with cancers

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POST PHLEBITIC SYNDROME = PPS

PPS-mild : mild edema of the lower limb(15-30%) mild skin manifestation

(hyperpigmentation)

PPS-severe: edema of the lower extremity

(5-10 %) pain

skin ulceration

510 years after acute DVT

Increased incidence of CVI = increased age

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Post Thrombotic Syndrome

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Pathogenesis of Thromboembolism

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VENOUS VALVES

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DVT:DIAGNOSIS and

DIFFERENTIALDIAGNOSIS

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Diagnosis of DVT

1. History of illness: Symptoms (+) or (-)

Risk Factors: Medical & Surgery2. Physical examination:

Pitting edema of the leg

Pain

No clear signs or symptoms(subocc lus ive thrombus)

3. Laboratory & Radioimaging examinations:

D-dimer

Veno/Phlebo-graphy (Gold Standard) Compression/ Dupplex ultrasonography

(9697 %) for sympt. Prox. DVT

Duplex scan

Im edance Pleth smo ra h

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CAUSES of EDEMA of the LOW

EXTREMITIES (differential diagnosis)

ACUTE EDEMA CHRONIC EDEMA

Deep vein thrombosis (DVT) Venous abnormalities:

Superficial Thrombophlebitis - post thrombotic syndrome/

Cellulitis post phlebitic syndrome

Joint effusion/Haemarthrosis - chronic vein insufisiency

Fractures - lipodermatosclerosis

Arthritis - venous obstruction / suppression

Dermatitis Lymphedema: - tumors

- infections

- trauma, dll

Diseases : - hemangioma

- congenital

Others: = heart failure

- idiopathic edema in women

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DIAGNOSTIC APPROACH

ofDVT

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The WELLS SCORE for patients

clinically SUSPECTED DVTWells clinical prediction score for DVT Points

Cancer + 1

Paralysis or recent immobilization + 1

Bedridden > 3 days, or surgery / trauma < 4 weeks + 1

Pain or palpitation of the deep veins + 1

Edema of thigh and calf + 1

Pitting edema (symptomatic side only) + 1

Alternative diagnosis as least as likely DVT - 2

Clinically probability:

Low 0

Intermediate 1 - 2

High 3

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Algorithm for the diagnosis workup of suspected DVT

Clinical probability of DVT

Low Intermediate High

Sensitive or less sensitive

D-dimer (DD)

Sensitive DD

Negative

No Th/

Positive

CUS

Negative

No Th/

Positive

CUS CUS

No DVT

No Th/DVT

Th/

No DVT

No Th/

DVT

Th/

No DVT

phlebography

DVT

Th/

(Colman RW)

CUS = compression

ultrasonography

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MANAGEMENT of DVT

A. Acute Treatment of DVT

B. Duration of Anticoagulant Administration

to prevent recurrent DVT (localized DVT)

to prevent acute distant consequences (PE)

to prevent chronic local consequences:

- venous valve damage / destruction

- chronic valve insufficiency (CVI)

- Post thrombotic / Post phlebitic syndrome

(PTS / PPS)

C. Treatment of Underlying Causes (Risk/ Trigger Factors)

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MANAGEMENT of DVT

1. General Measures:- elevation of the feet

- compression with elastic stocking

& intermittent pneumatic compression

- early mobilization

2. Medications:

a. Heparin: UF-heparin or LMWH

b. Warfarin (oral anticoagulant)c. Fibrinolytic agents

c. Others

3. Surgery:in recurrent / chronic DVT

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MEDICATIONS for DVT

Other anticoagulants:

- Direct thrombin inhibitors:

- Hirudin & Hirulog

- Argatroban- Melagatran

- Factor X inhibitors:

- Direct inhibitors of Factor Xa

- Activated Protein C &Soluble Trombomodulin

- Tissue Factor Pathway Inhibitor

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Right

Ileofemoral

DVT

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