G.R. MEDICAL COLLEGE G.R. MEDICAL COLLEGE DEPARTMENT OF DEPARTMENT OF

SURGERY SURGERY SEMINAR PRESENTATIONSEMINAR PRESENTATION

DEEP VENOUS THROMBOSISDEEP VENOUS THROMBOSIS

Guide:Guide: By: By:Prof. Dr. Achal Gupta Prof. Dr. Achal Gupta (M.S., DNB)(M.S., DNB) Dr Dr

Nikhil ChopraNikhil Chopra

HOD HOD 2 2ndnd yr yr PG PG StudentStudent

Definition Definition

• Deep vein thrombosis is the formation of Deep vein thrombosis is the formation of a blood clot in one of the deep veins of the a blood clot in one of the deep veins of the body, usually in the legbody, usually in the leg

• IncidenceIncidence: Indian population< Western population: Indian population< Western population• Around 2.7 per 1000 person-days of hospital stay with Around 2.7 per 1000 person-days of hospital stay with

50% hospitalised population at risk.50% hospitalised population at risk.• Ref: Sharma et al, Indian J med Dec 2009Ref: Sharma et al, Indian J med Dec 2009

ETIOLOGY ETIOLOGY DVT usually originates in the lower extremity DVT usually originates in the lower extremity

venous level ,starting at the calf vein level and venous level ,starting at the calf vein level and progressing proximally to involve progressing proximally to involve popliteal ,femoral ,or iliac system. popliteal ,femoral ,or iliac system.

80 -90 % pulmonary emboli originates here . 80 -90 % pulmonary emboli originates here .

Virchow triad Virchow triad

Virchow described a triad of factors of Virchow described a triad of factors of

a.a. Venous stasis, Venous stasis,

b.b. Endothelial damage, andEndothelial damage, and

c.c. Hypercoagulable stateHypercoagulable state

Venous stasis Venous stasis Prolonged bed rest (4 days or more) Prolonged bed rest (4 days or more) A cast on the leg A cast on the leg Limb paralysis from stroke or spinal cord injury Limb paralysis from stroke or spinal cord injury extended travel in a vehicleextended travel in a vehicle

Hypercoagulability Hypercoagulability Surgery and traumaSurgery and trauma Malignancy Malignancy Increased estrogenIncreased estrogen

Disorders of coagulation Disorders of coagulation

InheritedInherited Deficiencies of Deficiencies of

1.1. Protein ‘S,Protein ‘S,

2.2. Protein ‘C,’ andProtein ‘C,’ and

3.3. Antithrombin IIIAntithrombin III

AcquiredAcquireda.a. Nephrotic syndromeNephrotic syndrome

b.b. Antiphospholipid antibodiesAntiphospholipid antibodies

c.c. Inflammatory processes such as SLE, Sickle cell disease Inflammatory processes such as SLE, Sickle cell disease and IBDand IBD

Presentation and Physical Presentation and Physical Examination Examination

Calf pain/tendernessCalf pain/tenderness Swelling with pitting oedema Swelling with pitting oedema Increased skin temperature Increased skin temperature Superficial venous dilatation Superficial venous dilatation Assess limb perfusion. Assess limb perfusion. Detect acute arthritis/joint pathology. Detect acute arthritis/joint pathology. Neurologic evaluation Neurologic evaluation Homans'’ signHomans'’ sign

Wells Clinical Prediction Wells Clinical Prediction GuideGuide

Active cancer (treatment ongoing, or Active cancer (treatment ongoing, or within 6 months or palliative) = +1within 6 months or palliative) = +1

Paralysis or recent immobilization = +1Paralysis or recent immobilization = +1 Recently bedridden for >3 days or major Recently bedridden for >3 days or major

surgery <4 weeks = +1surgery <4 weeks = +1

Localized tenderness along the distribution of the Localized tenderness along the distribution of the deep venous system = +1deep venous system = +1

Entire leg swelling = +1Entire leg swelling = +1 Calf swelling >3 cm compared to the Calf swelling >3 cm compared to the

asymptomatic leg = +1asymptomatic leg = +1 Pitting edema (greater in the symptomatic leg) = Pitting edema (greater in the symptomatic leg) =

+1+1 Collateral superficial veins (nonvaricose) = +1Collateral superficial veins (nonvaricose) = +1 Alternative diagnosis (as likely or > that of DVT)= Alternative diagnosis (as likely or > that of DVT)=

-2-2

Total of Above ScoreTotal of Above Score

High probability: Score 3High probability: Score 3Moderate probability: Score = 1 or 2Moderate probability: Score = 1 or 2Low probability: Score 0 Low probability: Score 0

Diagnostic Studies Diagnostic Studies

Clinical examination alone is able to Clinical examination alone is able to confirm only 20-30% of cases of DVT confirm only 20-30% of cases of DVT

Blood Tests Blood Tests the D-dimerthe D-dimer INR. INR.

D-dimer D-dimer D-dimer is a specific degradation product of D-dimer is a specific degradation product of

cross-linked fibrin. Because concurrent cross-linked fibrin. Because concurrent production and breakdown of clot characterize production and breakdown of clot characterize thrombosis, patients with thromboembolic thrombosis, patients with thromboembolic disease have elevated levels of D-dimer disease have elevated levels of D-dimer

Three major approaches for measuring D-dimer Three major approaches for measuring D-dimer ELISA ELISA Latex agglutination Latex agglutination Blood agglutination testBlood agglutination test

False-positive D-dimers occur in patients withFalse-positive D-dimers occur in patients with recent (within 10 days) surgery or trauma,recent (within 10 days) surgery or trauma, recent myocardial infarction or stroke,recent myocardial infarction or stroke, acute infection,acute infection, disseminated intravascular coagulation,disseminated intravascular coagulation, pregnancy or recent delivery, pregnancy or recent delivery, active collagen vascular disease, or metastatic active collagen vascular disease, or metastatic

cancer cancer

Imaging Studies Imaging Studies InvasiveInvasive venography, venography, radiolabeled fibrinogen and.radiolabeled fibrinogen and. Noninvasive Noninvasive ultrasound, ultrasound, MRI techniques MRI techniques

VenographyVenography

Gold standard” modality for the diagnosis of DVT Gold standard” modality for the diagnosis of DVT

Nuclear Medicine Studies Nuclear Medicine Studies Can distinguish new clot fromCan distinguish new clot from an old clot an old clot

Ultrasonography Ultrasonography

Color-flow Duplex scanning is the imaging test of Color-flow Duplex scanning is the imaging test of choice for patients with suspected DVT choice for patients with suspected DVT

inexpensive,inexpensive, noninvasive, noninvasive, widely available widely available Ultrasound can also distinguish other causes of Ultrasound can also distinguish other causes of

leg swelling, such as tumor, popliteal cyst, leg swelling, such as tumor, popliteal cyst, abscess, aneurysm, or hematoma.     abscess, aneurysm, or hematoma.     

Clinical limitations Clinical limitations

expensive expensive reader dependent reader dependent Duplex scans are less likely to detect non-Duplex scans are less likely to detect non-

occluding thrombi. occluding thrombi. During the second half of pregnancy, ultrasound During the second half of pregnancy, ultrasound

becomes less specific, because the gravid uterus becomes less specific, because the gravid uterus compresses the inferior vena cava, thereby compresses the inferior vena cava, thereby changing Doppler flow in the lower extremities changing Doppler flow in the lower extremities

Magnetic Resonance Imaging Magnetic Resonance Imaging

It detects leg, pelvis, and pulmonary thrombi and It detects leg, pelvis, and pulmonary thrombi and is 97% sensitive and 95% specific for DVT.is 97% sensitive and 95% specific for DVT.

It distinguishes a mature from an immature clot.It distinguishes a mature from an immature clot. MRI is safe in all stages of pregnancy. MRI is safe in all stages of pregnancy.

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

CellulitisCellulitisThrombophlebitisThrombophlebitis

ArthritisArthritisPeripheral edemaPeripheral edemaLymphangitisLymphangitisExtrinsic compression Extrinsic compression of iliac veinof iliac veinLymphedemaLymphedema

Muscle or soft tissue Muscle or soft tissue injuryinjuryNeurogenic painNeurogenic painPostphlebitic Postphlebitic syndromesyndrome

Prolonged Prolonged immobilization or limb immobilization or limb paralysisparalysisRuptured Baker cystRuptured Baker cystStress fractures or Stress fractures or other bony lesionsother bony lesionsSuperficial Superficial thrombophlebitisthrombophlebitisVaricose veinsVaricose veins

MANAGEMENTMANAGEMENT

RISK DOPPLER FINDINGS

DIAGNOSIS

High/Moderate Positive DVT

Low Negative DVT ruled out

High Negative +/-

Low Positive +/-

EMERGENCY DEPARTMANT CAREEMERGENCY DEPARTMANT CARE Objectives:Objectives:

1.1. prevent pulmonary embolism, prevent pulmonary embolism,

2.2. reduce morbidity, andreduce morbidity, and

3.3. prevent or minimize the risk of developing the prevent or minimize the risk of developing the postphlebitic syndrome. postphlebitic syndrome.

Treatment options:Treatment options: AnticoagulationAnticoagulation Thrombolytic therapyThrombolytic therapy SurgerySurgery Compression stockingsCompression stockings

AnticoagulationAnticoagulation Heparin prevents thrombus extension. Heparin prevents thrombus extension. Dose: Bolus-80U/kg f/b 18U/kg/hrDose: Bolus-80U/kg f/b 18U/kg/hr Monitoring: aPTTMonitoring: aPTT Target: 1.5-2.3Target: 1.5-2.3

Advantages of Low-Molecular-Weight Heparin Over

Standard Unfractionated Heparin Superior bioavailability Superior or equivalent safety and efficacy Subcutaneous once- or twice-daily dosing No laboratory monitoring* Less phlebotomy (no monitoring/no intravenous line) Less thrombocytopenia

At the present time, 3 LMWH preparations, At the present time, 3 LMWH preparations, Enoxaparin,Enoxaparin, Dalteparin, andDalteparin, and Ardeparin Ardeparin

Warfarin Warfarin

Interferes with hepatic synthesis of vitamin K-Interferes with hepatic synthesis of vitamin K-dependent coagulation factors dependent coagulation factors

Monitoring: INRMonitoring: INR caution in active tuberculosis or diabetes; caution in active tuberculosis or diabetes;

patients with protein C or S deficiency patients with protein C or S deficiency

Thrombolytic therapy for DVTThrombolytic therapy for DVT Advantages: Advantages: prompt resolution of symptoms, prompt resolution of symptoms, prevention of pulmonary embolism, prevention of pulmonary embolism, restoration of normal venous circulation, restoration of normal venous circulation, preservation of venous valvular function, preservation of venous valvular function, prevention of postphlebitic syndromeprevention of postphlebitic syndrome

Thrombolytic therapy does not prevent Thrombolytic therapy does not prevent clot propagation,clot propagation, rethrombosis, orrethrombosis, or subsequent embolization.subsequent embolization.

Surgery for DVT Surgery for DVT

IndicationsIndications

a.a. when anticoagulant therapy is ineffectivewhen anticoagulant therapy is ineffective

b.b. unsafe, unsafe,

c.c. contraindicated. contraindicated.

These pulmonary emboli removed at autopsy These pulmonary emboli removed at autopsy look like casts of the deep veins of the leg look like casts of the deep veins of the leg where they originated. where they originated.

This patient underwent a thrombectomy. The This patient underwent a thrombectomy. The thrombus has been laid over the approximate thrombus has been laid over the approximate location in the leg veins where it developed.location in the leg veins where it developed.

Filters for DVT Filters for DVT

Indications:Indications:

a.a. Pulmonary embolism Pulmonary embolism

b.b. Recurrent pulmonary embolism despite adequate Recurrent pulmonary embolism despite adequate anticoagulation anticoagulation

Controversial indications:Controversial indications:a.a. DVT DVT b.b. In patients with pre-existing pulmonary In patients with pre-existing pulmonary

hypertension hypertension c.c. Free floating thrombus Free floating thrombus d.d. Failure of existing filter device Failure of existing filter device e.e. Post pulmonary embolectomyPost pulmonary embolectomy

Compression stockings Compression stockings (routinely recommended (routinely recommended

Further Inpatient Care Further Inpatient Care

Most patients with confirmed proximal vein DVT Most patients with confirmed proximal vein DVT may be treated safely on an outpatient basis. may be treated safely on an outpatient basis. Exclusion criteria for outpatient management are Exclusion criteria for outpatient management are as follows: as follows:

a.a. Suspected or proven concomitant pulmonary Suspected or proven concomitant pulmonary embolism embolism

b.b. Significant cardiovascular or pulmonary Significant cardiovascular or pulmonary comorbidity comorbidity

c.c. Morbid obesity Morbid obesity

d.d. Renal failure Renal failure

e.e. Unavailable or unable to arrange close follow-up Unavailable or unable to arrange close follow-up carecare

Duration of anticoagulation in patients Duration of anticoagulation in patients with deep vein thrombosiswith deep vein thrombosis

a.a. Transient cause and no other risk factors: Transient cause and no other risk factors: 3 months 3 months

b.b. Idiopathic: 3-6 months Idiopathic: 3-6 months

c.c. Ongoing risk: 6 -12 months Ongoing risk: 6 -12 months

d.d. Recurrent pulmonary embolism/DVT: 6-Recurrent pulmonary embolism/DVT: 6-12 months 12 months

e.e. Patients with high risk of recurrent thrombosis Patients with high risk of recurrent thrombosis exceeding risk of anticoagulation: indefinite exceeding risk of anticoagulation: indefinite duration (subject to review)duration (subject to review)

Complications Complications

Acute pulmonary embolismAcute pulmonary embolism Hemorrhagic complications Hemorrhagic complications Chronic venous insufficiencyChronic venous insufficiency

Prognosis: Prognosis:

All patients with proximal vein DVT are at long-term All patients with proximal vein DVT are at long-term risk of developing chronic venous insufficiency.risk of developing chronic venous insufficiency.

Proximal DVT---- 20% PE --10% mortalityProximal DVT---- 20% PE --10% mortality

DVT confined to the calf: no PEDVT confined to the calf: no PE

Patient Education: Patient Education:

Advise women taking estrogen of the risks Advise women taking estrogen of the risks and common symptoms of and common symptoms of thromboembolic disease.thromboembolic disease.

Discourage prolonged immobility, Discourage prolonged immobility, particularly on plane rides and long car particularly on plane rides and long car tripstrips

DVT PROPHYLAXIS IN SURGICAL DVT PROPHYLAXIS IN SURGICAL PATIENTSPATIENTS

A VTE risk assessment should follow the following A VTE risk assessment should follow the following steps:steps:

Step 1 Step 1 Assess the patient’s baseline risk of VTE, Assess the patient’s baseline risk of VTE, taking into account inherited and acquired pt factorstaking into account inherited and acquired pt factors

Step 2 Step 2 Assess the patient’s additional risk of VTE, Assess the patient’s additional risk of VTE, taking account of the reasons for hospitalisation.taking account of the reasons for hospitalisation.

Step 3 Step 3 Assess the patient’s risk of bleeding.Assess the patient’s risk of bleeding. Step 4 Step 4 Formulate an overall risk assessment (with Formulate an overall risk assessment (with

consideration of VTE risk and bleeding risk).consideration of VTE risk and bleeding risk). Step 5 Step 5 Select appropriate methods of Select appropriate methods of

thromboprophylaxis based on the risk assessment.thromboprophylaxis based on the risk assessment.

Thromboprophylaxis is initiated depending on Thromboprophylaxis is initiated depending on combination of multiple risk factors:combination of multiple risk factors:

Individual pt risk factorsIndividual pt risk factors Risk factors related to acute medical illnessRisk factors related to acute medical illness Risk related to surgical procedureRisk related to surgical procedure

Individual patient risk factorsIndividual patient risk factors:: ageage pregnancy and the puerperiumpregnancy and the puerperium active or occult malignancyactive or occult malignancy previous VTEprevious VTE varicose veinsvaricose veins marked obesitymarked obesity prolonged severe immobilityprolonged severe immobility use of oestrogen-containing hormone replacement use of oestrogen-containing hormone replacement

therapy or oral contraceptivestherapy or oral contraceptives • • inherited or acquired thrombophiliainherited or acquired thrombophilia

Risks related to an acute medical illness:a. acute or acute on chronic chest infectionb. heart failurec. myocardial infarctiond. stroke with immobilitye. some forms of cancer chemotherapyf. acute inflammatory bowel diseaseRisks related to an injury or surgical procedure:All surgical procedures but especially abdominal, pelvic, thoracic or orthopaedic surgical procedures

BLEEDING RISKBLEEDING RISK

recent central nervous system bleedingrecent central nervous system bleeding intracranial or spinal lesion at high risk for intracranial or spinal lesion at high risk for

bleedingbleeding current active major bleeding, defined as current active major bleeding, defined as

requiring at least two units of blood or blood requiring at least two units of blood or blood products to be transfused in 24 hoursproducts to be transfused in 24 hours

current chronic, clinically significant and current chronic, clinically significant and measurable bleeding over 48 hoursmeasurable bleeding over 48 hours

GuidelinesGuidelines

Identification of risk:Identification of risk:

RISK SURGERY AGE (yrs) RISK FACTORS

Low <30min <40 Nil

Moderate <30 min<30 min>30 min

--40-60<40

+ntNilNil

High <30 min>30 min

>60> 40

+nt+nt

Highest >30 min 60 +nt plus history of VTE

PROPHYLAXISPROPHYLAXIS

Non pharmacological methodsNon pharmacological methods::a.a. Early mobilisationEarly mobilisation

b.b. Elastic stockingsElastic stockings

c.c. Pneumatic compression devicesPneumatic compression devices

Pharmacological methodsPharmacological methods::a.a. AspirinAspirin

b.b. Unfractionated heparinUnfractionated heparin

c.c. LMWHLMWH

d.d. Oral anticoagulantsOral anticoagulants

RISK PROPHYLAXIS

Low Nil

Moderate Compression stockingsPneumatic compressionUFHEnoxaparin

High Compression stockingsPneumatic compressionUFHEnoxaparin