Deep Vein Thrombosis

Hossam Bahy, MD

Venous ThromboEbolismDeep Vein Thrombosis & Pulmonary Embolism

Venous Thrombo-Embolism

• Clinical entity, lethal, recurrent.

• Hospitalized and non hospitalized persons.

• Long term complication:

a. Chronic thrombo-embolic pulmonary hypertension

b. Post thrombotic syndrome

Pulmonary Hypertension

• Group I no known cause or inherited.

• Group II with left heart disease.

• Group III associated with lung diseases.

• Group IV thrombo-embolic

• Group V by various other diseases

Post thrombotic syndrome

• Due to damage of venous valves and venous hypertension.

• Leg edema, skin changes( hyperpigmentationlipodermatosclerosis), pain and stasis ulcer

• Compressing stocking for two years.

• Early ambulation.

Incidence of TVE

• 10-20 % in medical hospitalized patients.

• 15-40 % in surgical hospitalized patients.

3rd most common cuase of hospital related death in USA

DVT

• Aim of management is to prevent PE & PTS.

• Popliteal vein and above 50 % estimated risk.

• Below(calf vein) 25 %

Virchow's Triad

• Stasis.

• Hyper-coagulability.

• Injury to vessel wall.

Inherited Hyper-coagulability.

• Factor V leiden

• Prothrombin gene mutation (G20210A)

• Protein C and protein S deficiency

• Anti thrombin deficiency

• Hyperhomocysteinemia

• Elevated factor VIII

Aquired Hyper-coagulability.

• Immobilization• Surgery• Trauma• Pregnancy• OCP & HRT• Malignancy• Antiphospholipid

syndrome (lupus anticoagulant & anticardiolipin antibodies).

• HIT• Myeloproliferative

disorders• Smoking• Obesity• Inflammatory bowel

disease• CVP and pacemakers• Nephrotic syndrome.

Clinical manifestation

Symptoms of DVT

• Pain

• Swelling

Signs of DVT

• Increased warmth

• Tenderness

• Edema

• Presence of dilated veins

• Erythema

• Cyanosis/gangrene

Various signs

• Homan’s sign

• Louvel’s sign

• Lowenberg’s sign

Phlegmasia cerulea dolens

• Complete occlusion of venous outflow.

• Malignancy, HIT, hypercoagulable state.

• Capillary bed hypertension (massive limb swelling).

• Ischemia and necrosis.

• Vascular emergency.

Phlegmasia cerulea dolensTREATMENT

• Leg elevation.

• Anticoagualtion

• Thromolysis

• Thrombectomy (Surgical or cathter based).

• Fasciotomy (compartmental syndrome).

DVT diagnosis

• Clinical.

• Pretest probability (Wells score).

Pretest probability (Wells score)Clinical feature Score

Active cancer. 1

Paralysis, paresis, recent plaster immobilization of LL. 1

Recently bed ridden > 3d or major surgery in last 4 weeks. 1

Localized tenderness along distribution of deep vein system. 1

Entire leg swollen. 1

>3cm difference in calf circumference. 1

Unilateral pitting edema. 1

Collateral non-varicose superficial veins. 1

More likely alternative diagnosis -2

-2 -1 0 /1 2 / 3 4 5 6 7 8 Add 1 if previously documented DVT

-2 -1 0 1 / 2 3 4 5 6 7 8

Tools

• Venography was the gold standard.

• Duplex ultrasound.

• D-Dimer.

• MRI. Pelvic, IVC, mesenteric veins

• CT. Pelvic, IVC, mesenteric veins

Venography

• Was/ has been/ used to be …… gold standard.

• Filling defects intra-luminal.

• Abrupt cutoff

• Non filling of the deep system

• Collaterals.

• Contrast /radiology hazards

Duplex ultrasound

• 95 % sensitivity and 98 % specificity.

• Non-compressibility is diagnostic but difficult in iliac and abductor canal.

• Venous distension, decreased or absent spontaneous flow.

• Difficult with recurrent DVT.

• Pelvic mass cause non-compressibility of common femoral vein

Treatment

• Goal: relief symptoms

• Prevent PE, CTPH, PTS.

• Start anticoagulation at once

• Heparin 80 IU/Kg bolus> 18 U/kg/h IVI

• LMWH

• Fondaparinux.

• Oral anticoagulation.

Fondaparinux

• Indirect Xa inhibitor

• FDA approved for DVT prophylaxis.

• 2.5 mg prophylactic.

• Once daily subcutaneous injection.

• Contraindicated in less than 50 kg in prophylaxis @ orthopedic and abdominal surgery.

Fondaparinux

• FDA approved for acute DVT & PE treatment.

• < 50 kg 5 mg

• 50-100 kg 7.5 mg

• > 100 kg 10mg

• Contraindicated in severe renal impairment.

Thrombolytic therapy

• In only elected cases (threatened limb)

• Preferably locally via catheter.

• May be for extensive acute proximal DVT.

Vena caval interruption

IVC filter insertion is indicated if

Contraindicated anticoagulation.

Complication from anticoagulation.

Recurrent thrombo-embolization despite proper anticoagulation.

Vena caval interruption

IVC filter insertion may be indicated if

• Massive pulmonary embolism

• Ileocaval DVT.

• Free floating proximal DVT.

• Cardiac or pulmonary insufficiency.

• High risk anticoagulation as in frequent fall.

• Poor compliance.

Duration of treatment

Dependant on the risk of recurrence.

• Idiopathic DVT

• Hypercoagulable state.

• malignancy.

Duration of treatment

Dependant on the risk of recurrence.

• Old age

• Male sex

• obese

• Elevted D-dimer levels.

• Permanent IVC filter placement.

Duration of treatment

• 3 months of INR 2-3 for 1st DVT due to transient cause.

• 6-12 months of INR 2-3 for 1st idiopathic DVT.

• For life if recurrent unexplained DVT.

• For life with active malignancy or gene mutation.

Upper limb DVT

• Often related to CVP and pacemaker insertion.

• Thoracic outlet syndrome.

• Hyper-coagulant states including malignancy.

• Same anticoagulation duration.

• Thrombolysis for younger patients with effort thrombosis.

Superficial venous thrombosis

• Frequently after IV line in upper limb.

• May occur spontaneously.

• Generally no anticoagulation.

• Unless propagated to deep system or spontaneous.

• Heparin/ LMWH/Fondaparinux/ VKA

• Four weeks.

Post thrombotic syndrome

• Due to damage of venous valves and venous hypertension.

• Leg edema, skin changes( hyperpigmentationlipodermatosclerosis), pain and stasis ulcer

• Compressing stocking for two years.

• Early ambulation.

Heparin induced thrombocytopenia

• 3-5 % unfractionated heparin.

• < 1 % LMWH.

• Immunoglobulin G antibody to heparin. platelet factor 4 complex.

• 5-14 day after exposure to heparin.

• Isolated or thrombotic.

• Stop any heparin