Deep vein thrombosis
Done by: Mohammed A Qazzaz
Definition :Formation of a blood clot in one of the deep veins
of the body.
Deep veins of the body: LegArmPelvis
VTEDVT and pulmonary embolism
DVT of the lower limb.Distal / calfProximal / popliteal,
femoral, iliac veins
That was an old classification. But now its no longer used The
used to treat just the proximal DVT.. But now we treat both.
< 2% orginated from the upper arm DVT90% is from the leg
DVTIncidence: 2-3 / 1000 .Men > women >45 year old.
Risk Factors :
Venous stasis hypercoaguilableEndothelial enjuryVenous stasis
:Advanced age.obesity. Immobilizationparalysis. Pregnancy &
Endothelial Injury:Surgery .CatherterTrauma.vasculitsVirchow's
Cancer- chemotherapy. Estrogen / OCPNephrotic
Ant thrombin deficiency.Protein C deficiency.Protein S
Deficiency.Factor V Leiden.
Signs: Calf tenderness.Pitting Edema. Circumferences increased
> 3cm.Temperature. Superficial venous dilatation. Homans sign
Search for stigmata of PE
examin for signs of underlying factors.
Swelling .Pain .Redness/ erythema.
Phlegmasia alba dolens
(also colloquially known asmilk legorwhite leg). Historically,
it was commonly seen during pregnancy and in mothers who have just
given birth. In cases of pregnancy, it is most often seen during
the third trimester, resulting from a compression of the leftcommon
iliac vein against the pelvic rim by the enlargeduterus. Today,
this disease is most commonly (40% of the time) related to some
form of underlying malignancy. Pale & cold.Decreased arterial
pulse.Sudden or acute occlusion of iliac and femoral veins.
Phlegmasia cerulea dolens
(literally:painful blue edema) is an uncommon severe form ofdeep
venous thrombosiswhich results from extensivethromboticocclusion
(blockage by athrombus) of the major and thecollateralveins of an
extremity. it is characterized by sudden severe pain,
swelling,cyanosisandedemaof the affected limb. There is a high risk
of massive pulmonary embolism, even underanticoagulation.
Footgangrenemay also occur. An underlying malignancy is found in
50% of cases. Usually, it occurs in those afflicted by a
life-threatening illness.Sever leg pain, swelling, cyanosis,
edema.Venous gangreneCompartment syndrome.circulation collapse and
Deferential diagnosis :
Muscle strain, tear, twisting injury of the leg.Leg swelling in
paralyzed limb. Lymphangitis or lymphatic system obstruction.Venous
insufficiency.Popliteal (Bakers) cystCellulitis.Knee
CBC.PH.PT, PTT, INRCr--- GFRLFTsUrine pregnancy test --- risk of
TestsInvasiveNon- InvasiveDuplex U/S approach of choiceD-
dimer.MRICTVenogragh (gold stander)Nuclear study .
D- dimer:Degenration product of cross-linked fibrin.
Sensitivity 97%.Specificity 35%.It remains high for 7 days in
DVT.Used to rule out DVT.False +ve D-dimer include surgery, recent
MI, acute infection, DIC, pregnancy or recent delivery, Metastatic
Duplex U/S :
Decreased compressibility of vein .
Change in venous phase blood flow sound
Venogragh :Gold stander.When U/S ve + high probability . Use
MRI :Detect legs, pelvis, pulmonary thrombi.Sensitivity and
Treatment :Selection of agents
LMW heparinUF heparin.Fondaprinux.Oral Factor X inhibitors.Oral
direct thrombin inhibitor.
Heparin (UFH) :
DoseWight based protocol (preferred).fixed close protocol .
Wt. based Pro.Initial dose 80 Units/Kg as bolus IV. Then
Subsequent adjustment every 6 hr.s
Not Wt. based.
Initial IV UFH bolus 5000 units. Or 10000 if PE Then continous
IV heparine 2000 units per hour.
333 units/Kg as loading dose then 250 units/Kg every 12hr
Check the APPT daily 4-6 hours after dose of heparin.
LMW:SC.Enoxaparin 1mg/Kg q 12 hr. or 1.5 mg/Kg once daily.
Dalteparin 200 international units/kg once a day for the first
month; 150 international units/kg.
Tinzaparin 175 Units/kg once daily.
LMW is better than UFH.
Increase rate of thrombus regression.Decrease rate of
recurrence, bleeding, mortality.Better bioavailability. Longer
effect.Fixed dose.No need to monitoringLow risk for HIT . (heparin
induced thrombocytopenia).Used as out patient.
Antidote is protamin sulfate.
Side effect of heparin:
HIT . (heparin induced thrombocytopenia).
Increase level of transaminase.
Warfarin:Vitamin K antagonist .Preferred for long term anti
coagulation. Exception malignancy & pregnancy. LMWH is
Start at the same day (1st) with UFH or LMWH .Starting dose :
5mg/day orally . Dose adjustment until target INR 2-3 .Decrease the
dose when case of high risk of bleeding.
Side effect:BleedingSkin necrosis (protein C deficiency)
.Teratogenic for pregnancy.Vascular calcification.Allergy.
Risk of bleeding assessment:
Age > 65.Previous bleeding.Cancer metastatic.Renal
failure.Liver failure.Thrombocytopenia.Previous stroke.Anemia.Anti
ph therapy. Recent surgery.
recurrent DVTAnti phospholipids.Prosthetic valves. Coronary
artery graft thrombosis.
Vitamin K antagonist . Avoid rich food of Vit K.Avoid drugs that
interact with warfarin.Avoid the IM injection.Tell your surgeon
about your warfarin thereby.
Duration of treatment.
1st DVT + reversible risk factor (trauma, surgery) treat for 3
1st idiopathic DVT . At least 3 months (3-6).
Unprovoked proximal DVT. indefinite .
Distal DVT and provoked . 3 months .
Advanced cancer . Indefinite.
Provoked DVT + persistent risk factor. 6-12 month.
Contraindication of anticoagulantAbsoluteRelativeRecurrent
bleeding from GIIntracranial or spinal tumor.Abdominal aortic
aneurysm. Stable aortic dissection.
Active bleeding.Sever bleeding diathesis.Major trauma.H/O
Decrease rate of PE.No effect on other complication of DVT.