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: •Leg•Arm•Pelvis

VTEDVT and pulmonary embolism

DVT of the lower limb.•Distal / calf•Proximal / 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.

PE:

•< 2% orginated from the upper arm DVT•90% is from the leg DVT

Incidence: 2-3 / 1000 .Men > women >45 year old.

Risk Factors :

Veno

us st

asis

hypercoaguilable

Endothelial enjury

Venous stasis :Advanced age.obesity. Immobilizationparalysis. Pregnancy & post partum.

Endothelial Injury:Surgery .CatherterTrauma.vasculits

Virchow's triad

Hypercoaguliablity:

Cancer- chemotherapy. Estrogen / OCPNephrotic syndrome.SepsisHRTAntiphospholibidHyperhomocystinuria.Thrombophilia •Ant thrombin deficiency.•Protein C deficiency.•Protein S Deficiency.•Factor V Leiden.

Signs: Calf tenderness.Pitting Edema. Circumferences increased > 3cm.Temperature. Superficial venous dilatation. Homan’s sign .Pratt’s sign.

Search for stigmata of PE

examin for signs of underlying factors.

Symptoms:

Swelling .Pain .Redness/ erythema.

Phlegmasia alba dolens

(also colloquially known as milk leg or white 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 left common iliac vein against the pelvic rim by the enlarged uterus. 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 of deep venous thrombosis which results from extensive thrombotic occlusion (blockage by a thrombus) of the major and the collateral veins of an extremity. it is characterized by sudden severe pain, swelling, cyanosis and edema of the affected limb. There is a high risk of massive pulmonary embolism, even under anticoagulation. Foot gangrene may 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 gangrene•Compartment syndrome.•circulation collapse and shock .•PE.

Deferential diagnosis :

•Muscle strain, tear, twisting injury of the leg.•Leg swelling in paralyzed limb. •Lymphangitis or lymphatic system obstruction.•Venous insufficiency.•Popliteal (Baker’s) cyst•Cellulitis.•Knee abnormality.•Unknown.

Lab testing:

CBC.PH.PT, PTT, INRCr--- GFRLFTsUrine pregnancy test --- risk of teratology

Tests

Invasive Non- Invasive

•Duplex U/S approach of choice•D- dimer.•MRI•CT

•Venogragh (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 cancer.

Duplex U/S :

•Decreased compressibility of vein .

•Visualized thrombus.

•Change in venous phase… blood flow sound

Venogragh :•Gold stander.•When U/S –ve + high probability . Use it.•Side effect.Phlebitis.Anaphylaxis.

MRI :•Detect legs, pelvis, pulmonary thrombi.•Sensitivity and spasticity high

Venogragh

Treatment :Selection of agents

•LMW heparin•UF heparin.•Fondaprinux.•Oral Factor X inhibitors.•Oral direct thrombin inhibitor.

Heparin (UFH) :

Dose•Wight based protocol (preferred).•fixed close protocol .

Wt. based Pro.Initial dose 80 Units/Kg as bolus IV. Then 18Units/Kg/hr.

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.

SC heparin.

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 monitoring•Low risk for HIT . (heparin induced thrombocytopenia).•Used as out patient.

Antidote is protamin sulfate.

Side effect of heparin:

Bleeding

Osteoporosis

HIT . (heparin induced thrombocytopenia).

Increase level of transaminase.

Warfarin:•Vitamin K antagonist .•Preferred for long term anti coagulation. •Exception malignancy & pregnancy. LMWH is preferred.

•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:•Bleeding•Skin 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.

INRaround 2.5

•DVT•PE•AF

around 3.5

•recurrent DVT•Anti phospholipids.•Prosthetic valves. •Coronary artery graft thrombosis.

Warfarin:

•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 months.

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 anticoagulant

Absolute Relative

•Recurrent bleeding from GI•Intracranial or spinal tumor.•Abdominal aortic aneurysm. •Stable aortic dissection.

•Active bleeding.•Sever bleeding diathesis.•Major trauma.•H/O ICH.•H/O HIT.

IVC filter:

Decrease rate of PE.No effect on other complication of DVT.