Deep Venous Thrombosis

Introduction

•Definition
•Risk Factors
•Symptoms
•Investigations
•Treatment
•Prevention
 Definition

• presence of one or more

clots within the Deep
veins of the pelvis or
extremities
 Risk Factors
• Immobilization
• Surgery
• Stroke
• History of VTE
• Malignancy
• Preexisting
respiratory disease
• Chronic Heart
Disease
• Age >60
• Surgery requiring
>30mins of
anesthesia
• Recent travel (past
2weeks, >4 hours)
• Varicose veins
• Superficial vein thrombosis
Additional RF in Women:
• Obesity BMI >/=29
• Heavy smoking (>25cigs/day)
• Hypertension
• Pregnancy
Hereditary Risk factor:
• Factor V leiden mutation
• Protein C & S Deficiency
• Antithrombin III deficinency
 Clinical Presentation
• Classically :
A) calf pain or thigh often associated with
edema
B) Swelling:
According to the level of DVT
1- Calf Thrombosis swelling is limited to
foot & Ankle
2- Femoral Thrombosis swelling involve
calf & lower part of the thigh
3- Ilio Femoral thrombosisMassive
swelling in all L.L
C- Tenderness & redness

D- Homan’s sign: pain on

passive dorsiflexion of the
ankle
C- Tenderness & redness

D- Homan’s sign: pain on

passive dorsiflexion of the
ankle
 Well’s Criteria
Clinical Signs and Symptoms of DVT? +3
(Calf tenderness, swelling >3cm, errythema,
pitting edema affected leg only)
PE Is #1 Diagnosis, or Equally Likely +3
Heart Rate > 100 +1.5
Immobilization at least 3 days, or Surgery in the +1.5
Previous 4 weeks
Previous, objectively diagnosed PE or DVT? +1.5

Hemoptysis +1
Malignancy w/ Rx within 6 mo, or palliative? +1

>6: High Risk

2 to 6: Moderate Risk
2 or less: Low
Investigations
 D-Dimer
• Fibrin degradation product elevated
in active thrombosis
• Negative test can help exclude VTE
• Preferred test
– Quantitative Rapid ELISA – sensitivity
96/95% for DVT/PE
– Other methods include latex
agglutination and RBC agglutination
(SimpliRED)

Stein PD, Hull RD, Patel KC, et al. D-dimer for the exclusion of acute venous thrombosis
and pulmonary embolism: a systematic review. Ann Int Med. 2004;140(8):589-602
 Imaging

• Available imaging and ancillary

tests:
– Doppler US – first line test,
high sens/spec
– Duplex U/S
– CT scan
– Venography – gold standard
– MRI
 PE – Use of D-Dimer

• Sensitive assay can exclude PE in

low risk patient
• In patients with moderate pretest
probability only rapid quantitative
ELISA can adequately exclude PE
• Patients judged to be high risk for
PE would still have a posttest PE
probability of 5-20% even after
negative ELISA and require further
testing

Roy PM, Colombet I, Durieux R, et al. Systematic review and meta-analysis of strategies
for the diagnosis of suspected pulmonary embolism. BMJ. 2005;331(7511):259
VTE – Other Therapy Issues

• Anticoagulation same for DVT & PE

• Compression stockings prevent
post-phlebitic syndrome
• Thrombolysis - risk/benefit
uncertain; clinical outcomes
generally not improved
• Vena cava filters - limited evidence
and modest benefit
 VTE – Prophylaxis in Medical
Patients

• Indications
– CHF or severe respiratory disease
– Bedrest with additional risk factor
• Cancer •Acute neurologic disease
• Prior VTE •Inflammatory bowel disease
– Most ICU patients
• Options
– Low dose unfractionated heparin or LMWH
– Sequential compression devices
– Graduated compression stockings
Prophylaxis
1- Pre-Operative:
- Weight Reduction in obese
patients
- Stop OCP 4 weeks before
surgery
2- During Operation :
Elevate heels on sand bag, Avoid
pressure on calves
Post Operative:
• Physical Measures to reduce
venous stasis:
1- Early Ambulation after
surgery
2- Leg Exercise + Massaging
3- Adequate Hydration
4- Elastic Stocks
Prophylaxis

1- Low Dose Heparin

5000 IU SC 2 hrs before surgery
then every 12 hrs until
ambulation (5-7 days)
2- LMWH (clexane) once daily
3- LMW Warfarin (Marevan)
Heparin
- Acid Monopolysaccharide
- Mode of Action:
a) Enhance the activity of
Antithrombin III
b)Neutralizes the factors of IX, X,
XI
c) Mild Thrombolytic effect
(activation of fibrinolysis)
Treatment
Warfarin (Oral
Anticoagulant)
- Mode of Action
1- Block synthesis of prothrombin,
factor VII, IX, X (Vit. K
dependent clotting factor)
2- Inhibit the synthesis of protein
C&S
N.B.: Warfarin need to be
monitored by PT , PC & INR
Thrombolytic Therapy
• Fibrinolytic activators
dissolves Fresh Thrombi
• Examples:
1- Streptokinase
2- Urokinase
3- TPA (Tissue Plasminogen
Activator)
Operative Treatment

1- Venous thrombectomy using

fogarty’s catheter
2- Insertion of IVC filter