01-May-20

Venous
Thromboembolism

Dr. Rajib Pal Chowdhury

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• Deep vein thrombosis (DVT) is a well-known and, when complicated

by pulmonary embolus, potentially fatal complication of surgery (Table-
next).
• All hospitals must have a process for screening all surgical patients to
identify those at risk and for implementing prophylactic measures.
• There is international agreement on risk and therapeutic options.
Methods of prevention are guided by the risk score and include the use
of compression stockings, calf pumps and pharmacological agents,
such as low molecular weight heparin.
• The symptoms and signs of DVT include calf pain, swelling, warmth,
redness and engorged veins. However, most will show no physical
signs. On palpation the muscle may be tender and there may be a
positive Homans’ sign (calf pain on dorsiflexion of the foot), but this
test is neither sensitive nor specific.
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Table : Stratification surgical procedure and the

associated risk of deep vein thrombosis
Low
Post-thrombotic leg demonstrating
●Maxillofacial surgery
features of eczema, pigmentation
● Neurosurgery and mild lipodermatosclerosis.
● Cardiothoracic surgery
Medium
● Inguinal hernia repair
● Abdominal surgery
● Gynaecological surgery
● Urological surgery
High
● Pelvic elective and trauma surgery
● Total knee and hip replacement

Bailey Love 27ed p296 ©RPC 01.05.2020

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• Duplex Doppler ultrasound and venography can be used to assess flow

and the presence of a thrombosis.
• Other investigations include D-dimer.
• If a significant DVT is found (one that extends above the knee),
treatment with parenteral anticoagulation initially, followed by longer-
term warfarin or new oral anticoagulant (refer to national guidance, e.g.
NICE; see Further reading).
• In some patients with a large DVT, a caval filter may be required to
decrease the possibility of pulmonary embolism.

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Pulmonary Embolism (ecg – s1q3t3)

• It is not usually an immediate complication, but can present in the
early postoperative period. Thrombus can arise from DVT in the
legs/pelvis, venae cavae or the right atrium.
• Signs and symptoms depend on the size of the embolus and may range
from dyspnoea, cough, and pleuritic chest pain to sudden
cardiovascular collapse.
• Diagnosis of PE begins with history (including risk factors and recent
surgery) and physical examination (which may include signs of DVT).
• Investigations may include, depending on the presentation, ECG, chest
radiograph, blood tests (arterial blood gas and d-dimer) and
radiological tests (usually CT pulmonary angiography, CTPA).
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Pulmonary Embolism
• If the presentation includes cardiovascular collapse, resuscitation will be needed.
Thrombolysis can be considered with massive PE causing cardiovascular collapse,
but this should include senior clinical opinion and would generally follow
appropriate guidelines.
• The patient may need inotropes and admission to the intensive care unit (ICU).
In less severe cases of PE, supportive measures include oxygen therapy and
analgesia.
• After initial resuscitation, the patient will need anticoagulation, initially
parenteral anticoagulation, followed by long-term oral anticoagulation (refer to
national guidance, e.g. NICE; see Further reading).
• A venacaval filter may be needed if anticoagulation is not possible or if the
patient has an embolism while anticoagulated

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Telangiectasia and saphena varix

reticular veins.

Advanced skin
changes –
lipodermatosclerosis,
eczema and
atrophie blanche Severe
eczema

Pigmentation (haemosiderosis)
and mild eczema.

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Venous ulcer A Marjolin’s ulcer

Haemosiderosis and mild (squamous cell
lipodermatosclerosis of the cancer arising in
calf skin a chronic venous
ulcer)

Bailey Love 27th ©RPC 01.05.2020

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Patient position for

venous duplex examination of
The great saphenous system.

Micky Mouse’ transverse B-mode image of the right

common femoral vein (CFV) and artery (CFA), great
saphenous vein (GSV) and saphenofemoral junction

Varicogram

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Spectral Doppler trace of the sapheno-femoral junction

showing antegrade and retrograde flow.
The downward spike on the trace is the antegrade augmented flow
and this is followed by approximately 4 seconds of retrograde flow.

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Risk factors for venous thromboembolism.

• Patient factors • Disease or surgical procedure
• Age • Trauma or surgery, especially of pelvis, hip and
lower limb
• Obesity
• Malignancy, especially pelvic, and abdominal
• Varicose veins metastatic
• Immobility • Heart failure, Recent MI
• Pregnancy • Paralysis of lower limb(s)
• Puerperium • Infection, Inflammatory bowel disease
• Nephrotic syndrome
• High-dose oestrogen therapy
• Polycythaemia, Paraproteinaemia
• Previous deep vein thrombosis or • Paroxysmal nocturnal haemoglobinuria antibody or
pulmonary embolism
lupus
• Thrombophilia • Anticoagulant, Behçet’s disease
• Homocystinaemia ©RPC 01.05.2020
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Abnormalities of thrombosis & fibrinolysis (thrombophilia)

that lead to an increased risk of venous thrombosis.
Congenital
Deficiency of antithrombin III, protein C or protein S
Antiphospholipid antibody or lupus anticoagulant
Factor V Leiden gene defect or activated protein C resistance
Dysfibrinogenaemias
Acquired
Antiphospholipid antibody or lupus anticoagulant

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Modified Wells criteria for predicting DVT

Variable Score
Lower limb trauma or surgery or immobilisation in a plaster cast 1
Tenderness along the line of femoral or popliteal veins 1
Entire limb swollen 1
Calf >3 cm larger circumference than the other side 1
10 cm below the tibial tuberosity
Pitting oedema 1
Dilated collateral superficial veins (not varicose veins) 1
Previous DVT 1
Malignancy (including treatment up to 6 months ago) 1
Intravenous drug abuse 3 3
Alternative diagnosis more likely than DVT – 2
Low probability (5%) of DVT (score –2 to 0), moderate probability (17%) of DVT (score 1–2),
high probability (17–53%) of DVT (score >2). ©RPC 01.05.2020
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Modified Wells criteria for predicting PE

Variable Score
Clinical signs and symptoms of deep vein thrombosis (DVT) (minimum of 3
leg swelling and pain on palpation of deep veins)
Alternative diagnosis less likely than PE 3
Heart rate >100 bpm 1.5
Immobilisation >3 days or surgery within past 4 weeks 1.5
Previous DVT or PE 1.5
Haemoptysis 1 1
Malignancy (treatment or palliation within past 6 months) 1
A score of < 4 means PE is unlikely (12.4%), > 4 is suggestive of PE (37.1%).

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Risk patient groups for venous thromboembolism.

LOW RISK
Minor surgery <30 minutes; any age; no risk factors
Major surgery >30 minutes; age <40; no other risk factors
Minor trauma or medical illness
MODERATE RISK
Major surgery; age 40+ or other risk factors
Major medical illness: heart/lung disease, cancer, inflammatory bowel disease
Major trauma/burns
Minor surgery, trauma, medical illness in patient with previous DVT, PE or thrombophilia

HIGH RISK
Major orthopaedic surgery or fracture of pelvis, hip, lower limb
Major abdominal / pelvic surgery for cancer, Major lower limb amputation
Major surgery, trauma, medical illness in patient with DVT, PE or thrombophilia
Lower limb paralysis (e.g. stroke, paraplegia)
DVT, deep vein thrombosis; PE, pulmonary embolus
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Venous thromboembolism
 May be unprovoked, in which case an association with an inherited
‘thrombophilia’ should be considered
 Is much more commonly seen as a complication of illness or surgery
 Is associated with both quality of life impairment and a risk of mortality
 All healthcare professionals should actively assess the risk and consider
preventative measures where this risk is increased
 Management should involve measures to reduce the risk of extension
and/or embolisation, typically with systemic anticoagulation
 Consideration should be given to local thrombolysis to reduce the risk of
post-phlebitis limb

BL 27th page 991

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Garden 7th

• DVT is a common condition in medical and surgical patients, and

• PE is consistently cited as the most common cause of potentially
preventable death in the surgical patient.
• DVT also renders the leg prone to Chronic Venous Insufficiency and
ulceration (the so-called post-phlebitic limb or syndrome).

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Pathophysiology
• DVT probably begins in the calf in most cases.
• Clot may extend into the popliteal, femoral or iliac veins, and even the IVC. In
some cases, DVT originates in the pelvic veins. At first, the clot is free-floating
within a column of flowing blood. The risk of PE is highest at this point.
• Later, when thrombus has completely occluded the vein and incited an
inflammatory reaction in the vein wall, the clot becomes densely adherent and
is unlikely to embolise.
• The classic text book features of DVT are due to this occlusion (leg swelling,
dilated superficial veins) and thrombophlebitis (redness, pain and tenderness,
heat).
• The important point is that most surgical patients developing a clinically
significant postoperative PE do so on about the 7th–10th day and nearly
always have clinically normal legs.
• By the time a clinically apparent DVT has developed, the danger period for
PE has largely passed; for this reason, thromboembolic prophylaxis must be
considered in all patients undergoing open vascular or endovascular surgery.

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Aetiology

Thrombogenesis (Virchow’s triad):

• Venous stasis: immobility, obesity, pregnancy, paralysis, operation and trauma
• Intimal damage: external trauma to a vein, e.g., during a hip replacement
operation
• Hypercoagulability of the blood:
Congenital (primary): anti-thrombin, protein C and protein S deficiency, as
well as factor V Leiden (activated protein C resistance [APCR]) in a young
patient (<45 years), if there is a family history, or if thrombosis is recurrent or
at an unusual site.
Acquired (secondary): pregnancy, the puerperium, and malignancy.

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Diagnosis
• Clinical examination alone is unreliable at confirming or excluding the
presence of DVT.
• This means that the diagnosis of DVT cannot be made on clinical
grounds alone, and that some form of investigation is required.
• Colour duplex ultrasound imaging has largely replaced conventional
venography in the diagnosis of DVT. It is noninvasive, avoids ionising
radiation and contrast, and is as accurate as venography in most cases.
• At times of doubt, magnetic resonance (MRI) or CT venography may be
useful.

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Fate
• In certain circumstances, notably where there is underlying
malignancy or severe sepsis, DVT may propagate to involve not only
the main venous trunks, but also the venous collaterals and/or
microcirculation (arterioles and venules).
• The former leads to an intensely swollen, cyanosed limb (phlegmasia
caerulea dolens), whereas the latter can lead to obstruction of the
arterial inflow and the development of a swollen white leg
(phlegmasia alba dolens).
• The patient may then go on to develop venous gangrene.

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A foot with venous gangrene. The gangrene is

symmetrical involving all of the toes. There is
no clear-cut edge and there is marked
oedema of the foot.

Phlegmasia cerulea dolens.

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Prevention
• Rationale:
• Because of our inability to diagnose DVT easily in its early
asymptomatic but dangerous phase, prevention is very important.
• The most important risk factors are a history of previous DVT or
embolism, advanced age, malignant disease, obesity, and
congenital or acquired thrombophilia.
• Identification of patients is important so that prophylaxis
administered reduces the incidence of venous thromboembolism.

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Prevention

• General measures:
• Aspects of modern surgical care that help to reduce the likelihood of
postoperative DVT include -
regional anaesthesia,
accurate fluid replacement to avoid dehydration,
effective pain control to facilitate early ambulation and,
perhaps above all, the use of outpatient or day-case-based minimally
invasive alternatives to traditional open surgery.

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Prevention
• Physical methods
• Graduated compression (thromboembolic deterrent [TED]) stockings,
which exert a pressure of about 20 mmHg at the ankle, augment flow in
the deep veins and reduce the risk of thrombosis.
• Pharmacological methods
• Low-dose subcutaneous low-molecular-weight heparin (LMWH) protects
against DVT and PE. The first dose may be given with the premedication
(if an epidural is not being planned), and treatment is continued until the
patient is fully ambulant.
• In ‘high-risk’ patients, it can be continued following discharge, and there
is increasing evidence that this is of benefit in reducing venous
thromboembolism and, probably therefore, postthrombotic syndrome.

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Management
• Overview
• Before treatment is instituted, the diagnosis of DVT should normally have
been established by means of ultrasound or magnetic resonance (or
computed tomography) venography.
• However, where the clinical suspicion of DVT and/or PE is high and there
is no contraindication to heparin, the potential benefit of ‘blind’ treatment
until the diagnosis is confirmed often outweighs the risk of withholding
anticoagulation.
• The aims of treatment are to relieve the acute symptoms, protect against
PE, and minimize the risk of recurrent thrombosis and post-thrombotic
sequelae to the limb.

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Management
• Uncomplicated DVT
• If thrombus is confined to the calf, the patient is fully mobile and other risk
factors are reversible, then an elastic stocking and physical exercise may be all
that is required.
• However, the ‘surgical’ patient does not usually fulfil these criteria
postoperatively and there is a real risk of thrombus extension into the femoro-
popliteal segment.
• In these cases, specific treatment is indicated. For most uncomplicated DVT, it
is now clear that:
oBed rest is unnecessary and the patient can be mobilized immediately,
wearing an appropriately fitted compression stocking
oLow-molecular-weight heparin given by intermittent subcutaneous injection
is more effective than unfractionated heparin given by infusion.
• Thus, uncomplicated DVT is increasingly treated on an outpatient basis
by protocol-driven, specialist nurse-run clinics. ©RPC 01.05.2020
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Management
Complicated DVT
In a proportion of patients, however, treatment is more complicated
because of one or more of the following:
The DVT is more extensive (iliofemoral, vena cava, phlegmasia)
The DVT is recurrent
The patient has had PE
The patient has major irreversible congenital and/or acquired
thrombophilia
Heparinisation is contraindicated (heparin-induced thrombocytopenia,
trauma—especially intracranial, recent haemorrhage).

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Management
• Treatment must be tailored to the individual patient.
• In selected instances it may be appropriate to use thrombolysis, insert a
caval filter or consider thrombectomy.
• A high proportion of patients with extensive DVT have an underlying
malignancy, and reasonable steps should be taken to ensure that this is
diagnosed and appropriately treated in order, hopefully, to reduce the
thrombotic risk.

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Management
• Thrombolysis
• Catheter-directed intraclot thrombolysis (CDT) using recombinant tissue
plasminogen activator (rTPA) has been advocated as a means of rapidly
clearing the iliofemoral segment in patients with extensive proximal DVT.
• It is hoped that CDT will reduce the incidence of PE and postphlebitic
syndrome (by reducing venous pressure and preserving valves). Although
the rate and extent of clot clearance is certainly greater with CDT than
with heparin alone in the short term, it is not clear whether this results in
improved patency and clinical outcome in the long term.
• CDT is also associated with a small risk of bleeding, which can be serious
or even life threatening.

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Management
• Thrombolysis
• The other potential role for CDT is in phlegmasia with venous gangrene.
In this situation, not only is the rTPA given into the clot, it is also
administered into the arterial circulation to try to clear the
microcirculation.
• Again, although clots can be lysed in the short term, it is unclear whether
this confers long-term benefit.
• Many of these patients have underlying malignancy and, unless the
hypercoagulable state can be corrected, re-thrombosis seems likely.

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Management
• Surgical thrombectomy
• In the UK, surgical thrombectomy to clear iliofemoral thrombus is very
rarely performed nowadays. It is indicated in patients with iliofemoral
thrombosis and impending venous gangrene.
• Pharmaco-mechanical thrombectomy : There are now several
catheter-based devices on the market that allow the thrombus to be
isolated from the general venous circulation while being laced with
thrombolytic (reducing systemic effects) and at the same time
disrupted mechanically.
• Trials are ongoing to determine whether such pharmacomechanical
thrombectomy (PMT) results in long-term benefits and if the cost is
justified. ©RPC 01.05.2020
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Management
• Venous stenting : If ilio-femoral thrombus clearance reveals May–
Thurner syndrome as the likely cause of DVT, then a stent may be placed
to help keep the left iliac vein open in the long term.
• Caval filters : The rationale behind inserting an IVC filter is that it will
trap embolus that would otherwise have been destined for the lungs
causing a PE.
• The use of IVC filters varies enormously around the world. In the
UK, the accepted indications are in patients where:
Anticoagulation is contraindicated or has had to be discontinued owing to a
complication of therapy
PE is still occurring despite adequate anticoagulation (Recurrent PE)
Compromised cardiovascular reserve means that even a small PE might have
very serious clinical consequences. ©RPC 01.05.2020
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Other forms of thrombosis

• Superior Venacava Thrombosis

• Mediastinal tumours or enlarged lymph nodes (e.g., from breast or bronchial
carcinoma) may obstruct the superior vena cava (SVC) and induce thrombosis.
• Central venous catheters (CVCs) for parenteral nutrition, pressure monitoring or
haemodialysis may cause thrombosis of the SVC, or of the subclavian or axillary
veins.
• The patient experiences an unpleasant bursting feeling in the head, neck and
upper limbs. There is oedema, cyanosis and venous distension. The obstruction
is defined by CT or MR venography.
• In occlusion secondary to malignancy, percutaneous stenting, radiotherapy or
chemotherapy may relieve malignant obstruction, and whilst the outlook
remains poor, symptoms may be significantly relieved.
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Other forms of thrombosis

• Subclavian and axillary vein thrombosis

• Spontaneous axillary vein thrombosis is relatively common and usually occurs

in otherwise healthy young adults following exercise, when it is termed effort
thrombosis.
• There may be a previous history of intermittent venous obstruction in the
limb due to a mechanical cause at the thoracic outlet.
• A cervical rib, abnormal muscle or ligamentous band at the inner border of
the first rib, or a narrow interval between the clavicle and the first rib (the
costo-clavicular scissors) may constrict the vein and lead to thrombosis.

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Other forms of thrombosis

• Subclavian and axillary vein thrombosis
• The patient complains of an uncomfortable, heavy, cyanosed arm with venous
engorgement. Venous collaterals develop over the shoulder and anterior chest
wall.
• Upper limb venous duplex scanning and/or venography define the occlusion.
• The arm should be elevated, e.g., in a towel suspended from a drip stand.
• Heparin therapy followed by oral anticoagulants is standard treatment.
• CDT and PMT can be very effective in early cases.
• Many surgeons believe that after the axillary thrombosis has been cleared, the
thoracic outlet should be explored and the first rib or other obstructing element
removed.
• Once the rib is out, stenting of any underlying venous stenosis may be of value.

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Nice to know
• Chronic venous insufficiency is impaired venous return, sometimes causing lower
extremity discomfort, edema, and skin changes.
• Post-phlebitic (post-thrombotic) syndrome (PTS) is symptomatic chronic venous
insufficiency after deep venous thrombosis (DVT). Causes of chronic venous
insufficiency are disorders that result in venous hypertension, usually through
venous damage or incompetence of venous valves, as occurs (for example) after
DVT.
• Diagnosis is by history, physical examination, and duplex ultrasonography.
Treatment is compression, wound care, and, rarely, surgery. Prevention requires
adequate treatment of DVT and compression stockings.
• Read more also:
• https://vascularcures.org/post-thrombotic-syndrome/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6142466/pdf/bloodbook-2016-413.pdf
• https://thrombosisuk.org/post-thrombotic-syndrome.php
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THANKS

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