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Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The
affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is
more likely to cause a pulmonary embolism (PE) and is generally considered more serious.
Ultrasound can visualize the thrombus and anticoagulation is the primary mode of treatment; the
main objective is the prevention of development of a PE.
Last update:
8:06 am
Table of Contents
Epidemiology and Risk Factors
Pathophysiology
Clinical Manifestations
Diagnosis
Treatment
Differential Diagnosis
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Risk Factors
Smoking: Oxidant gases and other chemicals in cigarette smoke produce free radicals that
lead to platelet aggregation and an increase in the production of procoagulant molecules.
Hypertension: Increased shear stress leads to damage of the endothelium.
Surgery
Vascular catheter placement (hemodialysis catheters, peripherally inserted central
catheters [PICC] lines): most common cause of upper extremity DVT
Trauma, especially involving the vasculature
Nephrotic syndrome
o Leads to loss of anticoagulant proteins (antithrombin III, protein C and S) via the
urine due to damaged glomerular membranes
o Leads to an increase in the production of fibrinogen and other procoagulant
proteins in the liver due to protein loss and hypoalbuminemia
Antiphospholipid syndrome
Immobilization (long air travel, after orthopedic surgery): 20 times increased risk of
developing a DVT
Age > 60
Polycythemia
Resulting in hypercoagulability:
Hereditary thrombophilia
o Factor V Leiden
o Protein C or S deficiency
o Elevated levels of homocysteine
Pregnancy/oral contraceptive pill (OCP) use: Estrogen increases the production of
clotting factors in the liver.
Obesity
Cancer: gastric, pancreatic, pulmonary, gynecologic, and urologic tumors particularly
associated with increased risk of DVT (produce proteins and cytokines with
thrombophilic effect)
Chemotherapy: affects vascular endothelium, coagulation cascades, and tumor cell lysis
Heparin-induced thrombocytopenia
Mnemonic
Travel
Hypercoagulable/Hormone replacement therapy (HRT)
Recreational drugs
Old (age > 60)
Malignancy
Blood disorders
Obesity/Obstetrics
Surgery/Smoking
Immobilization
Sickness (congestive heart failure [CHF]/myocardial infarction [MI], inflammatory
bowel disease [IBD], nephrotic syndrome, vasculitis)
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1:33
Deep Vein Thrombosis: Epidemiology
4:02
Deep Vein Thrombosis: Etiology
2:45
Deep Vein Thrombosis: Risk Factors
Pathophysiology
Site of origin
Deep vein thrombosis commonly beings to form in the venous valves; the nature of the
blood flow causes this area to be hypoxic.
Veins affected the most:
o Femoral, popliteal, and iliofemoral veins
o During pregnancy: pelvis veins
Composition of thrombus
Image by Lecturio.
Complications of DVT
Pulmonary embolism:
o Potentially fatal
o Occurs as a result of mechanical obstruction of the pulmonary artery or its
branches by a variety of materials (e.g., thrombus, air, or fat)
o Has both cardiovascular and respiratory effects (hypotension and hypoxia)
Chronic venous insufficiency:
o Due to wear and tear, congenital causes, or presence of thrombus
o Most superficial venous insufficiency is attributed to valvular conditions of the
greater saphenous vein.
Post-thrombotic syndrome (most common complication of proximal DVT)
o Symptoms include pain and swelling.
o Ulcers develop in the long term on lower extremities.
o Mobility can be reduced.
o Some patients experience paresthesias.
o Occurs in 25%–50% of all patients with DVT
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3:28
Deep Vein Thrombosis: Pathogenesis
Clinical Manifestations
Symptoms/manifestations are usually unilateral.
o Pain
o Warmth
o Edema
o Intact distal pulses
o Fever (due to cytokine release)
o Homan sign: calf pain on dorsiflexion of the foot (neither sensitive nor specific)
o The first manifestation can be pulmonary embolism (e.g., chest pain, dyspnea)
o Chronic DVT can be asymptomatic and cause chronic venous insufficiency.
Phlegmasia cerulea dolens: obstruction of all veins of 1 extremity → limited arterial
flow → manifestations:
o Edema
o Pulselessness
o Pain
o Cyanosis
Phlegmasia alba dolens: total occlusion of deep iliofemoral venous system →
significant fluid sequestration, edema, and white coloring
o Presents with edema, pain, and blanching without cyanosis
o Edema precipitates phlegmasia cerulea dolens and compartment syndrome →
arterial occlusion and impending limb ischemia
o First described in pregnant and postpartum women
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6:24
Deep Vein Thrombosis: Symptoms
Diagnosis
First test, depending on degree of suspicion
If the suspicion of DVT is high (Wells score > 2), the test of choice is ultrasonography
with Doppler. Diagnostic imaging findings include:
o Lumen is noncompressible
o Hyperechoic mass
o Decreased/absent flow
If the suspicion of DVT is low (Wells score < 2), the first test should be D-dimer.
o Highly sensitive test
o Negative test rules out DVT
o Positive test warrants ultrasonography for confirmation
Diagnostic algorithm for DVT: If the Wells score is < 2, the first test is D-dimer. If the Wells
score is > 2, the first test is ultrasound.
Image by Lecturio.
Further tests
Treatment
Initial treatment
o Heparin bolus (80 units/kg) + heparin infusion (18 units/kg/hr) for 4–5 days
o Alternative to heparin: fondaparinux (indirect factor Xa inhibitor)
o In patients with renal failure, unfractionated heparin is preferred over
fondaparinux and low-molecular-weight heparin (LMWH)
Secondary prevention of DVT
o Initiate warfarin once activated partial thromboplastin time (aPTT) is 1.5–2.5x
normal (continue only heparin if the patient has increased risk of bleeding/peptic
ulcer disease)
o Alternative to warfarin for secondary prophylaxis:
Direct oral factor Xa inhibitor (e.g., rivaroxaban, apixaban)
Does not require regular monitoring of international normalized ratio
(INR), but is more expensive
Other preventive measures
o Early mobilization after surgery
o Postoperative anticoagulation
o Exercise
o Weight loss
o Stopping smoking
o Control of hypertension
o Avoidance of OCPs
o Compression stockings
Indications for thrombolysis (tPA, urokinase, streptokinase)
o Large proximal DVT
o Pulmonary embolism with hemodynamic instability (systolic blood pressure < 90)
o Refractory to anticoagulation
Indications for thrombectomy (removal of thrombus by a catheter)
o Phlegmasia cerulea dolens
o Large thrombus refractory to fibrinolysis
o Large thrombus + contraindications to anticoagulation/thrombolytics
Indications for an inferior vena cava (IVC) filter
o Contraindications to anticoagulation/thrombolytics/thrombectomy (e.g., major
bleeding)
o Patients who have DVT or PE while on appropriate anticoagulation
Treatment of phlegmasia alba dolens
o Initiation of adequate anticoagulation
o IV fluid resuscitation
Treatment of phlegmasia cerulea dolens
o Initiation of adequate anticoagulation
o Thrombectomy
o Fasciotomy if compartment syndrome present
o Fibrinolysis if thrombectomy fails
o Amputation: if both thrombectomy and fibrinolysis fail, leading to critical limb
ischemia and limb loss
Treatment of upper extremity DVT
o Anticoagulation (LMWH/unfractionated heparin [UFH]/fondaparinux)
o Fibrinolysis if refractory/large thrombus
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Deep Vein Thrombosis: Therapy
Differential Diagnosis
The following condtions are differential diagnoses of DVT:
Peripheral vascular disease: a chronic disease involving arteries in the extremities, and
the main cause of intermittent claudication. The chronic atherosclerotic process leads to
arterial stenosis and, at a later stage, to the complete occlusion of the arteries (either from
embolism or thrombosis).
Baker cyst: Baker cyst is a swelling in the popliteal space (space behind the knee). The
pain worsens if the patient fully flexes or extends the knee. Baker cysts are commonly
associated with rheumatoid arthritis. A ruptured Baker cyst can mimic an acute DVT.
Lymphedema: localized fluid retention and tissue swelling caused by a compromised
lymphatic system. Lymphedema can be caused by surgery, parasitic infections, or
hereditary conditions. The condition is often bilateral, unlike a DVT, which is unilateral.
Cellulitis: a condition that presents with localized swelling, warmth, redness, and pain in
an area. Cellulitis is an infection of the dermis and subcutaneous fat and may form
abscesses.