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Deep Vein Thrombosis

(DVT)

Definition
Thrombus: A solid mass of platelets
and/or fibrin (and other components
of blood) that forms locally in a
vessel.
Embolus: Detached intravascular
solid, liquid, or gaseous mass that is
carried by the blood to a site distant
from its point of origin.
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Virchows Triad
Endothelial Injury

Hypercoagulabilit
y

Venous Stasis

Virchows Triad
1. Endothelial Injury
Physical loss of epithelium
subendothelial extracellular matrix
exposure, platelet adhesion, TF
release, PGI2 & PAs depletion
Eg. Trauma/ surgery, haemodynamic
stress of hypertension, turbulent flow
over scarred valves
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Virchows Triad
2. Hypercoagulability
Any alteration of the coagulation
pathways that predisposes to
thrombosis
1 (Congenital): Factor V Leiden, Anti
thrombin III def., protein C & protein S
def.
2 (Acquired): Preganacy, puerperium,
malignancy
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Virchows Triad
3. Venous stasis
Immobility, Obesity, Pregnancy,
Paralysis, Operation, Trauma

Fate of Thrombus
1. Propagation
2. Embolization
3. Dissolution: Removed by fibrinolytic
activity
4. Organization: To fibrinnous thrombus
5. Recanalization: Capillary channels
formed in the organized thrombus
6. Culture medium for bacteria
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DVT Pathology

DVT Pathology

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Clinical Features
Symptoms

Signs

a. Asymptomatic

a. Erythema & swelling

b. Pain/ mild discomfort +

b. Stiff calf + tenderness over the

swelling (calf muscles &


along courses of deep vein)

course of the deep vein


c. Homans sign (resistance of the

c. Mild fever

calf muscles to forcible

d. Symptoms of PE

dorsiflexion of foot, unreliable

e. Plegmasia curulea dolens

and should not be performed)

(massive oedema + cyanosis d. Low grade pyrexia & tachycardia


and ischemia)
f. Phlegmasia alba dolens
(pale)

e. Signs of PE (SOB, pleuritic chest


pain, hemoptysis, syncope,
apprehension)
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Complications of DVT
Pulmonary embolism
Post thrombotic syndrome
Phlegmasia alba & caerulea dolens

Post Thrombotic
Syndrome
Characterised by:
Oedema
Hyperpigmentation
Venous ectasia
Redness
Pain during
compression
Skin induration
Ulcer
Further reading : http://circ.ahajournals.org/content/121/8/e217.full

Post Thrombotic
Syndrome

Phlegmasia Alba & Caerulea


Dolens
Extreme cases of lower-extremity DVT causing
critical limb ischemia and possible limb loss.
PAD:swollen & white leg d/t early compromise
of arterial flow 2 to extensive DVT. Also known
as milk leg (women in the third trimester of
pregnancy or post partum)
PCD: severe swelling & cyanosis of the
extremity.Precursor of frank venous gangrene

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DVT Investigation

Screening

Diagnostic

D-dimer test
not in Malaysia. Why?

Further reading : Malaysian CPG on Venous Thromboembolism, August 2013

DVT Investigation

Screening
1. Lack standardisation and cut off
value
2. Blood agglutination for D-dimer
test for most lab in Malaysia is
not sensitive to rule out VTE
not in Malaysia. Why?
3. Other causes of raised DVT
which limits the exclusion of VTE

D-dimer test

Further reading : Malaysian CPG on Venous Thromboembolism, August 2013

D-dimer test
Quick, non-invasive screening for
abnormal or excess clotting
Normal or negative D-dimer
result no acutecondition or
disease causing abnormal clot
formation and breakdown
Positive D-dimer - indicates
significant blood clot formation and
breakdown in the body, but it does
not tell the location or cause
Elevated levels may be seen in
recent surgery, trauma,
infection,myocardiac infarction,
malignancy or liver diease.
Further reading : https://labtestsonline.org/understanding/analytes/d-dimer/tab/test/

DVT Investigation

Screening
D-dimer test
not in Malaysia. Why?

Diagnostic

Contrast Compression
venography ultrasound
Why not???

Further reading : Malaysian CPG on Venous Thromboembolism, August 2013

DVT Investigation

Diagnostic

1. Invasive
Contrast Compression
2. Higher cost
venography ultrasound
3. Limited availability
(equipments, skilled
Why not???
professionals,
software)
Further
reading : Malaysian
CPG on Venous Thromboembolism, August 2013

Contrast Venography vs
Compression Ultrasound
Contrast
venography
Gold standard
Better in
identifying calf
vein thrombosis
Increased risk of
phlebitis and
contrast related
problems
Invasive and
painful

Compression
ultrasound

Non-invasive

Poor visualization of
iliac, and pelvic
veins

Requires skilled
operator
Can be repeated
serially to monitor
suspected DVT

Poor sensitivity in
identifying calf vein
urther reading : http://www.lumen.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/DVT1.ht
thrombi

Contrast Venography
Shows presence of
intraluminal filling
defect.
Venogram showing
a popliteal deep
vein thrombosis

Compression Ultrasound
compression

compression

transducer

(Normal)

transducer

(DVT)

Further reading : http://www.lumen.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/DVT1.h

Normal or not?

Normal or not?

Duplex Ultrasonography

Color flow in the


normal femoral
vein

DVT (clot) identified by


Duplex Scan

Colour Coded Doppler Ultrasonograph

Normal popliteal vein .


Compression of the veins
by the Doppler probe
causes the normal veins to
collapse COMPLETELY
(compressibility).

Transverse section color


Doppler images show failure
to fully compress the
affected part of the left
popliteal vein, which
confirms the presence of a
thrombus.

Treatment of DVT
Principle of treatment
Prevent thrombus extension
Prevent thrombus embolisation

Clinically suspicious? Start


LMWH/Fondaparinux until diagnosis excluded
Diagnosis established within 24 hours, start
warfarin + LMWH/Fondaparinux/Rivaroxaban
If renal failure offer UFH
basedonAPTTorLMWHwithdose
adjustments on anti-FXa assay
Further reading : Malaysian CPG on Venous Thromboembolism, August 2013

LMWH
Enoxaparin 1
mg/kg twice daily
Tinzaparin dose is
175 IU/kg once
daily

Fondaparinux
Fondaparinux- 7.5
mg daily
(5 mg if <50
kg,7.5mg if 50100 kg , 10 mgif
>100 kg)
continue for at least 5 days or until the INR is
2 for at least 24 hours

Further reading : Malaysian CPG on Venous Thromboembolism, August 2013

Duration of
Anticoagulant

Depends on the risk factor for recurrence


and risk factor for increased bleeding

Further reading : Malaysian CPG on Venous Thromboembolism, August 2013

Further reading : Malaysian CPG on Venous Thromboembolism, August 2013

DVT Prophylaxis

Mechanical
1. Compression stockings
2. Intermittent pneumatic
compression
3. Venous foot pump

Pharmacological
1. UFH
2. LMWH
3. Fondaparinux

Gradient compression
stockings
Gradient compression
stockings (GCS) provide
pressure that is strongest
around the foot and ankle
and looser as it moves up the
leg
Systematic review of
randomized, controlled trials
Sajid MS, Desai M, Morris RW, in 2012 found that knee- and
Hamilton G. Knee length versus
thigh-high GCS do not
thigh length graduated compression
stockings for prevention of deep vein significantly differ in their
thrombosis in postoperative surgical
patients.Cochrane Database Syst effectiveness in reducing the
Rev. 2012 May 16. 5:CD007162.
incidence of deep venous

Intermittent pneumatic
compression
In use, an inflatable cuff
encloses the limb requiring
treatment, and pressure
lines are connected between
the cuff and the air pump.
IPC devices have the
advantage of requiring no
monitoring, with no increase
in bleeding.
In a study of the efficacy of
IPC in multiple postoperative
patient groups versus no use
of prophylaxis, Urbankova et
al reported that the

Urbankova J, Quiroz R, Kucher N,


Goldhaber SZ. Intermittent
pneumatic compression and
deep vein thrombosis
prevention. A meta-analysis in
postoperative patients.Thromb
Haemost. 2005 Dec.

Comparison
Method
Graduated
compression
stockings

Function
Provide circumferential pressure
that gradually decreases from the
ankle to the thigh to promote
venous blood flow
Intermittent
Leggings repeatedly inflated and
pneumatic
deflated by a pneumatic pump with
compression
the goal of mimicking natural calf
muscle contractions that promote
venous return
Venous foot
Imitate the physiological pumping
pump
action of weight-bearing on the
venous plexus of the sole of the
foot to simulate the effect of
r reading : https://www.thrombosisadviser.com/en/vte-prevention/other-options-for-vte-prev
normal walking and increase

Pharmacological
prophylaxis
Q1 Who should be offered
prophylaxis?

Further reading : Malaysian CPG on Venous Thromboembolism, August 2013

Further reading : Malaysian CPG on Venous Thromboembolism, August 2013

Q2 When should we give


prophylaxis?

Further reading : Malaysian CPG on Venous Thromboembolism, August 2013

Q3 How long should it be


given?

Further reading : Malaysian CPG on Venous Thromboembolism, August 2013

Thrombolytic therapy
THROMBOLYTI
C THERAPY

Catheter
directed

Systemic

Thrombolytic agent : streptokinase, urokinase and


recombinant tissue-type plasminogen activator (r-tPA)

Venous thrombectomy
Insert a catheter sheath
through a small incision in the
femoral vein in the groin or the
popliteal vein below the knee.
Contrast dye is injected
through the sheath and
venography is performed, to
locate the clot site.
A larger incision over the
diseased vein is made and the
clot is removed with a catheter.

her reading : http://www.miamivascular.com/handler.cfm?event=practice,template&cpid=2