DVT deep venous thrombosis

Epidemiology:It is common disease in surgical patient of all types estimated incidence without prophylaxis;22%-33% in intra-abdominal surgery. 45%66% in orthopaedic surgery 50% prostatectomy 20% trauma 3% postpartum

Etiology and risk factors
3main factors contribute in development of DVT Stasis. Endothelial injury. Hypercoagulability. Theses are VIRCHOW'S TRIAD

Stasis: mainly caused by heart failure, prolonged immobility Endothelial injury: mainly caused by either direct trauma (severed vein) or local irritation (by chemotherapy, past DVT, phlebitis) Hypercoagulability: inherited (AT III def., protein C, S deficiency) or acquired (malignancy, pregnancy, AT III def., protein C, S deficiency as in nephritic syndrome, DIC and liver failure.

Other risk factors
Age>60 years Obesity Trauma Use of oral contraceptive

Pathogenesis:The thrombus usually originated in the soleal venous sinuses or valvular sinuses .the calf vein is the usual site It may also originate in the iliac or femoral vein.

Symptoms:Dull pain, heaviness, oedema and warm limb With extensive DVT:-massive oedema, cyanosis, dilated superficial collateral veins and low grade fever. With ilio-femoral DVT:Phlegmasia cerulea dolens (cyanosed limb due to obstructed vein) Phlegmasia alba dolens (pale, pulseless cold limb due to concurrent arterial spasm) AND THESE TWO UPPER CASES ARE LIMB THREATENING CONDITION!!

Signs
HOMAN'S sign (tenderness during passive dorsiflexion of foot). And it was contraindicated because of it’s role in thrombus deattachment and thus emobilization Hotness, cyanosis, oedema (non-pitting)

INVESTIGATIONS:
CBC for any abnormalities in Hb, WBC, and platelet count PT aPTT D-Dimer: too unspecific.

IMAGING STUDIES:
*The standard tool for diagnosis is phlebography using fluoroscope .the use of this study limited by is complications which are allergy, nephropathy and phlebitis. *Duplex ultrasound: Test of choice Sensitivity and specificity >95% Include both β-mode and Doppler studies. Able to detect other pathology like BAKER cyst.

The finding are:Acute DVT: Absence of spontaneous flow. Loss of flow variation with respiration. Failure to increase the flow after distal augmentation. Not visible thrombi (anechoic thrombi). Chronic DVT: Not well established Narrow vein Patent collateral Visible thrombi

The only disadvantage of duplex study is that, it is highly operator dependant!!!

*MRV (magnetic resonance venography):Is promising tool for diagnosis, 100%sensitivity, 96% specificity.

Differential diagnoses:
Unilateral limb involvement: muscular strain, tendon rupture, cellulites, lymphodema or retroperitoneal fibrosis pressing over the vein. Bilateral limb involvement: liver, heart or renal failure or IVC obstruction.

Complication of DVT
Recurrent DVT Varicose vein Chronic venous insufficiency Post phlebitic syndrome (pain, oedema and ulceration) PE

MANAGEMENT
The aim of management is:Prophylaxis against DVT Treatment of ongoing DVT

Methods of Prophylaxis:
1) Mechanical Leg elevation Graded compression stocking. early ambulation Pneumatic compression boot.

2) Pharmacological agents: Aspirin (anti platelet factor) not recommended currently. Dextran solution (40 and70) branched polysaccharide. Decrease platelets adhesiveness and aggregation. Disadvantages:- Increase rate of bleeding Pulmonary oedema (due to overload) Allergic reaction in 1% Recommended dose is15-20 cc/h IV infusion before surgery.

Warfarine (coumadine):Decrease incidence of DVTby66% and PE by 80%. Disadvantages:Sever hemorrhage Must be started 2-3 days preoperative. Require careful monitoring for PT.

Warfarine nomograph

Heparin
Unfractionated heparin:Inhibits AT III and potentiate disintegration of thrombi that form while it administered Low dose regimen is 5000 IU twice daily SQ two hours pre-operatively then q12hours post operative till the patient is completely ambulating. For morbidly obese patient: - micro-heparin drip at 1u/kg/hour Disadvantages;Risk of bleeding Thrombocytopenia (rare) Contraindicated in patient with actively bleeding peptic ulcer, uncontrolled HTN, bleeding disorder or recent use of ASA

Heparin-dihydroergotamine (DHE) combination:Cause vasoconstriction of capacitance veins and thus increase the venous return. Particular effectiveness in orthopedic cases. Contraindicated in case of hypotension, IHD and peripheral arterial occlusive diseases. Low molecular weight (enoxaparin):Lesser effect on thrombin and platelets aggregation. Longer life time so the dose will be once daily. More expensive than unfractionated heparin.

Heparin nomograph

Fibrinogen-depleting compound New class of anticoagulants but not well known. Prophylactic IVC filter placement. Also known as Greenfield filter. Used in high risk patient when other methods are contraindicated. Effective in preventing PE not DVT.

An approach to Prophylaxis
1/determine patient at risk Low risk (<40 years old, ambulating, minor surgery) Moderate risk (>40 years old, abdominal, pelvic or thoracic surgery) High risk (>60years old, prior DVTor PE malignancy, orthopedic surgery hypercoagulability state).

2/prohylaxis of choice Encourage all patients to ambulate as soon as possible Low risk patient don't need prophylaxis. Moderate risk pneumatic compression boot or low dose heparin prophylaxis. High risk combination of pneumatic compression boot and low dose heparin prophylaxis or Dextran. Coumadine or IVCfilter are considered. Ophthalmology or neurosurgery patient are NOT candidates for prophylaxis.

Treatment of DVT A: - anticoagulation Heparin bolus 100-150 u/kg IV stat then followed by constant infusion of 1000 u/hour with checking aPTT q4-6hours and keeping the ratio 50-70sec. Coumadine (Warfarine) usually started at day 35 after initial heparin is given and continue for 36 months .PT should be 17-20sec. and INR 2.02.5.

B:-thromolytic treatment( alteplase, streptokinase, urokinase) Promote rapid thrombus lysis.used in cases of sever PE .they have more bleeding complication. C:-venal caval interruption. (IVC filter) Prevent further embolism of thrombi D:- venous thrombectomy May be necessary in venous gangrene and septic thrombosis.

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