Dr. Heru Sulastomo, Sp.
JP (K), FIHA
Dr. Ahmad Yasa’, Sp.JP, FIHA, Mkes
The Management of DVT
Introduction
› 50% of untreated DVT’s will be
complicated by a PE.
› 26% of unrecognized pulmonary
embolisms are eventually fatal.
› P.E. accounts for 16% of all
hospital death.
The Worcester DVT Study. Arch Intern Med. 1991;151:933-938
Venous thromboembolism (VTE) =
Clinical spectrum from DVT to PE
VTE
Deep vein
PE insufficiency
Pulmonary Death Post-thrombotic
hypertension syndrome
Chronic PE Ulcus cruris
Deep vein thrombosis
Common femoral vein
Thrombus
Proximal
Knee
Distal
Veins of the leg
Virchow’s Triad
Risk Factors Are Cumulative
Cancer
Estrogen use Surgery
Family history Prior DVT
IBD Central venous access
Nephrotic syndrome Cancer chemotherapy
Blood transfusions or radiotherapy
Thrombophilia
Age >40 years
Immobilization
MI
CHF
Paralysis
CHF=congestive heart failure; DVT=deep vein thrombosis; IBD=inflammatory bowel disease; MI=myocardial infarction.
Geerts et al. Chest. 2004;126(suppl):338S-400S.
VTE – risk factors
Persistent Transient
Acquired • Pregnancy
• Age • Oral contraceptives
• History of VTE
• Hormone replacement
• Malignancy therapy
• Antiphospholipid antibody • Immobilisation
syndrome
Genetic • Surgery
• Thrombophilia
Clinical Features of DVT
• Asymtomatic
• Symtomatic :
Leg Swelling +/- pitting edema
Leg Pain
Redness and Warmth
Pallor or Cyanotic
Homan’s Sign
Algorithm for Diagnosing DVT
European Heart Journal (2017) 00, 1–14
Well’s Criteria (DVT)
Well’s Criteria (DVT)
Active cancer (tx within <6 months or palliative care) (1)
Calf swelling (3 cm difference – 10 cm below tib tub) (1)
Collateral superficial veins (1)
Paralysis, paresis, or recent immobilization LE (1)
Pitting edema confined to involved leg (1)
Bedridden within 3 days or surgery w/anesth <3mths (1)
Swollen leg (1)
Alternate diagnosis more likely
Probability: Low (0 pts) Intermediate (1-2) High (3)
Lancet 2002;350:1796.
D-Dimer
• 96-100% Sensitivity for active VTE if measured by ELISA or immunoturbidimetric
method.
• Most studies use cutoff <500 ng/mL.
• Not highly sensitive if measured by semiquantitative latex agglutination.
• A low Well’s Score Criteria plus a normal D-Dimer implies a LOW clinical risk of
VTE.
• 0.5% of patients develop DVT in 3 months.
• Can defer further testing.
What is the risk of DVT in a patient with a moderate or high risk Well’s score and
a normal D-Dimer?
Moderate: 3.5%
High risk: 21%
Fancher TL, White RH, Kravitz RL. Combined use of rapid D-dimer testing and estimation of clinical probability in the diagnosis of
DVT: systematic review. BMJ. 2004;329:821
Ann Fam Med 2007;5:57-62.
Lower Extremity Venous
Ultrasonography
• Compression U/S = B-mode imaging only
• Duplex U/S = B-mode plus Doppler waveform analysis
• Limited VS complete exam
• Iliac, common femoral, femoral, popliteal, greater saphenous, calf
veins
Advantages Limitations
• Cost • Low sensitivity and
• Portability risk of false positives
• May avoid further • No consistent protocol
diagnostic imaging if for technique
positive • Operator dependant
Turkstra F; Kuijer PM; van Beek EJ; Brandjes DP; ten Cate JW; Buller HR. Ann
Intern Med. 1997 May 15;126(10):775-81.
Thrombus in the CFV
Relaxation Compression
Venography
• Gold standard
• Invasive
• Expensive
• Primarily a research tool
http://www.jaapa.com/Media/Images/48/dximaging1207fig2_47609.jpg
Treatment of DVT
• The Treatment of DVT is aimed; at preventing its complication :
PE
Recurent DVT
Post thrombotic syndrome.
Death
TYPES THERAPEUTIC DOSE RECOMMENDATION
Unfractionated - Bolus 5000 Unit per IV - Proximal
Heparin - maintain 1000 U/hr per drip - Distal with
- aPTT target 2-3 times of unl severe risK
- given for 5 days
Enoxaparin -1 mg/kg every 12 hours - Proximal
- given for 5 days - Distal with
severe risK
Fondaparinux - 5 mg / 24 hr for <50 kg weight -Proximal
- 7.5 mg/24 hr for 50-100 kg wght - Distal with
- 10 mg / 24 hr for >100 kg weight severe risK
- given for 5 days
Warfarin / - 2-10 mg/day Usual maintenance
Coumadin - INR target 2.5-3
- given overlapping same days
during UHF / Enoxa. / Fonda.
European Heart Journal (2017) 00, 1–14
Fibrinolytic for Acute DVT
TYPES THERAPEUTIC DOSE RECOMMENDATION
Streptokinase - Bolus 250.000 U/IV for 30 Ilio Femoral
minutes
- Maintain 100.000 U/hr for
24 hours
Urokinase - Bolus 4400 U/kg for 10 mnt Iliofemoral
- Maintain 2000 U/kg/hr for
12 hours
tPA 100 mg IV over 2 hours iliofemoral
Note: No evidence catheter-directed method (local) has greater benefit than
systemic intravenous
Am J Med, 2007; 120: 18-25
• Vena cava filter
May be used when anticoagulation is absolutely contraindicated in
patients with newly diagnosed proximal DVT.
One major complication is filter thrombosis.Contraindication :
major bleeding, post major surgery, traumatic
• Elastic compression
Goal of compression is to relieve venous symptoms and eventually
prevent PTS.
