Deep Vein Thrombosis

By Dr. Muhammad Umair Chang

Definition

 Venous thromboembolism (VTE) is a blood clot that starts in a vein

 Deep vein thrombosis (DVT): a clot in a deep vein, usually in the leg, but sometimes in
the arm or other veins.
 Deep veins of legs include Tibial veins, soleal/gastrocnemius veins, popliteal vein
femoral vein, deep femoral vein, common femoral vein, iliac veins.
 This venous system holds a large amount of blood volume and often called
peripheral heart of the body
 Pulmonary embolism (PE): occurs when a clot breaks free from a vein wall, travels to
the lungs and blocks some or all of the blood supply.
History

 Earliest known reference of venous disease is found in eber papyrus which

dates back to 1550 BC and documents the potentially fatal hemorrhage
that may ensue from surgery on vericose veins
 In 1644, Schenk first observed the venous thrombosis when he described an
occlusion in the inferior vena ceva
 In 1846, Virchow explained the relationship between venoous thrombosis in
legs and PE
Pathophysiology

 Virchow’s Triad
 Alterations in blood flow -
Venous Stasis
 Alterations in blood
constituents
 Vascular endothelium
damage
Epidemiology

 Approximately 1 person in 20 develops a DVT in the course of his or her

lifetime. About 600,000 hospitalizations per year occur for DVT in the United
States.
 Deep venous thrombosis usually affects individuals older than 40 years. The
incidence of VTE increases with age in both sexes. The age-standardized
incidence of first-time VTE is 1.92 per 1000 person-years.
 The male-to-female ratio is 1.2:1, indicating that males have a higher risk of
DVT than females.
 From a demographic viewpoint, Asian and Hispanic populations have a
lower risk of VTE, whereas whites and blacks have a higher risk (2.5-4 times
higher).
Prognosis

 most cases of deep venous thrombosis (DVT) is occult and usually resolves
spontaneously without complication.
 Death from DVT is attributed to massive pulmonary embolism (PE), which
causes as many as 300,000 deaths annually in the United States.
 Untreated proximal dvt has a risk 30-50% of developing PE and 12-15%
mortality
 Treated DVT has a risk of less the 8% of developing PE and less than 2%
mortality
Predisposing Factors

 Principal Risk Factors

 Immobilization
 Trauma
 Surgery
 Infection
 Post-partum period

 Other Factors
 Age, Obesity, Malignancy, Previous VTE, Varicose Veins, Dehydration and
Hormonal Therapy
Signs and Symptoms

 Deep venous thrombosis (DVT) classically produces pain and limb edema;
however, in a given patient, symptoms may be present or absent, unilateral
or bilateral, or mild or severe.
 Edema is the most specific symptom of DVT. Thrombus that involves the iliac
bifurcation, the pelvic veins, or the vena cava produces leg edema that is
usually bilateral rather than unilateral.
 Leg pain occurs in 50% of patients, but this is entirely nonspecific. The pain
and tenderness associated with DVT does not usually correlate with the size,
location, or extent of the thrombus. Warmth or erythema of skin can be
present over the area of thrombosis.
 Pain can occur on dorsiflexion of the foot (Homans sign) but it is present in
only one third of patient presenting with DVT
Signs and Symptoms Cont.

 Superficial thrombophlebitis is characterized by the finding of a palpable,

indurated, cordlike, tender, subcutaneous venous segment can be present.
 In rare cases, the leg is cyanotic from massive ileofemoral venous
obstruction. This ischemic form of venous occlusion was originally described
as phlegmasia cerulea dolens (“painful blue inflammation”). The leg is
usually markedly edematous, painful, and cyanotic. Petechiae are often
present.
 In relatively rare instances, acute extensive (lower leg–to-iliac) occlusion of
venous outflow may create a blanched appearance of the leg because of
edema. The clinical triad of pain, edema, and blanched appearance is
termed phlegmasia alba dolens (“painful white inflammation”),
Signs and Symptoms of PE

 The classic presentation of pulmonary embolism is the abrupt onset of

pleuritic chest pain, shortness of breath, and hypoxia.
 However, most patients with pulmonary embolism have no obvious
symptoms at presentation. Rather, symptoms may vary from sudden
catastrophic hemodynamic collapse to gradually progressive dyspnea.
 Patients with pulmonary embolism may present with atypical symptoms,
such as the following: Seizures, Syncope, Abdominal pain, Fever Productive
cough, Wheezing, Decreasing level of consciousness, New onset of atrial
fibrillation, Hemoptysis, Flank pain, Delirium (in elderly patients)
 The diagnosis of pulmonary embolism should be suspected in patients with
respiratory symptoms unexplained by an alternative diagnosis.
Work up
 American College of Physicians (ACP) provides four recommendations for
the workup of patients with probable DVT).
 First, Wells clinical prediction rules for DVT and PE should be used to
estimate the pretest probability of venous thromboembolism (VTE)
 Second, in appropriately selected patients with low pretest probability of
DVT or pulmonary embolism, it is reasonable to obtain a high-sensitivity D-
dimer.
 Third, in patients with intermediate to high pretest probability of lower-
extremity DVT, Doppler ultrasonography is recommended.
 Fourth, patients with intermediate or high pretest probability of pulmonary
embolism require diagnostic imaging studies. Options include a ventilation-
perfusion (V/Q) scan, multidetector helical computed axial tomography
(CT), and pulmonary angiography
 Coagulation studies and levels of Protein S, protein C, ATIII, factor V Leiden,
prothrombin 20210A mutation, antiphospholipid antibodies, and
homocysteine levels can be measured to rule out any hypercoagulable
states.
Wells Criteria
 The Wells clinical prediction guide quantifies the pretest probability of deep
venous thrombosis (DVT). The model enables physicians to reliably stratify
patients into high-, moderate-, or low-risk categories.
Low Risk Wells
 The American College of Physicians (ACP) has created guidelines based on
the 3 risk group stratification for first-time DVT.
Moderate Risk Wells
High Risk Wells
Treatment

 The primary objectives for the treatment of deep venous thrombosis (DVT)
are to prevent pulmonary embolism (PE), and also
 Prevention of thrombus growth
 Relief of signs and symptoms
 Prevention of recurrence of DVT and PE
Treatment Cont.

 The mainstay of medical therapy in DVT has been anticoagulation drugs

 LMW Heparin followed by coumarin anticoagulant like warfarin was the
standard for a long time and still in practice in many countries.
 However Xa inhibitors like rivaroxaban, fondaparinux , apixaban are now
recommended over warfarin because of wider therapeutic index and
lesser interactions with other drugs
 Thrombolytics like streptokinase, alteplase are only considered to treat dvt
in only hypotensive patients and in acute pulmonary embolism.
 Vena caval filter can be inserted to prevent PE in patients with strong
contraindication to anti coagulation drugs.
Treatment Cont.

 The optimal duration of anticoagulation is between 6 weeks to 6 months.

 However in patients with irreversible cause, treatment can continue for life,
however there is no evidence of better prognosis in patients taking
anticoagulation drugs for more than 6 months.
RIVAROXIBAN

 Rivaroxaban is an oral factor Xa inhibitor that inhibits platelet activation by

selectively blocking the active site of factor Xa without requiring a cofactor
(eg, antithrombin III) for activity.
 It has advantage of no need of LMWH to start the treatment, no INR
monitoring and a wider therapeutic index than warfarin however it is noted
in einstien dvt trial that the decrease in mortality is not significant as
compare to warfarin.
 Dosage for DVT is 15 mg twice a day for 21 days then one 20 mg tablet per
day
 Side effects include Post haemorrhagic Anemia, Back pain, bleeding gums,
bloody stools and bowel or bladder dysfunction
THANKS