Diagnosis and Treatment

of Deep Venous
Thrombosis and
Pulmonary Embolism

Beth Stuebing, MD, MPH

History
 Susruta (Ayurveda physician
and surgeon, 600-1000 B.C.) –
patient with a “swollen and
painful leg that was difficult to
treat”

 Giovanni Battista Morgagni,

1761 – recognized clots in
pulmonary arteries after
sudden death, but didn’t make
the connection to DVT
Virchow Strikes Again
 “Discovered” PE in 1846 –
“the detachment of larger
or smaller fragments from
the end of a softening
thrombus which are carried
along the current of blood
and driven into remote
vessels. This gives rise to
the very frequent process
on which I have bestowed
the name Embolia”
Deep Venous Thrombosis
- Epidemiology
 1969 paper by Kakker
– 30% of post-op patients develop clot in calf
veins
– 35% of these lysed within 72 hrs
– 15% of pts with persistent thrombosis developed
PE
 Recent studies put incidence at 50 per
100,000 person years
 Incidence greatly increases with age, 18%
of 80yr old patients have asymptomatic DVT
 DVT Diagnosis
 Wells clinical prediction rules
 D dimer ELISA assay >90% sensitive, but 40-
50% specific
 When D dimer is negative and clinical
suspicion low, further studies are
unwarranted
 Ultrasound most sensitive and specific
(>90%) for symptomatic, proximal vein
 US only 50-70% sensitive for asymptomatic
pts
 Sens. And spec. much lower for symptomatic
arm DVT (60-90%)
DVT Treatment (medicine)
 Initial treatment with UFH or LMWH
 Goal aptt (with heparin) 1.5-2.5x nl
 25% pts resistant to heparin, better to monitor anti-factor Xa instead
 LMWH monitoring not necessary, but can be done with goal anti Xa
level 0.6-1 U/ml (drawn 4hr after dose)
 Age increases bleeding risk
 Some studies suggest lower mortality with LMWH in elderly

 Transition to warfarin (goal INR 2-3), or continue with LMWH

 Starting with large doses (10mg) NOT recommended
 3 months treatment with temporary, known risk factor (fracture,
pregnancy, air travel)
 At least 6 months treatment with no discernible cause
 Hypercoagulable workups not necessary in the elderly
 Length of treatment a risk:benefit analysis
 Major bleeding risk 1-3% per year with INR 2-3
DVT Treatment - Filters

 Consider in pts with contraindications to

anticoagulation or develop recurrent DVT or
PE despite adequate medical therapy
 Randomized trial of anticoagulation +/-
IVCF:
– PE at day 12 reduced with filter, but benefit
didn’t persist
– Double risk of recurrent DVT with IVCF
Pulmonary Embolism -
Epidemiology
 1/3 of people with DVT may develop
symptomatic PE
 1975 paper
– Incidence 630,000 per year
– Death within 1 hour in 11%
– Undiagnosed 1 hr survivors: eventual 30%
mortality
– Diagnosed 1 hr survivors (treated): 8% mortality
PE Diagnosis
 Clinical diagnosis is nonsensitive and
nonspecific
 ECG
 ABG
 CXR
 Angiogram
 VQ scan
 ECHO
 CT chest
ECG Changes
 “S1 Q3 T3”
 S wave in lead I
 Q wave in lead III
 Flipped T in lead III
 Possible RBBB

 Signs of cor pulmonale

 Classic, but uncommon
 Arterial Blood Gas
 Hyperventilation leads to low pCO2
 Difficulty in oxygenation
 Alveolar-arterial gradient may be
elevated (80% of cases)
 A-a O2 Gradient = [ (FiO2) *
(Atmospheric Pressure - H2O
Pressure) - (PaCO2/0.8) ] -
PaO2 from ABG

Nl Gradient Estimate = (Age/4) + 4

CXR – even post mortem!
 Westermark sign - ischemia appeared as a clarified
area with diminished vascularity corresponding to
the extent of the embolized artery
Pulmonary Angiography

 Started in 1950s
 47% positive
studies had no
signs on CXR
 1st confirmatory test
other than autopsy
VQ scan
 Started in 1960s
 Correlated well with
angiogram and
autopsy
 “High probability”
scans: 41% sensitive,
97% specific
 Adequate for diagnosis
in a minority of
patients
ECHO for PE

 RV dilates and LV is smaller in most

patients
 Unreliable in pts with prior cardiac
dysfunction
 TEE reported to be >90% sensitive
and specific
 Right heart dysfunction resolves after
thrombolytic therapy
CT Chest

 Spiral CT chest
introduced in early
1990s
 Sensitivity 86-
100%, specificity
92-96% for central
PE
 63% sensitive for
subsegmental PE
PE Treatment

 Heparin
 Embolectomy
 Thrombolytics
 Venous interruption
 IVC filter
Heparin - Warfarin

 Not used until 1940s

 Only prospective randomized trial in
1960s
– 2 weeks of anticoagulation after PE
– No deaths or nonfatal PE in treatment
group
 1990s - LMWH found equally effective
Trendelenburg’s Procedure

 Thromboembolectomy,
described in 1908
 First survivor of the
procedure not until 1924
 Via left chest
thoracotomy
Thrombolytics

 Introduced in 1960s
 Unclear benefit over heparin,
significant bleeding risk
 Now used for massive PE with
hemodynamic deterioration
 Can be direct or systemic
 2-3% risk intracranial hemorrhage
Venous Interruption

 Started with femoral vein ligation in

1930s
 1940s, Homan suggested IVC ligation
instead
 Led to the first IVC nonextractable
filter in 1969
 IVC Filters

 Decousus, et.al., 1998

randomized trial for DVT:
heparin/warfarin alone
versus heparin/warfarin
plus IVCF
– No difference in 2 year
mortality
– Less PE but more recurrent
DVT in filter group
Prevention

 1960s study: heparin q12h for 7 days

after major surgery decreased DVT
from 42% to 8%
 Established as standard of care after
1975 study with similar results
 60-70% relative risk reduction for DVT
and fatal PE post-op
DVT and PE in the ICU

 One study: routine Doppler shows DVT in up

to 30-40% of all ICU patients, regardless of
prophylaxis
 Much less likely to have physical exam
findings
 One study showed 38% of ICU pts with
known DVT had undiagnosed PE on VQ scan
 One autopsy study: 84% of PE were not
diagnosed antemortem
DVT and PE in the ICU
 Chemical prevention has similar risk
reduction of 60-70%, variety of meds
studied
 CT chest is higher risk (contrast load, travel
with critical patient) and often unfeasible
 VQ scans essentially uninterpretable given
multitude of pulmonary pathology
 Higher risk: personal or family history, renal
failure, platelet transfusion, vasopressor
use, longer time on ventilator
Thanks, and Questions?