DEEP VEIN THROMBOSIS

Diagnostic and Management

Dairion Gatot,

Hematology -Onkology Medic Division

Internal Departement of Medical Faculty of North
Sumatera University/Haji Adam Malik General Hospital,
Medan 2018
KASUS
 DEEP VEIN THROMBOSIS
DVT PROBLEM IS NOT DEATH

SEQUALE
& COMPLICATION

PERMANENT BLOOD VESSEL

DAMAGE OF INFERIOR EXTREMITY
POST THROBOSIS OF VEIN INSUFISIENCY

POST PHLEBITIS SYNDROMA

PULMONAL EMBOLI
PULMONAL HIPERTENSION
 DVT:
PATOGENESIS
Thrombus Generation and Extension
Pathogenesis of Thromboembolism
 Pulmonary embolism
can occur at any site in the lung vascularisation

Small VTE & large VTE ???  PE

 DVT:
DIAGNOSIS and
DIFFERENTIAL
DIAGNOSIS
 Diagnosis of DVT
1. History of illness: Symptoms (+) or (-)
Risk Factors: Medical & Surgery
2. Physical examination:
• Pitting edema of the leg
• Pain
• No clear signs or symptoms (subocclusive
thrombus)
3. Laboratory & Radioimaging examinations:
• D-dimer
• Veno/Phlebo-graphy (“Gold Standard”)
• Compression/ Dupplex ultrasonography (96 –
97 %) for sympt. Prox. DVT
• Duplex scan
• Impedance Plethysmography
 CAUSES of EDEMA of the LOW
EXTREMITIES (differential diagnosis)
ACUTE EDEMA CHRONIC EDEMA

Deep vein thrombosis (DVT) Venous abnormalities:

Superficial Thrombophlebitis - post thrombotic syndrome/
Cellulitis post phlebitic syndrome
Joint effusion/Haemarthrosis - chronic vein insufisiency
Fractures - lipodermatosclerosis
Arthritis - venous obstruction / suppression
Dermatitis Lymphedema: - tumors
- infections
- trauma, dll
Diseases : - hemangioma
- congenital
Others: = heart failure
- idiopathic edema in women
 DVT >< AIL
Diagnotic: Symptom and Sign

DVT AIL
• Symtom (stasis) (ischemia)
- edema pain:
usually unilateral - thromboemboli: onset akut
- silent DVT - thrombotic: slowly
- pain dan hard (intermittent claudication)

• Simtom & - pain - “6 Ps”: pain, pallor, pares-

sign - pitting edema thesia,paralysis,pulseless-
- flebitis:inflamasi ness, poikylothermia
- dilatasi v.superfisial - awal: nyeri & parestesia
- sianosis (ileofemoral) - palpasi : arteri pulse (-)
DIAGNOSTIC APPROACH
of
DVT
 RISK FACTORS of
SUSPECTED DVT
• Risk factor scoring systems:
- the Wells score for suspected DVT
(7 objective + 1 subjective factors)
- the Geneva score for suspected DVT
(objective factors: blood gases analysis)

• Low risk group

• Intermediate risk group
• High risk group
 The WELLS SCORE for patients
clinically SUSPECTED DVT
Wells clinical prediction score for DVT Points

Cancer +1
Paralysis or recent immobilization +1
Bedridden > 3 days, or surgery / trauma < 4 weeks +1
Pain or palpitation of the deep veins +1
Edema of thigh and calf +1
Pitting edema (symptomatic side only) +1
Alternative diagnosis as least as likely DVT - 2

Clinically probability:
Low ≤0
Intermediate 1-2
High ≥3
 LABORATORY TESTS for DVT
A. D-dimer (cutoff value 500 ug/L):
- D-dimer < 500 ng/ml  excluding acute DVT or PE
- negative predictive value for DVT & PE: 98 %
- especially in low & intermediate risk groups
- highly sensitive, but no specific: post surgery, DIC,
inflamation, infection, necrosis, cancers, etc 
D-dimer (+)
- ELISA VIDAS DD: quick & accurate result
(sensitivity:98–100%)

B. Other hemostasis lab tests:

- underlying disease:hereditary/acquired thrombophilia
(AT III & Protein C deficiencies , APS, etc)
 to determine the duration of anticoagulants
 Radioimaging examinations:

• PLETHYSMOGRAFI

• VENOGRAFI CONTRAS (Golden standard)

• USG (USG Kompresi, Duplex USG, Colour flow

doppler imaging)

-DUPLEX ULTRASOUND:
Sensitiviti 93%, spesificiti 98% (average 97%)

• SPIRAL COMPUTED TOMOGRAFI VENOGRAFI

& MRI.
MANAGEMENT of DVT
 MANAGEMENT
A. Acute Treatment of DVT
• B. Duration of Anticoagulant Administration
 to prevent recurrent DVT (localized DVT)
 to prevent acute distant consequences (PE)
 to prevent chronic local consequences:
- venous valve damage / destruction
- chronic valve insufficiency (CVI)
- Post thrombotic / Post phlebitic syndrome
(PTS / PPS)
C. Treatment of Underlying Causes (Risk/ Trigger
Factors)
 MANAGEMENT
1. General Measures:
- elevation of the feet
- compression with elastic stocking
& intermittent pneumatic compression
- early mobilization

2. Medications:
a. Heparin: UF-heparin or LMWH
b. Warfarin (oral anticoagulant)
c. Fibrinolytic agents
c. Others
3. Surgery: in recurrent / chronic DVT