You are on page 1of 27
DEEP VENOUS THROMBOSIS DR GOURANGA KUMAR SAHA MBBS,MD,FESC,FACC Associate Professor Cardiology NICVD, DHAKA Definition of DVT   A deep venous thrombosis is a blood clot that forms in a large, deep vein of the leg, thigh or pelvis. Rarely, a deep venous thrombosis can be formed in the arms. Venous thromboembolism consists of DVT & PE. EPIDEMIOLOGY Incidence of Venous Thromboembolism General population: 0.1% Elderly: 1% Hospitalized patients: 15%    Pathogenesis  Three mechanisms are involved in the pathogenesis of venous thrombosis (Vircow¶s triad), they are: *venous stasis, *injury to the venous wall, *hypercoagulable states. Etiology/ Risk factors of Deep Venous Thrombosis Acquired *Surgery *Major trauma *Malignancy Protein S deficiency factor X1 *Prolong bed rest Fibrinogen *Antiphospholipid syndrome Factor V leiden hyperhomocysteinemia *Puerperium dysfibrinogenemia *Pregnancy *Obesity *Oral pill / HRT *Central venous catheter *Antiphospholipid syndrome *Polycythemia rubra vera/Myloproliferative disorder *Long haul travel *Age •60 Inherited Mixed/unknown Antithrombin III deficiency factor VIII Protein C deficiency factor IX Signs and Symptoms of DVT        50% no symptom Swelling in one or both legs Pain or tenderness in one or both legs, which may occur only while standing or walking Warmth in the skin of the affected leg Red or discolored skin in the affected leg Visible surface veins Leg fatigue Physical examination   Homans' test: Dorsiflexion of foot elicits pain in posterior calf . Pratt's sign: Squeezing of posterior calf elicits pain. Complications of DVT Pulmonary Embolism Postthrombotic Syndrome Other DVT Complications a) Blood clot in the kidney, called renal vein thrombosis b) Blood clot in the heart, leading to heart attack c) Blood clot in the brain, leading to stroke    signs and symptoms of postthrombotic syndrome: Pain oedema hyper pigmentation Skin ulcers varicose veins Recurring DVT or PE Possible causes of pain or swelling of the lower limb Venous:      Deep vein thrombosis Superficial thrombophlebitis Post-thrombotic syndrome Chronic venous insufficiency Venous obstruction Other causes of pain or swelling of lower limb *Cellulitis *Baker's cyst *Torn gastrocnemius muscle *Fracture *Haematoma *Acute arterial ischaemia *Lymphoedema *Hypoproteinaemia (for example, *cirrhosis, nephrotic syndrome) Screening investigations for DVT  D-dimer tests. * Laboratory tests: Enzyme linked immunosorbent assay (ELISA) Latex agglutination * Near patient tests: SimpliRED (agglutination test) Simplify (immunochromatography test) Plethysmography *Digital photoplethysmography *Strain gauge plethysmography *Impedance plethysmography  Definitive investigations for DVT * Venography  Ultrasonography: Compression ultrasound Duplex ultrasonography Colour coded Doppler ultrasonography Computed tomography Magnetic resonance imaging   An algorithm for Diagnosis of DVT Wells Clinical Prediction Rule for DVT Clinical feature Points 1 1 Active cancer (treatment within 6 months, or palliation) 1 Paralysis, paresis, or immobilization of lower extremity 1 Bedridden for more than 3 days because of surgery (within 4 wks)1 Localized tenderness along distribution of deep veins 1 Entire leg swollen Unilateral calf swelling of greater than 3 cm (below tibial tuberosity)1 Unilateral pitting oedema 1 Collateral superficial veins 1 Alternative diagnosis as likely as or more likely than DVT -2 Total points: Risk score interpretation (probability of DVT): 3 points: high risk (75%); 1 to 2 points: moderate risk (17%);<1 point: low risk (3%). 1 1 Indication of Hospitalization ‡Bilateral DVT ‡ Renal insufficiency ‡Body weight >70 kg/154 lbs ‡Recent immobility ‡Chronic heart failure ‡ cancer PHARMACOTHERAPY     Heparin: a) Unfractionated heparin b) Low-molecular-weight heparin 1. enoxaparin 2. dalteparin 3. tinzaparin 4. nadroparin Warfarin. Thrombin Inhibitors Thrombolytics :Catheter-Directed Thrombolysis Anticoagulation :Heparin A protocol for IV heparin :      Give an initial bolus of 80 U/kg Initiate a constant maintenance infusion of 18 U/kg Check the aPTT or Heparin Activity level 6 hours after the bolus & adjust the infusion rate accordingly Continue to check the aPTT or heparin Activity level every 6 hours until 2 successive values are therapeutic Monitor the aPTT or Heparin Activity level, hematocrit, and platelet count every 24 hours Advantages of LMWH over UH * Decreased ³heparin resistance´ ‡ No need for laboratory monitoring  Higher bioavailability - 90% vs 30%  Longer plasma half-life(4 to 6 hours vs 0.5 to 1 hour)  Less inhibition of platelet function  Lower incidence of HIT syndrome Dose of Heparin in initial treatment Method of adm. Dose I/V 5000iu or 80mg/kg infusion LMWH Enoxaparin s/c 1mg/kg 12 hrly or 1.5mg /kg daily Deltaparin s/c 100U/kg 12 hrly or 100U/kg daily Drug UFH warfarin therapy        Warfarin therapy is overlapped with heparin for 4-5 days Heparin must be overlapped with oral warfarin because of the initial transient hypercoagulable state The anticoagulant effect of warfarin should be kept at an INR of about 2.5 (desirable range, 2.0-3.0) Warfarin is metabolized by the hepatic microsomal enzyme pathway so chance of drug interaction should be avoided throughout pregnancy, especially during the first and third trimester Early exposure causes calcified epiphyses (chondrodysplasia punctata) and a characteristic nasal hypoplasia in offspring later exposure is associated with central nervous system abnormalities, including microcephaly. Other Types of Treatment    Vena Cava Filter Graduated Compression Stockings Surgery for DVT : Thrombectomy Thrombolytic Therapy for DVT : advantages      prompt resolution of symptoms the prevention of PE the restoration of normal venous circulation the preservation of venous valvular function the prevention of postphlebitic syndrome Duration of Therapy for Venous Thromboembolism*.     6±12 Weeks-Isolated symptomatic calf vein thrombosis 3±6 Months-First event with reversible or time-limited risk factor (surgery, trauma, immobilization, estrogen use) •6 Months-First event, idiopathic (unexplained) venous thromboembolism 12 Months±life - First event in patients with cancer (unless cured), antiphospholipid syndrome, antithrombin deficiency Recurrent event, idiopathic or with thrombophilia Summary points       Deep vein thrombosis is an important cause of morbidity and mortality Clinical diagnosis is unreliable Screening investigations include D-dimer tests and plethysmographic techniques Definitive diagnosis is usually by venography or ultrasonography Initial treatment is with heparin²unfractionated or low molecular weight²followed by oral anticoagulation Outpatient treatment of deep vein thrombosis is safe Thank you