Deep vein thrombosis

Deep venous thrombosis

Venous thrombi typically develop within a deep vein at a site of vascular trauma and in areas of sluggish blood flow, such as valve cusps and the venous sinuses of the calf. Accumulation of fibrin and platelets causes rapid growth in the direction of blood flow, potentially reducing venous return. Endogenous fibrinolysis results in partial or complete resolution of the thrombus. Residual thrombus will organize. Incomplete recanalization of the vein often results in narrowing of the lumen and valvular incompetency. An extensive collateral network can develop.

Types of DVT
Distal DVT - Affects calf veins - Usually asymptomatic, but can extend proximally Proximal DVT - Affects popliteal, femoral, or iliac veins - Symptoms usually do not develop until proximal leg veins are involved -risk of PE ~50% of patients with symptomatic proximal DVT have
silent PE at time of diagnosis

Deep Vein Thrombosis

Symptomatic Patients

DVT

80 % proximal thrombosis

20% calf vein thrombosis

50% progress to PE

30% progress to proximal

Deep Vein Thrombosis (DVT)

Natural History
Acute Non-Acute

or

platelets

thrombus

propagation embolization organization

activated platelets - present in acute but not non-acute thrombi

flow

Acute DVT
Originates in the deep veins of the lower extremities Signs and symptoms are non-specific Only 20-50% of symptomatic patients have confirmed acute DVT1,2 As many as 90% originate in the calves3,4

1.Wells RD et al. Lancet 1995; 345:1326-1330. 2. Stamatakis JD et al. Br J Radiol 1978 65:449-451. 3. Nicolaides AN et al. Br J Radiol 1971; 44:653-663. 4. Stein PD et al. Circulation 1967; 35:671-681.

Conditions Associated with Acute DVT

Cancer Major surgery Immobilization Prior history of DVT Trauma Oral contraceptives, obesity, heart disease, pregnancy, advanced age

Location of Venous Thrombosis:

Signs and Symptoms of DVT

Calf pain and tenderness Calf or leg swelling Erythema Leg warmth Dilation of superficial veins Palpable cord Homans sign

Risk Factors Virchows Triad

1. Stasis of blood 2. Hypercoaguability 3. Vessel Wall Trauma / Change

Risk of DVT in Absence of Prophylaxis in Hospitalized Patients

General medical patients 10 - 20% General surgery 15 - 40% Major gynecologic surgery 15 - 40% Neurosurgery 15 - 40% Stroke 20 - 50% Hip/knee replacement, hip fracture 40 - 60% Spinal cord injury 60 - 80% Critical care patients 10 - 80%

CHEST 2004;126(3):338S-400S

Diagnosis of DVT
CLINICAL FINDINGS CONVENTIONAL X-RAY CONTRAST VENOGRAM DUPLEX DOPPLER ULTRASOUND D-DIMER (BLOOD TEST) RADIONUCLIDE METHODS

ALL METHODS HAVE STRENGTHS AND WEAKNESSES IDEAL EXAM:

NON-INVASIVE NON-MORBID PERFORMED IN REASONABLY SHORT TIME FRAME RELATIVELY CHEAP STUDY ALL PERTINENT SEGMENTS DEMONSTRATE AGE AND SIZE OF CLOT

DIAGNOSTIC METHODS

CLINICAL FINDINGS
CONTRAST VENOGRAM DOPPLER D-DIMER NUCLEAR

CLINICAL FINDINGS
LEG PAIN/SWELLING POSITIVE HOMANS SIGN (PAIN ON DORSIFEXION OF FOOT) PALPABLE CORD SUPERFICIAL THROMBOPHLEBITIS 1/3 OF DVTS ASYMPTOMATIC OF DVTS FOUND AT AUTOPSY ABOVE CALF, ONLY 19% HAD SYMPTOMS/SIGNS

CLINICAL CONTD.
CONVERSELY, VENOGRAMS (+) FOR DVT IN ONLY 46% OF CLINICALLY SUSPECTED CASES DDX:
CELLULITIS BAKER CYST (ESPECIALLY WITH RUPTURE) HEMATOMA ETC.

CLINICAL FINDINGS: UNRELIABLE

DIAGNOSTIC METHODS
CLINICAL

CONTRAST VENOGRAM
DOPPLER D-DIMER NUCLEAR

Contrast Venography
Gold Standard for imaging DVT - when technically adequate can image entire lower extremities sensitive in asymptomatic patients

Limitations
painful technically inadequate/difficult to interpret in 10-30% of cases1,2

1. Hirsh J et al. Circulation 1996; 93:2212-2245. 2. Anand SS et al. JAMA 1998; 279:1094-1099.

Venogram shows DVT

CONTRAST VENOGRAPHY CONTD. COMPLICATIONS OF CONTRAST VENOGRAM

DVT CAUSED BY DYE IN PT WITHOUT DVT

IONIC CONTRAST - UP TO 25% NONIONIC CONTRAST - UP TO 7% NON ISOSMOLAR, NONIONIC - STUDIES PENDING

ALLERGIC REACTION RENAL AND OTHER TOXICITIES DEATH

External iliac vein deep venous thrombosis diagnosed by compression duplex ultrasound. The distal external iliac vein is dilated and contains echogenic material. The image on the right demonstrates lack of compressibility (arrow).

DIAGNOSTIC METHODS
CLINICAL CONTRAST VENOGRAM

DOPPLER
D-DIMER NUCLEAR

DUPLEX DOPPLER ULTRASOUND

ONLY RELIABLE FROM INGUINAL LIGAMENT TO TAKE-OFF OF TIBIAL VEINS MULTIPLE TRIALS:
92% SENSITIVITY (FOR ALL CLOT IN LEG, EVEN THOUGH CALF VESSELS NOT SEEN) 99% SPECIFIC

Color duplex scan of DVT

DOPPLER

CONTD.

METHOD

PULSED DOPPLER/BETTER WITH COLOR COMPRESSION AT EVERY LEVEL FROM UPPER COMMON FEMORAL TO LOWER POPLITEAL (EVEN IF CLOT NOT SEEN, INCOMPLETE COMPRESSABILITY SUGGESTS PRESENCE OF CLOT)

NORMAL WITHOUT COMPRESSION

NORMAL WITH COMPRESSION

PARTIALLY OBSTRUCTING THROMBUS

Ultrasonography
Advantages
high sensitivity (82-100%) for proximal DVT (thighs and knees) in patients with localizing signs and symptoms1 fast low cost per procedure

1. Rose SC. RSNA Categorical Course in Vascular Imaging. 1998:139-156.

Venous ultrasonography

DRAWBACKS TO VENOUS DOPPLER

HEAVILY OPERATOR-DEPENDENT SOME SEGMENTS MAY BE BLIND TO SAMPLING CALF VEINS USUALLY NOT STUDIED, BUT WITH NEW GENERATION EQUIPMENT CALF VEINS CAN BE RELIABLY SEEN IN 60-90%; IF SEEN, DOPPLER 90% SENSITIVE AND SPECIFIC FOR CLOT IN THEM.

Anatomic Imaging Modalities

Contrast Venography and Ultrasonography

not specific for acute DVT cannot reliably differentiate acute from non-acute DVT

DIAGNOSTIC METHODS

CLINICAL CONTRAST VENOGRAM DOPPLER

D-DIMER
NUCLEAR

D-DIMER: BLOOD TESTING FOR ACUTE THROMBOSIS

DEGRADATION PRODUCT OF CIRCULATING CROSS-LINKED FIBRIN ELEVATED LEVELS IN ACUTE THROMBOSIS

Fig. 2: Diagnostic algorithm using D-dimer testing and ultrasound imaging in patients with suspected DVT

Scarvelis, D. et al. CMAJ 2006;175:1087-1092

Copyright 2006 Canadian Medical Association or its licensors

RECENT LITERATURE REVIEW: (BECKER, et al ARCHIVES INT MED, MAY 96

VARIOUS ASSAYS NOT STANDARDIZED (ELISA, LATEX, IMMUNOFILTRATION) STUDIES HAVE NOT LOOKED FOR PRESENCE OR ABSENCE OF BOTH DVT AND P.E.
(I.E. PTS CONSIDERED FREE OF P.E. MAY HAVE HAD SILENT DVT, AND VICE VERSA)

DIAGNOSTIC METHODS
CLINICAL VENOGRAPHY DOPPLER D-DIMER

NUCLEAR MEDICINE

NUCLEAR VENOGRAPHY
99MTc-MAA SENSITIVITY 94%/SPECIFICITY 92%
(SIEGEL, USC)

PROS:
LUNG PERFUSION; ILIACS/IVC

CONS:
CALF VEINS; NONOBSTRUCTING CLOT WITHOUT COLLATERALS

Patient with suspect symptomatic Acute lower extremity DVT

Venous duplex scan

positive

negative

Low clinical probability High clinical probability

observe
negative

Evaluate coagulogram /thrombophilia/ malignancy

Repeat scan / Venography

Anticoagulant therapy contraindication
yes

IVC filter

No

pregnancy OPD

LMWH LMWH UFH

hospitalisation

warfarin

Compression treatment

Thrombophilia screening Factor V leiden, Prot C/S deficiency Antithrombin III deficiency

Idiopathic DVT < 50 years Family history of DVT Thrombosis in an unusual site Recurrent DVT

Recommendation for duration of warfarin

3-6 months first DVT with reversible risk factors At least 6 months for first idiopathic DVT 12 months to lifelong for recurrent DVT or first DVT with irreversible risk factors malignancy or thrombophilic state

Goals of Acute DVT Treatment

Short-term objectives: - Prevent extension of thrombus -Prevent development of pulmonary embolism - Prevent early recurrence Long-term objectives: - Prevent delayed recurrences - Prevent sequelae such as postthrombotic syndrome and pulmonary hypertension

Antithrombotic Agents for DVT Treatment

Heparins - Unfractionated heparin (UFH) - Low-molecular weight heparin (LMWH) Factor Xa inhibitor - Fondaparinux (pentasaccharide) Warfarin

General Surgery
Heparin 5,000 units SC q8h (begin 2h preop) Enoxaparin 40 mg SC q24h (begin 2h preop) Dalteparin 5,000 units SC q24h (begin 12h preop, or give 2,500 units 2h preop)

Orthopedic Surgery
Enoxaparin 40 mg SC q24h Enoxaparin 30 mg SC q12h Dalteparin 5,000 units SC q24h Fondaparinux 2.5 mg SC q24h Warfarin, target INR 2.0-3.0

LMWH in Neurological Surgery

307 patients undergoing neurological surgery randomized to Enoxaparin 40 mg daily or Placebo. All had bilateral leg venography predischarge No pneumoboots

Placebo: 32% DVT rate Enoxaparin: 17% DVT rate Major Bleeding: 3% each group

Agnelli et al; NEJM 1998; 339:80-85

Summary
DVT and PE are common in hospitalized patients and represents among the most common preventable adverse outcomes Routine prophylaxis is not common given Standard use of prophylaxis reduces adverse events