Download DEEP VEIN THROMBOSIS

VENOUS THROMBOEMBOLISM Composite term for
DVT &PE

The presence of thrombus with in deep veins is
termed as deep vein thrombosis
It is a life threatening condition that may lead to
sudden death in the short term or long term.
 morbidity due to the development of post
thrombotic limb and venous ulceration
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CLASSIFICATION :
PROXIMAL DVT :thrombus formed in veins
above the knee joint (femoral, iliac, popliteal)
DISTAL DVT : those formed below the knee
joint (calf veins)
Venous thrombosis are
difficult to recognize
clinically. The documented
cases probably represent
only tip of the Ice Berg.
SILENT KILLER
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M:F 1.2:1
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Age more than 40 years.
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VT occur in more than 50% of patient’s having
orthopaedic surgical procedures.
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10 to 20% of patient with idiopathic DVT have or
develop cancer.
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1/3rd to 1/4th patient having proximal DVT may
develop PE.
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About 10% of hospital deaths attributable to PE
(from DVT)
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Calf vein - most common
Ilio femoral - most symtomatic
IVC - most lethal
AIR TRAVEL AND DVT
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Up to 1 out of 10 air line passengers develop small
asymptomatic blood clots.
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Due to hypoxia and reduced cabin pressure.
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VT occurs in patients regularly without any damaged to the
blood vessels.
VTE Risk Patient Factors
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Age
Previous VTE
Malignancy
Advancing age
Obesity
Prolonged immobility
Trauma
Surgery
Pregnancy/ postpartum
Indwelling central venous catheter
Deficiency of anti-thrombin III
Protein C or S
Contd...
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Paralysis of lower limbs
Polycythaemia
Medical illness
◦ stroke
◦ MI
◦ CHF
◦ pneumonia
◦ COPD
◦ infections
◦ nephrotic syndrome
◦ inflammatory bowel disease
Oral contraceptives
Varicose veins
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Pregnancy and postpartum period.
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Immobilization longer than 3 days
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Major surgery in previous 4weeks
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Long air or car trips >4hrs in previous 4
weeks
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1.
2.
3.
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Predisposing Factors :
Stasis
Vascular damage
Hyper coagulability
Imbalance between thrombogenesis &
thrombolytic agents
1.
2.
3.
4.
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Propagation
Embolization
Dissolution
Organization & recanalization
ORGIN
DVT usually originates from veins of calf
around the valve cusps or with in soleal
plexus
A minority of cases occurs directly in
ilio femoral veins

In practical terms the development of VT is best
understood as activation of coagulation in areas of
reduced blood flow.

Majority of calf vein thrombus dissolve completely.
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Only 20% progress proximally.
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Propagation occurs before embolization.
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The process of adherence and organization of
venous thrombus does not begin until 5 to 10
days after thrombus formation.
This non adherent thrombus may propagate or
embolise.
Propagation
or
organization
of
venous
thrombus  destruction of valves & varying
degree of venous outflow obstruction  chronic
venous insufficiency.
1.
2.
3.
Fatal PE
Non-fatal PE
Post-thrombotic syndrome
 Consequence
of recanalization of major
venous thrombus
 Due
to incompetence of valves
 Long
term morbidity
 Causes
chronic edema &venous ulcers

Swelling/edema
most specific sign
unilateral
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Leg pain (50%)
non specific

Redness/erythema
over the thrombus
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Tenderness(75%)
calf or along the involved veins
does not correlate size, site, extent
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Low grade pyrexia
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Signs and symptoms of PE
 Pain
or discomfort in leg on forceful
dorsiflexion of foot with knee straight
 Present only in 10% of confirmed DVT
 Highly non-specific
 Present in 50% of cases with out DVT
 Misleading sign
 No longer used
In approximately 70% of patients with clinically
suspected DVT, alternate diagnoses are ultimately
found as follows:
Arthritis
Cellulitis, lymphangitis
Hematoma
Lymphedema
Muscle or soft tissue injury
Neurogenic pain
Postphlebitic syndrome
Prolonged immobilization or limb paralysis
Ruptured Baker cyst
Stress fractures or other bony lesions
Superficial thrombophlebitis
Varicose veins
D- dimer level :
This cross-linked fibrin degradation product is an
indication that thrombosis is occurring , and that
the blood clot is being dissolved by plasmin.
D-dimer is measured by latex agglutination or by
an enzyme-linked immunosorbent assay (ELISA)
test that is considered positive if the level is
greater than 500 ng/mL
Other blood tests
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Complete blood count (CBC)
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Primary coagulation studies (PT ,PTT ,Fibrinogen )
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Liver Enzymes
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Renal function and electrolytes .
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Protein S, protein C, anticromin III,, antiphospholipid
antibodies and homocysteine levels can be measured.
 investigations for these abnormalities are primarily
indicated when DVT is diagnosed in patients younger
that 35 years or when venous thrombosis is detected
in unusual sites.
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CONTRAST VENOGRAPHY
DUPLEX ULTRASONOGRAPHY
CONTRAST VENOGRAPHY
IMPEDANCE PLETHYSMOGRAPHY
MRI
CONTRAST C.T.
MEDICAL TREATMENT
 Bed
rest
 Affected limb is elevated above the level of
heart.
 Anticoagulant prevent thrombus propagation
and allow the endogenous lytic system to
operate
 Pain relief.
 Initial
bolus 7500 to 10000 IU followed by
continuous in infusion to 1000 to 1500
IU/hr.
 Infusion rate adjusted so that aPTT is
approx twice the control value
 Every 6 hrs aPTT monitered till therapeutic
range is reached
 Duration :5 days
 Discontinue when platelet count <75,000
 Effective
and better than conventional
heparin.
 Different preparations available.
 Administered SC in fixed doses once or
twice daily.
 Duration -7 to 14 days
 Anticoagulant effect by inhibiting the
activated factor X.
 Hemorrhagic complications doesn’t occur
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To be taken along with heparin for initial 4
to5 days.
Dose adj to maintain prothrombin time at
INR 2.0 to3.0
Continued for 3 to6 months for pts with
acute idiopathic DVT
For recurrent DVT/PE low intensity warfarin
continued indefinitely maintaining INR 1.5
to2.0
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a)
b)
c)
d)
Early administration
Prompt resolution of symptoms
Accelerate clot lysis
Preserve venous valves
Decrease the potential for developing postphlebitic syndrome
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Does not prevent clot propagation or
rethrombosis.
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Heparin and oral anti coagulant therapy
must follow a course of thrombolysis.
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Haemorraghic complications reduced by
regionally administering with flouroscopic
control.
Streptokinase,urokinase.
SURGICAL TREATMENT
1.
1.
Indicated when anticoagulant therapy is
ineffective, unsafe or contraindicated.
Major surgical procedures : clot removal and
partial interruption of IVC to prevent PE.
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To restore venous patency and valvular function.
Alone it is not indicated because rethrombosis is
frequent.
Heparin therapy is a necessary adjunct.
Best reserved for patients with massive vein thrombosis
when limb viability is at risk.
FILTERS FOR DVT
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First suggested by Trousseau in 1868.
introducing intracaval devices percutaneosly and floating
them into position with fluoroscopy is the procedure of
choice for filter placement.
 Severe
hemorrhage complications of
anticoagulant therapy.
 Absolute
contra indications to
anticoagulation.
 Failure
of anticoagulation such us new or
recurrent VTE or PE.
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YES - Overall reduction in DVT and PE is by
40% to 60%
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Designed to address stasis & coagulation
Usually combination of therapies
EARLY MOVT & REHABLITATION
II.
MECHANICAL METHODS
lower extremity exercises
graded compression stockings
intermittent pneumatic compression devices
I.
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Graduated compression stockings
Exercise
Avoid alcohol &sleeping tablets
HIGH RISK PATIENTS
 LMWH ,single dose SC before the flight
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PAGET VON SCHROTTER DISEASE
Axillary and sub clavian vein thrombosis
Reduced incidence
Thoracic outlet synd &cervical ribs
Thrombolytic therapy is treatment of choice
Since restoring venous patency more
important in upper limb
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Early- Progression Pulmonary embolism
Paradoxical embolism
Acute compartment syndrome
venous gangrene
Late - Rec DVT, Post phlebitic syndrome