DEEP VEIN THROMBOSISBY DR.ARAIB GHEGA

CASE PRESENTATIONPresentationXYZ is a 75-year old man with a recent (4 weeks ago) admission to hospital for hip replacement. The procedure was performed under general anaesthetic. During admission, XYZ received the following VTE prophylaxis (to be continued until patient no longer had significantly reduced mobility):• Antiembolism stockings• pharmacological VTE prophylaxis.Patient reports that his right leg has been swollen & painful for over 2 weeks. He thought it was healing after the operation, which is why he has not told anyone sooner. He presented to his GP and the GP has referred him to your accident and emergency (A&E) department.

DIFFERENTIAL DIAGNOSIS Cellulitis Deep vein thrombosis Achilles tendonitis Arthritis Muscle strain or tear Hematoma Soft-tissue injury Stress fracture Varicose veins Hepatic disease Renal failure

DEFINITION

Deep vein thrombosis is the formation of a blood clot in one of the deep veins of the body, usually in the leg.

EPIDEMIOLOGY Venous ThromboEmbolism related

deaths 3,00,000/anum

7% diagnosed and treated

34% sudden pulmonary embolism

59% as undected

Without prophylaxis the incidence of deep vein thrombosis is about –

14% in gynaecological surgery 22% in neurosurgery 26% in abdominal surgery 45%-60% in patients undergoing hip and

knee surgeries. 

15% to 40% Urologic surgery.

ETIOLOGY

Starts in Lower

extremity calf veins

progressing

proximally to involve

Popliteal, Femoral,

iliac system

Venous stasis

Endothelial damage

Hypercoagulable state

PATHOPHYSIOLOGY

Vessel trauma stimulates the clotting cascade.

Platelets aggregate at the site particularly when venous stasis present

Platelets and fibrin form the initial clot

RBC are trapped in the fibrin meshwork

The thrombus propagates in the direction of the blood flow.

Inflammation is triggered, causing tenderness, swelling, and erythema.

Pieces of thrombus may break loose and travel through circulation- emboli.

Fibroblasts eventually invade the thrombus, scarring vein wall and destroying valves. Patency may be restored valve damage is permanent, affecting directional flow.

PRESENTATION AND PHYSICAL EXAMINATION Calf pain or tenderness, or both

Swelling with pitting oedema

Increased skin temperature and fever

Superficial venous dilatation

Cyanosis can occur with severe obstruction

CLINICAL EXAMINATION

Palpate distal pulses and evaluate capillary refill to assess limb perfusion.

Move and palpate all joints to detect acute arthritis or other joint pathology.

Neurologic evaluation may detect nerve root irritation; sensory, motor, and reflex deficits should be noted

Homans sign: pain in the posterior calf or knee with forced dorsiflexion of the foot.

Moses sign Gentle squeezing of the lower part of

the calf from side to side.Neuhofs sign Thickening and deep tenderness

elicited while palpating deep in calf muscles.

Lintons sign After applying torniquet at

saphenofemoral junction patient made to walk , then limb is elevated in supine position prominent superficial veins will be observed.

WELLS CLINICAL PREDICTION GUIDE

It pre-test probability score

Helps in early risk stratification and appropriate use of laboratory tests and imaging modalities.

wells criteria is an additional tool to diagnosis rather than being a stand-alone test.

Variable Wells

Active cancer (rx within last 6 months or palliative) 1

Calf swelling >3 cm compared to other calf 1

Collateral superficial veins (non-varicose) 1

Pitting edema 1

Swelling of entire leg 1

Localized pain along distribution of deep venous system 1

Paralysis, paresis, or recent cast immobilization of lower extremities 1

Recently bedridden > 3 days, or major surgery requiring regional or general anesthetic in past 12 weeks 1

Previously documented DVT 1

Alternative diagnosis at least as likely deep vein thrombosis -2

Interpretation

High probability: ≥ 3 (Prevalence of DVT - 53%)

Moderate probability: 1-2 (Prevalence of DVT - 17%)

Low probability: ≤ 0 (Prevalence of DVT - 5%)

DIAGNOSTIC STUDIES

Clinical examination alone is able to confirm only 20-30% of cases of DVT

Blood Tests The D-dimer

Imaging Studies

ALGORITHM FOR DIAGNOSTIC IMAGING

Assess clinical

likelihood

Low D dimer

Normal

No DVT

High Imaging test needed

High Imaging test needed

IMAGING STUDIES Invasive venography, radiolabeled fibrinogen

noninvasive ultrasound, plethysmography, MRI techniques

VENOGRAM:POPLITEAL VEIN THROMBOSIS

Venography

ULTRASONOGRAPHY color-flow Duplex scanning is the imaging

test of choice for patients with suspected DVT

inexpensive, noninvasive, widely available Ultrasound can also distinguish other causes

of leg swelling, such as tumor, popliteal cyst, abscess, aneurysm, or hematoma.     

MANAGEMENT Using the pretest probability score calculated

from the Wells Clinical Prediction rule, patients are stratified into 3 risk groups—high, moderate, or low.

The results from duplex ultrasound are incorporated as follows:

If the patient is high or moderate risk and the duplex ultrasound study is positive, treat for DVT.

GENERAL THERAPEUTIC MEASURES :

Bed rest .

Encourage the patient to perform gentle foot & leg exercises every hour.

Increase fluid intake upto 2 l/day unless contraindicated.

Avoid deep palpation .

SPECIFIC TREATMENT :

Anticoagulation

Thrombolytic therapy for DVT

Surgery for DVT

Filters for DVT

Compression stockings

ANTICOAGULANTION THERAPY Initial treatment of DVT is with low-

molecular-weight heparin or unfractionated heparin for at least 5 days, followed by warfarin (target INR, 2.0–3.0) for at least 3 months.

OTHER DRUGS Fondaparinux Apixaban Dabigatran

THROMBOLYTIC THERAPY

Consider catheter-directed thrombolytic therapy for patients with symptomatic iliofemoral DVT who have:• symptoms of less than 14 days’ duration and • good functional status and• a life expectancy of 1 year or more and• a low risk of bleeding.

SURGERY FOR DVT Indications

when anticoagulant therapy is ineffective unsafe, contraindicated. The major surgical procedures for DVT are

clot removal and partial interruption of the inferior vena cava to prevent pulmonary embolism.

options Thrombectomy

FILTERS FOR DVT Inferior vena cava filters reduce the rate of

pulmonary embolism but have no effect on the other complications of deep vein thrombosis

PROPHYLAXIS

Indicated in who underwent major abdominal trauma or orthopaedic surgery or patient having prolonged immobolization (> 3 days).

Benefits of VTE Prophylaxis Improved patient outcomesReduced costs

METHODS OF VTE PROPHYLAXIS Mechanical:

Graduated Compression Stockings (GCS)

Intermittent Pneumatic Compression Devices (IPC)

Pharmacologic Low molecular weight Heparin.(5000u

sc 8hourly ) It inhibits factor Xa and IIA activity.

NICE GUIDELINES FOR ORTHOPAEDICS SURGERY

ELECTIVE HIP AND KNEE REPLACEMENT At admission Offer mechanical VTE prophylaxis with any one of: anti-embolism stockings (thigh or knee length), intermittent pneumatic compression devices (thigh or knee

length). Continue until patient's mobility is no longer significantly reduced.

Elective hip replacement 1–12 hours after surgery Provided there are no contraindications, offer pharmacological VTE

prophylaxis. Continue pharmacological VTE prophylaxis for 28–35 days.

Elective knee replacement 1–12 hours after surgery Provided there are no contraindications, offer pharmacological VTE

prophylaxis. Continue pharmacological VTE prophylaxis for 10–14 days.

HIP FRACTURE At admission Offer mechanical VTE prophylaxis with any one of: anti-embolism stockings (thigh or knee length), used with caution foot impulse devices intermittent pneumatic compression devices (thigh or knee length). Continue until patient's mobility is no longer significantly reduced. Provided there are no contraindications, offer LMWH (or UFH for

patients with severe renal impairment or established renal failure) if using.

24 hours before surgery Stop fondaparinux if it has been used (only recommended after

surgery). 12 hours before surgery Stop LMWH (or UFH for patients with severe renal impairment or

established renal failure) if using. 6 hours after surgical closure Offer fondaparinux if using, provided haemostasis has been established

and there is no risk of bleeding. Continue for 28–35 days. 6–12 hours after surgery Restart LMWH (or UFH for patients with severe renal impairment or

established renal failure) if using. Continue for 28–35 days.

UPPER LIMB SURGRY Do not routinely offer VTE prophylaxis to

patients undergoing upper limb surgery. If a patient is assessed to be at increased risk of VTE, follow the advice for other orthopaedic surgery, below.