deep vein thrombosis

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DR. NAWIN KUMAR

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Page 1: Deep vein thrombosis

DR. NAWIN KUMAR

Page 2: Deep vein thrombosis

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

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DVT ususally originates in the lower extremity venous level ,starting at the calf vein level and progressing proximally to involve popliteal ,femoral ,or iliac system. .80 -90 % pulmonary emboli originates here .

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More than 100 years ago, Virchow described a triad of factors of

venous stasis, endothelial damage, and hypercoagulable state

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prolonged bed rest (4 days or more) A cast on the leg Limb paralysis from stroke or spinal cord

injury extended travel in a vehicle

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Surgery and trauma responsible for up to 40% of all thromboembolic disease

Malignancy Increased estrogen (due to a fall in

protein ‘S) Increased estrogen occurs during

all stages of pregnancy— the first three months postpartum, after elective abortion, and during treatment with oral

contraceptive pills

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deficiencies of protein ‘S,’ protein ‘C,’ and antithrombin III.

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nephrotic syndrome results in urinary loss of antithrombin III, this diagnosis should be considered in children presenting with thromboembolic disease

Antiphospholipid antibodies accelerate coagulation and include the lupus anticoagulant and anticardiolipin antibodies.

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Inflammatory processes, such as• systemic lupus erythematosus (SLE),

• sickle cell disease, and •inflammatory bowel disease (IBD),

also predispose to thrombosis, presumably due to hypercoagulability

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Trauma, surgery, and invasive procedure may disrupt venous

integrity Iatrogenic causes of venous thrombosis

are increasing due to the widespread use of central venous catheters, particularly subclavian and internal jugular lines. These lines are an important cause of upper extremity DVT, particularly in children.

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The nidus for a clot is often an intimal defect

When a clot forms on an intimal defect, the coagulation cascade promotes clot growth proximally. Thrombus can extend from the superficial veins into the deep system from which it can embolize to the lungs.

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Opposing the coagulation cascade is the endogenous fibrinolytic system. After the clot organizes or dissolves, most veins will recanalize in several weeks. Residual clots retract as fibroblasts and capillary development lead to intimal thickening.

Venous hypertension and residual clot may destroy valves, leading to the postphlebitic syndrome, which develops within 5-10 years

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Edema, sclerosis, and ulceration characterize this syndrome, which develops in 40-80% of patients with DVT.

patients also can suffer exacerbations of swelling and pain, probably as a result of venous dilatation and hypertension

     Pulmonary embolism (PE) is a serious complication of DVT. Many episodes of pulmonary embolism go unrecognized, and at least 40% of patients with DVT have clinically silent PE on VQ scanning

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Calf pain or tenderness, or both Swelling with pitting oedema Swelling below knee in distal deep vein

thrombosis and up to groin in proximal deep vein thrombosis

Increased skin temperature Superficial venous dilatation Cyanosis can occur with severe

obstruction

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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

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Search for stigmata of PE such as tachycardia (common), tachypnea or chest findings (rare), and

exam for signs suggestive of underlying predisposing factors.

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The Wells clinical prediction guide incorporates risk factors, clinical signs, and the presence or absence of alternative diagnoses

. Wells Clinical Prediction Guide for DVTClinical ParameterScore

Active cancer (treatment ongoing, or within 6 months or palliative)1

Paralysis or recent plaster immobilization 1

Recently bedridden for >3 days or major surgery <4 weeks1

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Localized tenderness along the distribution of the deep venous system1

Entire leg swelling1 Calf swelling >3 cm compared to the

asymptomatic leg 1 Pitting edema (greater in the

symptomatic leg)1 Collateral superficial veins

(nonvaricose)1 Alternative diagnosis (as likely or > that

of DVT)

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Total of Above Score

High probability: Score ³3Moderate probability: Score = 1 or 2Low probability: Score £0

Adapted from Anand SS, et al. JAMA. 1998; 279 [14];1094

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

Blood Tests the D-dimer INR. Current D-dimer assays have

predictive value for DVT, and the INR is useful for guiding the

management of patients with known DVT who are on warfarin (Coumadin)

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D-dimer is a specific degradation product of cross-linked fibrin. Because concurrent production and breakdown of clot characterize thrombosis, patients with thromboembolic disease have elevated levels of D-dimer

three major approaches for measuring D-dimer

ELISA latex agglutination blood agglutination test (SimpliRED

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False-positive D-dimers occur in patients with

recent (within 10 days) surgery or trauma,

recent myocardial infarction or stroke, acute infection, disseminated intravascular coagulation, pregnancy or recent delivery, active collagen vascular disease, or

metastatic cancer

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Invasive venography, radiolabeled fibrinogen and. noninvasive ultrasound, plethysmography, MRI techniques

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gold standard” modality for the diagnosis of DVT

Advantages Venography is also useful if the patient

has a high clinical probability of thrombosis and a negative ultrasound,

it is also valuable in symptomatic patients with a history of prior thrombosis in whom the ultrasound is non-diagnostic.

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phlebitis anaphylaxis

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Because the radioactive isotope incorporates into a growing thrombus, this test can distinguish new clot from an old clot

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Plethysmography measures change in lower extremity volume in response to certain stimuli.

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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.     

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expensive reader dependent Duplex scans are less likely to detect

non-occluding thrombi. During the second half of pregnancy,

ultrasound becomes less specific, because the gravid uterus compresses the inferior vena cava, thereby changing Doppler flow in the lower extremities

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It detects leg, pelvis, and pulmonary thrombi and is 97% sensitive and 95% specific for DVT.

It distinguishes a mature from an immature clot.

MRI is safe in all stages of pregnancy.

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o Cellulitis Thrombophlebitis

o ArthritisAsymmetric peripheral edema secondary to CHF, liver disease, renal failure, or nephrotic syndrome lymphangitisExtrinsic compression of iliac vein secondary to tumor, hematoma, or abscessHematomaLymphedema

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Muscle or soft tissue injuryNeurogenic painPostphlebitic syndrome Prolonged immobilization or limb paralysisRuptured Baker cystStress fractures or other bony lesionsSuperficial thrombophlebitisVaricose veins

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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.

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If the duplex study is negative and the patient is low risk, DVT has been ruled out.

• When discordance exists between the pretest probability and the duplex study result, further evaluation is required.

If the patient is high risk but the ultrasound study was negative, the patient still has a significant probability of DVT

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a venogram to rule out a calf vein DVT surveillance with repeat clinical

evaluation and ultrasound in 1 week. results of a D-dimer assay to guide

management If the patient is low risk but the

ultrasound study is positive, some authors recommend a second confirmatory study such as a venogram before treating for DVT

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The primary objectives of the treatment of DVT are to

prevent pulmonary embolism, reduce morbidity, and prevent or minimize the risk of

developing the postphlebitic syndrome.

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Anticoagulation Thrombolytic therapy for DVT Surgery for DVT Filters for DVT Compression stockings

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Heparin prevents extension of the thrombus

Heparin's anticoagulant effect is related directly to its activation of antithrombin III. Antithrombin III, the body's primary anticoagulant, inactivates thrombin and inhibits the activity of activated factor X in the coagulation process.

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Heparin is a heterogeneous mixture of polysaccharide fragments with varying molecular weights but with similar biological activity. The larger fragments primarily interact with antithrombin III to inhibit thrombin.

The low molecular weight fragments exert their anticoagulant effect by inhibiting the activity of activated factor X. The hemorrhagic complications attributed to heparin are thought to arise from the larger higher molecular weight fragments.

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The optimal regimen for the treatment of DVT is anticoagulation with heparin or an LMWH followed by full anticoagulation with oral warfarin for 3-6 months

Warfarin therapy is overlapped with heparin for 4-5 days until the INR is therapeutically elevated to between 2-3.

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After an initial bolus of 80 U/kg, a constant maintenance infusion of 18 U/kg is initiated. The aPTT is checked 6 hours after the bolus and adjusted accordingly. .

The aPTT is repeated every 6 hours until 2 successive aPTTs are therapeutic. Thereafter, the aPTT is monitored every 24 hours as well as the hematocrit and platelet count.

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Superior bioavailability Superior or equivalent safety and efficacy Subcutaneous once- or twice-daily dosing No laboratory monitoring* Less phlebotomy (no monitoring/no intravenous

line) Less thrombocytopenia Earlier/facilitated

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At the present time, 3 LMWH preparations,

Enoxaparin, Dalteparin, and Ardeparin

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Interferes with hepatic synthesis of vitamin K-dependent coagulation factors

Dose must be individualized and adjusted to maintain INR between 2-3

2-10 mg/d PO caution in active tuberculosis or

diabetes; patients with protein C or S deficiency are at risk of developing skin necrosis

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Advantages include prompt resolution of symptoms, prevention of pulmonary embolism, restoration of normal venous circulation, preservation of venous valvular

function, and prevention of postphlebitic

syndrome.

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Thrombolytic therapy does not prevent

clot propagation, rethrombosis, or subsequent embolization. Heparin therapy and oral anticoagulant

therapy always must follow a course of thrombolysis.

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Thrombolytic therapy is also not effective once the thrombus is adherent and begins to organize

The hemorrhagic complications of thrombolytic therapy are formidable (about 3 times higher), including the small but potentially fatal risk of intracerebral hemorrhage.

The uncertainty regarding thrombolytic therapy likely will continue

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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.

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These pulmonary emboli removed at autopsy look like casts of the deep veins of the leg where they originated.

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Indications for insertion of an inferior vena cava filter

Pulmonary embolism with contraindication to anticoagulation

Recurrent pulmonary embolism despite adequate anticoagulation

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Controversial indications: Deep vein thrombosis with

contraindication to anticoagulation Deep vein thrombosis in patients with

pre-existing pulmonary hypertension Free floating thrombus in proximal vein Failure of existing filter device Post pulmonary embolectomy

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Inferior vena cava filters reduce the rate of pulmonary embolism but have no effect on the other complications of deep vein thrombosis. Thrombolysis should be considered in patients with major proximal vein thrombosis and threatened venous infarction

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Most patients with confirmed proximal vein DVT may be treated safely on an outpatient basis. Exclusion criteria for outpatient management are as follows:

Suspected or proven concomitant pulmonary embolism

Significant cardiovascular or pulmonary comorbidity

Morbid obesity Renal failure Unavailable or unable to arrange close

follow-up care

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Patients are treated with a low molecular weight heparin and instructed to initiate therapy with warfarin 5 mg PO the next day. Low molecular weight heparin and warfarin are overlapped for about 5 days until the international normalized ratio (INR) is therapeutic.

If inpatient treatment is necessary, low molecular weight heparin is effective and obviates the need for IV infusions or serial monitoring of the PTT.

With the introduction of low molecular weight heparin, selected patients qualify for outpatient treatment only if adequate home care and close medical follow-up care can be arranged.

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Platelets also should be monitored and heparin discontinued if platelets fall below 75,000.

While on warfarin, the prothrombin time (PT) must be monitored daily until target achieved, then weekly for several weeks. When the patient is stable, monitor monthly.

Significant bleeding (ie, hematemesis, hematuria, gastrointestinal hemorrhage) should be investigated thoroughly since anticoagulant therapy may unmask a preexisting disease (eg, cancer, peptic ulcer disease, arteriovenous malformation).

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Transient cause and no other risk factors: 3 months

Idiopathic: 3-6 months Ongoing risk for example, malignancy: 6 -

12 months Recurrent pulmonary embolism or deep

vein thrombosis: 6-12 months Patients with high risk of recurrent

thrombosis exceeding risk of anticoagulation: indefinite duration (subject to review)

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Patients with suspected or diagnosed isolated calf vein DVT may be discharged safely on a nonsteroidal anti-inflammatory drug (NSAID) or aspirin with close follow-up care and repeat diagnostic studies in 3-7 days to detect proximal extension.

At certain centers, patients with isolated calf vein DVT are admitted for full anticoagulant therapy.

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Patients with suspected DVT but negative noninvasive studies need to be reassessed by their primary care provider within 3-7 days.

Patients with ongoing risk factors may need to be restudied at that time to detect proximal extension because of the limited accuracy of noninvasive tests for calf vein DVT.

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Acute pulmonary embolism Hemorrhagic complications Chronic venous insufficiency

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All patients with proximal vein DVT are at long-term

risk of developing chronic venous insufficiency.

About 20% of untreated proximal (above the calf)

DVTs progress to pulmonary emboli, and 10-20% of

these are fatal. With aggressive anticoagulant

therapy, the mortality is decreased 5- to 10-fold.

DVT confined to the calf virtually never causes

clinically significant emboli and thus does not

require anticoagulation

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Advise women taking estrogen of the risks and common symptoms of thromboembolic disease.

Discourage prolonged immobility, particularly on plane rides and long car trips

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Ideidentify any patiant who is at risk. Prevent dehydration. During operation avoid prolonged calf

compression. Passive leg exercises should be

encourged whilst patient on bed. Foot of bed should be elevated to

increase venous return. Early mobilization should be rule for all

surgical patients.