DEEP VEIN THROMBOSIS

FAIZAL DRISSA HASIBUAN

BAGIAN PENYAKIT DALAM
FK UNIVERSITAS YARSI
JAKARTA 2011

DEEP VEIN
THROMBOSIS
(DVT):
Terminology and
Clinical Manifestation

DVT (1)
Terminology:
- thrombus which occurs in the deep vein system
- a part of venous thrombosis ( VT ) or venous
thromboembolism ( VTE )
Sites:- VT/VTE in all venous system: upper &
lower extremities, renal, mesenterical, splenchnic ,
portal, cerebral veins, etc
- DVT indicated to deep veins of the lower
extremities & pelvic vein
Superficial thrombophlebitis / superficial venous
thrombosis >< DVT

Venous
thrombosis
(VT) or
Venous
tromboembo
li (VTE) in
venous
system

DVT in the LEGS vs

Superficial VT

DVT (2)

In general:
- predilection sites : at the calf veins
(posterior tibial vein / peroneus vein)
- rarely: anterior tibial vein
- extended to the proximal veins
ascending thrombosis
In certain cases (e.g. pregnancy, tumor)
- more proximal: external iliac veins
& common iliac veins
- more distal = descending thrombosis

VENOUS
SYSTEM
of the
LOWER
EXTREMIT
IES

Obstetrics /
Cancers

Descen
thromb

Ascen
thromb
<<<:
ant
tibial

>>>
pos
ttib

DVT

ACUTE DVT

LOCAL CHRONIC
Consequences :
CHRONIC DVT

Symptoms or /
and signs (+)
=
SYMPTOMATIC
DVT

COMPLICATIONS of the LOWER

EXTREMITIES VEINS
Permanently venous damages
Venous valve insuficiency

Distance Acute
/ Chronic
Consequences:

Post-phlebitic / thrombotic
syndrome
Symptoms or /
and signs (-)
=
ASYMPTOMATIC
DVT

COMPLICATIONS of the LUNG &

HEART VASCULARIZATIONS:
Pulmonary Embolism (PE)
Chronic Thromboembolic
Pulmonal Hypertension (CTEPH)

ACUTE DVT :
SYMPTOMATIC & ASYMPTOMATIC DVT
SYMPTOMATIC DVT:
- pain and edema in the upright position
> obvious than in the bedridden position

ASYMPTOMATIC:
- occurs more prominent in bedridden
patients:
- especially post surgical period

RECURRENT DVT
ASYMPTOMATIC DVT:
recurrent DVT in week 1 no symptoms
or signs appear
SYMPTOMATIC DVT:
- recurrent DVT in patients on warfarin
- may be divided into two groups:
* those who are with non-adequate anti
coagulant dosages
* those who are with cancers

POST PHLEBITIC SYNDROME = PPS

PPS-mild
(15-30%)

: mild edema of the lower limb

mild skin manifestation
(hyperpigmentation)
PPS-severe: edema of the lower extremity
(5-10 %)
pain
skin ulceration
5 10 years after acute DVT
Increased incidence of CVI = increased age

Post Thrombotic Syndrome

Superficial Vein versus Deep Vein

Pathogenesis of Thromboembolism

VENOUS VALVES

DVT:
DIAGNOSIS and
DIFFERENTIAL
DIAGNOSIS

Diagnosis of DVT
1. History of illness: Symptoms (+) or (-)
Risk Factors: Medical & Surgery
2. Physical examination:
Pitting edema of the leg
Pain
No clear signs or symptoms
(subocclusive thrombus)
3. Laboratory & Radioimaging examinations:
D-dimer
Veno/Phlebo-graphy (Gold Standard)
Compression/ Dupplex ultrasonography
(96 97 %) for sympt. Prox. DVT
Duplex scan
Impedance Plethysmography

CAUSES of EDEMA of the LOW

EXTREMITIES (differential diagnosis)
ACUTE EDEMA

CHRONIC EDEMA

Deep vein thrombosis (DVT)

Superficial Thrombophlebitis
Cellulitis
Joint effusion/Haemarthrosis
Fractures
Arthritis
Dermatitis

Venous abnormalities:
- post thrombotic syndrome/
post phlebitic syndrome
- chronic vein insufisiency
- lipodermatosclerosis
- venous obstruction / suppression
Lymphedema: - tumors
- infections
- trauma, dll
Diseases
: - hemangioma
- congenital
Others: = heart failure
- idiopathic edema in women

DIAGNOSTIC APPROACH
of
DVT

RISK FACTORS of
SUSPECTED DVT
Risk factor scoring systems:
- the Wells score for suspected DVT
(7 objective + 1 subjective factors)
- the Geneva score for suspected DVT
(objective factors: blood gases analysis)
Low risk group
Intermediate risk group
High risk group

The WELLS SCORE for patients

clinically SUSPECTED DVT
Wells clinical prediction score for DVT

Points

Cancer
Paralysis or recent immobilization
Bedridden > 3 days, or surgery / trauma < 4 weeks
Pain or palpitation of the deep veins
Edema of thigh and calf
Pitting edema (symptomatic side only)
Alternative diagnosis as least as likely DVT

+1
+1
+1
+1
+1
+1
- 2

Clinically probability:
Low
Intermediate
High

0
1-2
3

Algorithm for the diagnosis workup of suspected DVT

Clinical probability of DVT

(Colman RW)

Low

Intermediate

Sensitive or less sensitive

D-dimer (DD)

Negative
No Th/

Positive
CUS

High

Sensitive DD

Negative
No Th/

Positive
CUS

CUS

CUS = compression
ultrasonography

No DVT
No Th/

DVT
Th/

No DVT
No Th/

DVT
Th/

No DVT
phlebography

DVT
Th/

LABORATORY TESTS for DVT

A. D-dimer (cutoff value 500 ug/L):
- D-dimer < 500 ng/ml excluding acute DVT or PE
- negative predictive value for DVT & PE: 98 %
- especially in low & intermediate risk groups
- highly sensitive, but no specific: post surgery, DIC,
inflamation, infection, necrosis, cancers, etc
D-dimer (+)
- ELISA VIDAS DD: quick & accurate result
(sensitivity:98100%)

B. Other hemostasis lab tests:

- underlying disease:hereditary/acquired thrombophilia
(AT III & Protein C deficiencies , APS, etc)
to determine the duration of anticoagulants

MANAGEMENT of DVT
A. Acute Treatment of DVT
B. Duration of Anticoagulant Administration
to prevent recurrent DVT (localized DVT)
to prevent acute distant consequences (PE)
to prevent chronic local consequences:
- venous valve damage / destruction
- chronic valve insufficiency (CVI)
- Post thrombotic / Post phlebitic syndrome
(PTS / PPS)
C. Treatment of Underlying Causes (Risk/ Trigger Factors)

MANAGEMENT of DVT
1. General Measures:
- elevation of the feet
- compression with elastic stocking
& intermittent pneumatic compression
- early mobilization
2. Medications:
a. Heparin: UF-heparin or LMWH
b. Warfarin (oral anticoagulant)
c. Fibrinolytic agents
c. Others
3. Surgery: in recurrent / chronic DVT

MEDICATIONS for DVT

Other anticoagulants:
- Direct thrombin inhibitors:
- Hirudin & Hirulog
- Argatroban
- Melagatran
- Factor X inhibitors:
- Direct inhibitors of Factor Xa
- Activated Protein C &
Soluble Trombomodulin
- Tissue Factor Pathway Inhibitor

Right
Ileofemoral
DVT