nil

2. DEEP VEIN THROMBOSIS
BY DR.ARAIB GHEGA

3. CASE PRESENTATION
Presentation
XYZ 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.

4. 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

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

7. EPIDEMIOLOGY
 Venous ThromboEmbolism related deaths
3,00,000/anum
 7% diagnosed and treated
 34% sudden pulmonary embolism
 59% as undected

8. 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.

9. ETIOLOGY
Starts in
Lower
extremity
calf veins
progressing
proximally
to involve
Popliteal,
Femoral,
iliac system

10. Venous stasis
Endothelial
damage
Hypercoagulable
state

11. 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

12.  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.

14. 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

16. 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

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

18.  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.

19. 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.

20. 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

21. Interpretation
 High probability: ≥ 3 (Prevalence of DVT - 53%)
 Moderate probability: 1-2 (Prevalence of DVT -
17%)
 Low probability: ≤ 0 (Prevalence of DVT - 5%)

22. DIAGNOSTIC STUDIES
 Clinical examination alone is able to
confirm only 20-30% of cases of DVT
 Blood Tests
The D-dimer
 Imaging Studies

23. ALGORITHM FOR DIAGNOSTIC IMAGING
Assess
clinical
likelihood
Low D
dimer
Normal No DVT
High Imaging test
needed
High Imaging test
needed

24. IMAGING STUDIES
 Invasive
 venography,
 radiolabeled fibrinogen
 noninvasive
 ultrasound,
 plethysmography,
 MRI techniques

25. VENOGRAM:
POPLITEAL VEIN
THROMBOSIS
Venography

26. 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.

27. 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.

28. 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 .

29. SPECIFIC TREATMENT :
 Anticoagulation
 Thrombolytic therapy for DVT
 Surgery for DVT
 Filters for DVT
 Compression stockings

30. 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

31. 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.

32. 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

33. 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

34. PROPHYLAXIS
 Indicated in who underwent major abdominal
trauma or orthopaedic surgery or patient having
prolonged immobolization (> 3 days).
 Benefits of VTE Prophylaxis
 Improved patient outcomes
 Reduced costs

35. 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.

37. NICE GUIDELINES FOR
ORTHOPAEDICS SURGERY

38. 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.

39. 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.

40. 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.