2. Introduction
Part of VTE
Most DVT can resolve spontaneously but also can lead to fatal pulmonary embolism
Tapson VF. Acute pulmonary embolism. N Engl J Med. 2008 Mar 6. 358(10):1037-52.
5. Epidemiology
80 cases per 100,000 population occur annually
1 person in 20 develops a DVT in the course of his or her lifetime
In elderly persons, the incidence is increased four-fold
M > F (1.2:1)
Hispanic and Asian lower risk
6. Risk Factors
Age
Immobilization longer than 3 days
Pregnancy and the postpartum period
Major surgery in previous 4 weeks
Long plane or car trips (>4 hours) in previous 4
weeks
Cancer
Previous DVT
Stroke
Acute myocardial infarction (AMI)
Congestive heart failure (CHF)
Sepsis
Nephrotic syndrome
Ulcerative colitis
Multiple trauma
CNS/spinal cord injury
Burns
Lower extremity fractures
Systemic lupus erythematosus (SLE) and the
lupus anticoagulant
7. Risk Factors
Prothrombin 20210A mutation
Factor V Leiden
Dysfibrinogenemias and disorders of
plasminogen activation
Intravenous (IV) drug abuse
Oral contraceptives
Estrogens
Heparin-induced thrombocytopenia (HIT)
Behçet syndrome
Homocystinuria
Polycythemia rubra vera
Thrombocytosis
Inherited disorders of coagulation/fibrinolysis
Antithrombin III deficiency
Protein C deficiency
Protein S deficiency
8. Clinical Manifestation
Edema - Most specific symptom
Leg pain - Occurs in 50% of patients but is nonspecific
Tenderness - Occurs in 75% of patients
Warmth or erythema of the skin over the area of thrombosis
Clinical symptoms of PE as the primary manifestation
9. Physical Examination
Calf pain on dorsiflexion of the foot (Homans sign)
A palpable, indurated, cordlike, tender subcutaneous venous segment
Variable discoloration of the lower extremity
Blanched appearance of the leg because of edema (relatively rare)
11. Management
(In-patient Indication)
Suspected or proven concomitant PE
Significant cardiovascular or pulmonary
comorbidity
Iliofemoral DVT
Contraindications to anticoagulation
Familial or inherited disorder of coagulation:
antithrombin III (ATIII) deficiency, prothrombin
20210A, protein C or protein S deficiency, or
factor V Leiden
Familial bleeding disorder
Pregnancy
Morbid obesity (>150 kg)
Renal failure (creatinine >2 mg/dL)
Unavailable or unable to arrange close follow-
up care
Unable to follow instructions
Homeless
No contact telephone
Geographic (too far from hospital)
Patient/family resistant to outpatient therapy
12. Management (Inpatient)
•LMWH :
Prophylaxis: 40 mg SC qDay
Treatment: 1 mg/kg SC q12hr, OR 1.5 mg/kg SC
qDay
•Fondaparinux :
Prophylaxis: 2.5 mg SC once daily
Treatment:
<50 kg: 5 mg SC once daily
50-100 kg: 7.5 mg SC once daily
>100 kg: 10 mg SC once daily
• Unfractioned Heparin (UFH)
Prophylaxis:
5000 units SC q8-12hr, OR
7500 units SC q12hr
Treatment:
80 units/kg IV bolus, THEN continuous infusion of
18 units/kg/hr, OR
5000 units IV bolus, THEN continuous infusion of
1300 units/hr, OR
250 units/kg (alternatively, 17,500 units) SC,
THEN 250 units/kg q12hr
13. Management (Inpatient)
• Warfarin 5 mg PO daily is initiated and overlapped for about 5 days until the international
normalized ratio (INR) is therapeutic >2 for at least 24 hours.
• For admitted patients treated with UFH, the activated partial thromboplastin time (aPTT) or
heparin activity level must be monitored every 6 hours while the patient is taking intravenous
(IV) heparin until the dose is stabilized in the therapeutic range.
• Heparin or LMWH should be discontinued if the platelet count falls below 75,000. Fondaparinux
is not associated with hepatin-induced thrombocytopenia (HIT)
14. Management (Outpatient)
• Without cancer: NOAC / Warfarin
-Rivaroxaban: Prophylaxis (10 mg qDay) ; Treatment (15 mg PO q12hr for 21 days with food, THEN
20 mg PO qDay)
- Warfarin: 2 and 10 mg/day
• With cancer: LMWH
15. Duration of Anticoagulation
For the first episode of deep venous thrombosis (DVT), patients should be treated for 3-6
months. Recurrent episodes should be treated for at least 1 year.
16. Endovascular Treatment
Indication:
- Phlegmasia or symptomatic inferior vena cava thrombosis that responds poorly to
anticoagulation alone,
- Symptomatic iliofemoral or femoropopliteal DVT in patients with a low risk of bleeding.
18. Post-Thrombotic Syndrome
Vazquez SR, Freeman A, VanWoerkom RC, Rondina MT. Contemporary issues in the prevention and management of postthrombotic syndrome. Ann Pharmacother. 2009; 43: 1824–1835.
