dvt

1. APPROACH TO
DIAGNOSIS AND
TREATMENT OF LOWER
LIMB DVT
- K.shilpa.

2. INTRODUCTION
• DVT and PE are the two manifestations of VTE.
• DVT –distal (calf ) due to thrombi of deep calf
veins
-- proximal more asso. With PE .mostly seen
in popliteal ,femoral and iliac veins.

3. EPIDEMIOLOGY
• Men > women
• Increases with age in both sexes
RISK FACTORS FOR VTE:
• Hospitalisation or prolonged bed rest-52%
• Cancers like stomach n pancreas-48%
• Surgery-42%
• Trauma-6%
• Others
-age>75yrs,prior VTE,obesity,stroke,pregnancy,
oc pills,HRT,APLAS n thrombophilias.

4. APPROACH TO PT WITH DVT
• Not all the people with calf swelling have DVT
only minority people will have actual disease.
• Correct diagnosis of DVT is necessary bcoz
prox.lower extremity DVT ie not treated will
cause fatal PE n anticoagulating a pt who does
not have DVT will cause life threatening
bleeding.

5. HISTORY???
• Symptoms:
swelling
pain
erythema
warmth n tenderness
• Age of onset : < 50 r >50
• Site of prior thrombosis
• H/O myeloproliferative diseases,atherosclerosis
n nephrotic syndrome.
• drugs-hydralazine,procainamide,phenothiazines.

6. • Family h/o: family members n first degree
relatives having DVT r not.
• Recurrent unprovoked DVT in pts <50yrs see
for any inherited hypercoagulable state n
cong. Anomalies of IVC.
• Recurrent LL DVT seen in MAY THURNER
SYND. It is thrombosis of lt.iliac vein due to
compression of vein b/w overlying rt.iliac
artery n vertebral column.

7. O/E:
• Thrombosed vein may be palpable as cord.
• Calf n thigh muscles tenderness
• u/l leg swelling with warmth n erythema
• MOSES SIGN N HOMANS SIGN may be positive bt
they are unreliable.
• Difference b/w calf muscle diameters is
significant in diagnosing DVT. Absence of swelling
n diff in calf diameters rules out DVT.

8. • In Hepatic vein thrombosis(Budd-chiari synd)
there will be ascites n hepatomegaly.
• In nephrotic synd there will be
hypercoagulable state which leads to Renal
vein thrombosis.
• PHLEGMASIA CERULEA DOLENS:
• It is a uncommon massive prox venous
thrombosis(iliofemoral veins) presents with
sudden severe leg pain with
swelling,cyanosis,edema,venous
gangrene,comp.synd n arterial compromise
followed by circulatory collapse n shock.

9. SCREENING FOR WHOM??
• Age <50yrs
• Positive family history
• Recurrent VTE
• Thrombosis in unusual sites like
portal,hepatic,mesenteric n cerebral veins
• Pts with h/o warfarin induced skin necrosis
indicates protein C def.
• Screening the pts for malignancy

10. SCREENING TESTS FOR DVT
• Lab tests:
CBP, platelet count,PT, APTT, RFT, LFT n urine
analysis.
• Screening for malignancies.
Screening for hypercoagulable states:
• -cong/inherited:thrombophilias,factor v leiden
def,protein C n protein S def.
• -acquired:surgeries,pregnancy,oc pills etc

11. SPECIFIC INVESTIGATIONS
• Contrast venography
• Impedence plethysmography
• Compressive ultrasonography( most
commonly used non invasive test with
accuracy upto 94%)
• D-dimer testing
Risk stratification ??.

13. DIFFERENTIAL DIAGNOSIS
• Muscle tear,strain,twisting injury-40%
• Swelling in paralysed limb-9%
• Lymphangitis n lymph obstruction-7%
• Popliteal cyst-5%
• Cellulitis-3%
• Superficial thrombophlebitis
• Drug induced-ca chnl blockers

14. MANAGEMENT OF DVT
Initial treatment:
• DVT r PE- LMWH,fondaparinux,unfractionated
IV heparin,dose adjusted s/c heparin.
• Unfractionated heparin dose should be
sufficient to prolong aPTT to 1.5 to 2.5 times
n platelet count should be monitered
regularly.
• If Count <1lakh treatment should be stopped.

15. • DOSAGE: LMWH 1mg/kg s/c 12hrly for 5days
n oral vit.k anticoagulant warfarin should be
started with in 72hrs untill INR reached to 2.5
• Thrombolytic agents streptokinase,ateleptase
etc, surgical thrombectomy, percutaneous
mechanical thrombectomy may be done in
unstable PE,massive iliofemoral thrombosis n
in pts with low risk of bleed.

16. • IVC filter placement like GREEN WAY KIM r
MODDIN UDDIN FILTER with pulmonary
embolectomy or pul.thromboendartectomy
should be done in pts with recurrent
thrombosis despite adequate anticoagulation.
Duration of treatment:
• 1st time thrombosis due to surgery or trauma-
3months.
• 1st time idiopathic thrombosis-3m n evaluate
for risk/benefits of treatment.

17. • Advanced cancers n unprovoked prox.DVT –
treatment should be given for indefinite
period.
Other treatment:
• Early ambulation shold be encouraged aftr
surgery r trauma.
• Usage of elastic graduated compression
stockings.

18. THANK YOU