a brief account of DV and PE diagnosis and management

1. Venous thromboembolic
diseases
Dr. Mohammed Elamin Elsidig
S.ROD
Department of Surgery
Prince Abdul alRahman alSudairy
Central Hospital - Sakakah

2. Definition
VTE
DVT
PE

3. Key priorities for
implementation
- Diagnosis
- Treatment
Pharmacological interventions
Thrombolytic therapy
Mechanical interventions
- Thrombophilia

4. Diagnosis
Diagnostic investigations for DVT (NICE)
signs or symptoms of DVT
1- history and a physical examination
2- two-level DVT Wells score

5. Two-level DVT Wells score
1Active cancer (treatment ongoing, within 6 months, or palliative)
1Paralysis, paresis or recent plaster immobilization of the lower
limbs
1Recently bedridden for 3 days or more or major surgery within
12 weeks requiring general or regional anesthesia
1Localized tenderness along the distribution of the deep venous
system
1Leg swollen (Entire)
1
Calf swelling at least 3 cm larger than asymptomatic side
1
Pitting edema confined to the symptomatic leg
1
Collateral superficial veins (non-varicose)
1
Previously documented DVT
2

6. Clinical probability simplified score
DVT likely
2 points or more
DVT unlikely
1 point or less

7. DVT likely
Either : Doppler
U/S scan within
4 hours. If negative
do D- dimer test
Or: AD-dimer test
and anticoagulant
with Doppler u/s
within 24 hours.

8. Repeat the proximal leg vein Doppler u/s
6–8 days later for all patients with a
positive D- dimer test and a negative
proximal leg vein Doppler u/s .

9. DVT unlikely
D-dimer test and if
the result is positive
Doppler ultrasound
scan carried out
within 4 hours
Parenteral
anticoagulant and
Doppler u/s within
24 hours

10. Consider alternative diagnoses
Unlikely Wells
score
Negative
D-dimer test
Positive
D-dimer test
and a negative
Doppler u/s.
Likely Wells
score
Negative
Doppler u/s +
negative
D-dimer
Repeat
negative
Doppler u/s

11. Advise patients in these two groups
that it is not likely they have DVT,
and discuss with them the signs
and symptoms of DVT and when
and where to seek further medical
help.

12. Diagnostic investigations for PE
signs or symptoms of PE
1- history, physical examination and a
chest X-ray .
2- two-level PE Wells score to estimate
the clinical probability of PE.

13. Two-level PE Wells score
3Clinical signs and symptoms of DVT (minimum of leg
swelling and pain with palpation of the deep veins)
3An alternative diagnosis is less likely than PE
1.5Heart rate > 100 beats per minute
1.5Immobilisation for more than 3 days or surgery in the previous
4 weeks
1.5Previous DVT/PE
1Haemoptysis
1Malignancy (on treatment, treated in the last 6 months, or
palliative)1

14. Clinical probability simplified scores
PE likely
More than 4 points
PE unlikely
4 points or less

15. PE likely
Immediate CTPA
parenteral anticoagulant
flowed by CTPA , if a CTPA
cannot be carried out
immediately

16. Consider a proximal leg vein
ultrasound scan if the CTPA
is negative and DVT is suspected.

17. PE unlikely
a D-dimer
positive
Immediate CTPA parenteral anticoagulant
flowed by CTPA , if a
CTPA cannot be carried
out immediately

18. If not available, ANTICOAGULATE
Allergy or risk
from irradiation
V/Q SPECT V/Q planar
scan

19. V/Q SPECT

20. Diagnose PE and treat patients with
a positive CTPA or in whom PE is
identified with a V/Q SPECT or
planar scan

21. Advise these patients that it is not likely they have PE
and discuss with them the signs and symptoms of PE,
and when and where to seek further medical help.
consider alternative diagnoses
unlikely Wells
score
negative D-
dimer test
positive D-
dimer test and
a negative
CTPA
likely Wells
score
negative CTPA
& no suspected
DVT

22. Treatment (NICE)
Pharmacological interventions
parenteral anticoagulant
DVT OR PE LMWH
IN CASE OF
Renal impairment or
ESRD.
Increase risk of bleeding.
Hemodynamic instability.
UFH

23. Start oral VKA and continue parenteral anticoagulant for
at least 5 days or until the (INR) is 2 or above for at
least 24 hours, whichever is longer.
Oral VKA
to be started in DVT or PE within 24 hours of diagnosis
and continued for 3 months. At 3 months, assess the
risks and benefits of continuing VKA treatment .

24. Thrombolytic therapy (NICE)
CDTT
In symptomatic
iliofemoral DVT
less than
14 days
life
expectancy
of 1 year or
more
low risk of
bleeding
good
functional
status

25. Thrombolytic therapy (NICE)
PE
haemodynamic instability
systemic
thrombolytic
therapy
haemodynamic stability
NO systemic
thrombolytic
therapy

26. Mechanical interventions (NICE)
Compression stockings
Wearing for at least
2 years
Replaced two or
three times per
year
Worn only on the
affected leg
Inferior vena caval filters
Not tolerate
anticoagulation
treatment
Remove the inferior vena caval filter
when the patient becomes eligible
for anticoagulation treatment.
Recurrent proximal DV Tor
PE despite increasing target
INR to 3–4

27. Patient information (NICE)
 How to use anticoagulants.
 Duration.
 Side effects
 Adverse effects
 Monitoring.
 Effect on dental treatment
 Taking anticoagulants in pregnancy.
 effect on sports and travel
 when and how to seek medical help.
 'anticoagulant information booklet' and an
'anticoagulant alert card'
 Be aware for patients who have concerns about
using animal products.
 Correct application and use of below-knee
graduated compression stockings.

28. Thrombophilia
Congenital
Factor V Leiden
Protein S deficiency
Protein C deficiency
Antithrombin III deficiency
Familial dysfibrinogenemia
Blood group
Acquire
d
Antiphospholipid syndrome
HIT
Sickle-cell disease
Polycythemia
Cancer
IBD
Obesity
Pregnancy
Unclear
elevated
levels of:
factor VIII
factor IX
factor XI
fibrinogen

29. Thrombophilia testing (NICE)
 Not for patients on anticoagulation
treatment.
 Testing for antiphospholipid antibodies in
patients with unprovoked DVT or PE if it is
planned to stop anticoagulation treatment.
 Testing for hereditary thrombophilia in
patients with unprovoked DVT or PE and
who have a first-degree relative who has
had DVT or PE if it is planned to stop
anticoagulation treatment.
 Do not offer to patients with provoked DVT
or PE.
 Not routine in first-degree relatives in DVT
or PE pt with thrombophilia.

30. Investigations for cancer (NICE)
All patients with unprovoked DVT or PE who
are not known to have cancer:
 Physical examination.
 Chest X-ray.
 Blood tests.
 Urinalysis.
 Consider abdomino-pelvic CT scan (and a
mammogram for women) in all patients
aged over 40 years with a first unprovoked
DVT or PE who do not have signs or
symptoms of cancer based on initial
investigations.

31. Thank you
Discussion