This document discusses deep vein thrombosis (DVT). It begins with an overview of risk factors for DVT, including oral contraceptive use and antiphospholipid antibodies. The clinical presentation of DVT is then described, including signs of swelling, pain, warmth, and redness in the affected leg. Complications of DVT include pulmonary embolism and post-thrombotic syndrome. The diagnosis of DVT involves clinical assessment using Well's criteria, D-dimer testing, and imaging with ultrasound or other modalities. Treatment consists of anticoagulation with low molecular weight heparin or warfarin. Prevention strategies incorporate early mobilization, mechanical methods, and pharmacological prophylaxis.

1. DEEP VEIN THROMBOSIS
“DVT”
Interactive Lecture

2. INDEX
 Introduction
 Risk Factors
 Clinical Presentation
 Complications
 Diagnosis
 Treatment
 Prevention

3. OVERVIEW AND THE RISK FACTORS
OF DVT By Mohammed A.
Elgheriani

4. CASE
A 38-year-old woman presents to the emergency department with a
painful left calf. She had woken that morning to notice that her calf
was swollen and found it painful to put her foot to the ground. There
was no history of recent air travel or long-distance car journeys. She
is otherwise well, is not breathless and has no chest pain. She has
had no previous medical illnesses other than some cartilage problems
in the knees. She has had no previous medical illnesses. There is no
family history of note. The patient is married. She is a teacher of
physical education and exercises regularly. She neither smokes
tobacco nor drinks alcohol. The oral contraceptive is the only
medication that she takes. In her obstetric history she has had two
first-trimester miscarriages and has not had any successful
pregnancies.

5. O/E
She is a little overweight. Her left leg is clearly swollen, with a 4 cm
difference in circumference around the left calf measured 10 cm below
the tibial tuberosity. There is tenderness on palpation of the calf. The
left calf is slightly warmer than the right. There is some pitting
oedema in the left ankle and there are superficial veins evident in the
left leg. Physical examination is otherwise normal.
•CBC and blood sugar are normal.
•RFT is normal.
•PT is normal.
•D-dimer is raised.
•APTT is prolonged.

6. What is the cause of her swollen leg?

7. DDX IN THIS CASE
1. DVT
2. Acute Cellulitis
3. Ruptured Baker’s Cyst
4. Trauma
5. Postphlebitic syndrome/venous insufficiency
(previous DVT)
“Other causes of chronically swollen legs are obesity, lymphoedema, congestive
cardiac failure.”

8. WHAT IS DEEP VEIN THROMBOSIS
“DVT”?
Deep vein thrombosis (DVT) refers to the formation of one or more
blood clots in one of the body's large veins, most commonly in the
lower limbs (e.g., lower leg or calf). It is an important member of the
family of peripheral venous disease.
Peripheral venous disease include:
1) Varicose Veins
2) Thrombosis
- Superficial Vein Thrombosis (Thrombophlebitis)
- Deep Vein Thrombosis (DVT)

9. RISK FACTORS FOR DVT

10. RISK FACTORS IN THE CASE
1. Oral contraceptive use
2. The history of miscarriage and the raised activated partial
thromboplastin time suggest:
Antiphospholipid antibodies may be present as part of systemic
lupus erythematosus (SLE) or may be an isolated finding, primary
antiphospholipid antibody syndrome. Although the antibodies
prolong the activated partial thromboplastin time (APTT) they
predispose to thrombosis.
Patients may present with idiopathic recurrent DVT, arterial
gangrene, livedo reticularis, cerebral infarcts, chorea and multi-
infarct dementia.

11. CLINICAL PRESENTATION AND
DIAGNOSIS OF DVT By Mohamed T.
Shembesh

12. CLINICAL PRESENTATION
Swelling (usually unilateral)
Gradual onset of pain and tenderness
Redness
Warmth to the touch
Mild fever
Worsening leg pain when bending the foot
Leg cramps, especially at night, and often starting in the calf
Bluish discoloration of skin

13. CLINICAL PRESENTATION
The extent of swelling
and higher risk of
complications.
Distal DVT
Proximal DVT

14. HOW DOES THIS HAPPEN?

15. CLINICAL PRESENTATION

16. CLINICAL PRESENTATION
Some people with deep vein thrombosis do not experience any
symptoms.
What is the significance of this
presentation?

17. CASE
A 51-year-old woman presents to the ED with the chief complaint of
left leg swelling. She recently underwent bunion correction surgery to
her left foot 7 weeks ago, and her cast was removed one week ago.
Over the last day or two she has had significantly increased leg
swelling and more recently reports some dull pain described as”
heaviness” to the affected leg. The patient denies chest pain,
shortness of breath, or cough. On physical examination, her
respiratory exam is unremarkable, and her left leg is 2.5 cm greater
in circumference than her right, with mild pitting edema in the left leg
only. The edema does not encompass the entire left leg. There is no
tenderness to palpation of the popliteal fossa or medial thigh and
there are no visibly engorged collaterals veins. The patient’s past
medical history includes well-controlled hypertension but she is
otherwise healthy.

18. Do you think we should request imaging
(USS or MRI) for isolated distal DVT?
If not, why and what is the alternative?

19. COMPLICATIONS OF DVT
Name 2 Complications of DVT.
1) Pulmonary
Embolism
2) Post-thrombotic
Syndrome
Complication of long-standing
DVT.
Caused by inflammation and
damage to the venous valves.
Symptoms include pain,
ulceration, heaviness, itching
and tingling, varicose veins and
skin discoloration
DVT is the most common cause
of PE.
Detachment of a segment of
the thrombus > Pulmonary
circulation.
Symptoms vary according the
size of the embolus, may
include acute dyspnea, chest
pain and hemoptysis.

20. DIAGNOSIS OF DVT
The diagnosis of DVT depend on 3 main criteria:
1) Clinical Assessment (Well’s Score)
2) Laboratory Investigation (D-dimer)
3) Imaging

21. WELL’S
CRITERIA

22. D-DIMER
Excludes but does not diagnose.
Highly sensitive but not specific.
Elevated in other conditions such as pregnancy,
post-op, infection and malignancy.

23. IMAGING
Duplex Ultrasound: The first diagnostic method that is usually performed
to image or see the clot is ultrasound.
“Duplex” refers to the two parts of the process, part one: imaging and
compression, part two: Doppler USS measuring the blood flow.
Inability to compress the vein, or an absent blood flow are diagnostic of
DVT.

24. IMAGING
 Figure showing
the normal
compression
process of
Duplex USS.

25. IMAGING
 Popliteal deep
venous
thrombosis
Popliteal vein (PV)
superficial to the
popliteal artery
(PA), no collapse
with compression
(arrowhead)

26. OTHER IMAGING MODALITIES
1. MRI (MRV)
2. Venography (phlebography or ascending phlebography) – X-ray
with a special dye.
Sometimes the ultrasound is negative because there is a clot in a vein in the pelvis, hidden from
the ultrasound. Although isolated pelvic vein thrombosis is uncommon, it can occur in women
who are pregnant or who have recently delivered a baby, in people who have had pelvic cancer,
or in people who have had recent pelvic surgery.
When the USS is negative, and there is high suspicion of DVT (Well’s
score), other imaging modalities can be used such as:

27. OTHER IMAGING MODALITIES
 MRV image with DVT in iliac vein.  Conventional Venography with
Iodine Dye

28. DVT IN A
NUTSHEL
L
If there is high
clinical suspicion of
DVT (Well’s Score equal
or > 2) you can
request imaging
directly.
If the clinical
suspicion of DVT is
low (Well’s Score < 2),
request D-dimer
first.
D-dimer is highly
sensitive and will
always exclude DVT
when it’s not there

29. NICE
DIAGNOST
IC
ALGORITH
M

30. TREATMENT AND PREVENTION OF
DVT By Mohamed K. Elsaiti

31. TREATMENT
1. LMWH (e.g. enoxaparin 1.5mg/kg/24h SC) or fondaparinux and
UFH in renal failure or if high risk of bleeding; dose guided by
APTT.
2. Cancer patients should receive LMWH for 6 months (then review).
3. In others, start warfarin simultaneously with LMWH.
4. Inferior vena cava filters may be used in active bleeding, or when
anticoagulants fail, to minimize risk of pulmonary embolus.
5. Thrombolytic therapy (to reduce damage to venous valves) may
reduce complications but risks major bleeding.

32. PREVENTION
Stop the oral contraceptive pill 4 weeks pre-op.
Mobilize early.
Low Molecular Weight Heparin (LMWH, e.g. enoxaparin20mg/24h SC, and
40mg for high-risk patients, starting 12h pre-op).
Fondaparinux (a factor Xa inhibitor) reduces risk without increasing the
risk of bleeding.
Graduated Compression Stockings (C/I: ischaemia) and Intermittent
Pneumatic Compression Device.

33. PREVENTION
 Graduated Compression Stockings
 Intermittent Pneumatic Compression
Device

35. REFERENCES
•Oxford Handbook of Clinical Medicine 10th Edition
•Harrison's Principles of Internal Medicine 19th Edition
•https://www.stoptheclot.org/learn_more/signs-and-symptoms-of-
blood-clots/how_dvt_is_diagnosed/
•https://canadiem.org/isolated-distal-dvt-diagnostic-and-
management/
•https://www.emedicinehealth.com/blood_clot_in_the_legs/article_em
.htm#facts_and_definition_of_dvt_deep_vein_thrombosis
•https://www.mayoclinic.org/diseases-conditions/deep-vein-
thrombosis/symptoms-causes/syc-20352557