Deep Vein Thrombosis (DVT) is a blood clot that forms in the deep veins of the legs, thighs, pelvis or arms. Risk factors for DVT include immobilization, recent surgery or trauma, certain medications, and inherited or acquired hypercoagulability. Symptoms include leg pain, tenderness, swelling, warmth, and skin discoloration of one leg. Diagnosis is made through Doppler ultrasound, CT venography, or MRI imaging along with blood tests. Treatment involves anticoagulant drugs like heparin or warfarin to prevent pulmonary embolism and further clots.

1. Deep Vein Thrombosis (DVT)

2. Deep Vein Thrombosis (DVT) DVT: Blood clot in a vein located deep in the muscles of the legs, thighs, pelvis or arms DVT is the result of 3 principle factors 1. Reduce or stagnant blood flow in deep veins 2. Injury to the blood vessels wall 3. Increase clotting activity (hyper-coagulability or thrombophilia)

3. Risk of DVT Immobilization: prolong sitting, bed rest Recent surgery or trauma: especially hip, knee or gynecological surgery, fracture, childbirth The use of medication: estrogen, birth control pills, tamoxifen Inherited or acquired hypercoagulability, Hx. of polycythemia vera, malignant tumor Note : Approximately 75-90% of DVT have at least one established risk factor : Inherited thrombophilias can be identified in 24-37% of patients

4. Sign and Symptoms Leg pain or tenderness Leg swelling Increase wormth of one leg,change in skin color (redness) Homans sign positive Note: these can occur in other conditions: musculoskeletal injuries, cellulitis

5. Investigation: Doppler (Duplex) ultrasonography Helical CT venography Contrast venography MRI Blood test D-dimer testing For hypercoagulability: antithrombin III, protein C, protein S, antithrombin, plasminogen Footer V leiden mutation, prothrombin G2021OA mutation, hyperhomocysteinemia Antiphospholipid antibodies

6. Treatment: To prevent PE and another DVT Anticoagulant: heparin, warfarin (Coumadin) to keep INR between 2-3 , duration vary from 3 month to life long Thrombolytic drugs: streptokinase, alteplase (Activase) Inferior vena cava filter Surgery: Embolectomy

7. Prevention: Mobilization Drug: LMW Heparin, Warfarin Graduated compression stocking or pneumatic compression stockings Complication and prognosis: Most disappear without difficulty Pulmonary embolism (up to 30% of DVT) and PHT Post-phlebitic syndrome ( 25-50%): chronic pain, swelling, pigmentation in the leg, almost always occur within the first 2 yrs

8. Buerger’s disease (thromboangritis obliterans) First reported by buerger in 1908 , who described the characteristic pathologic findings of acute inflammation and thrombosis of arteries and veins, affected hands and feet Most common in young male ( 20-40 yrs) who is a heavy smoker More recently a higher percentage of men and women over 50 yrs old have been recognized Most common in Orient, SEA, India, Middle East

9. Classic symptoms and signs Claudicaiton or pain at rest Numbness or tingling in the limbs Raynaud’s phenomenon Skin ulceration and gangrene of the digits Ulcer and gangrene of digits Angiogram demonstrating lack of blood flow to VV. of the hand

10. causes Association with tabacco use It has been postulated that it is an autoimmune reaction triggered by some constituent of tabacco

11. Diagnosis History and physical finding Doppler ultrasound Angiograms of upper and lower extrimities: diagnostic angiographic findings are “corkscrew” appearance of arteries and or occlusions or stenosis in multiple area of both arms and legs Skin biopsies: rarely performed

12. Differential Diagnosis Atherosclerosis Endocarditis Other types of vasculitis Severe Raynaud’s phenomenon associated with connective tissue disorder: SLE, scleroderma Clotting disorder of blood

13. Treatment Stop smoking immediately and completely Antiinflammatory agents (steroid) or anticoagulation (aspirin, worfarin) have not proven effective