Its a elaborate presentation on deep vein thrombosis by surgery resident. Inform me if any thing needed to be correction. thank you. Dr Syed Aftub Uddin, MBBS,CCCD, MS ( Resident) email: aftub_16@yahoo.com

2. Dr Syed Aftub Uddin
MS-Phase A
Resident – General Surgery
Chittagong Medical College Hospital

4. Terminology
Thrombus: Local coagulation or clotting of
blood. The clot itself is termed thrombus.
Thrombosis: The formation or presence of
a blood clot in a blood vessel.
Thromboembolism: If the clot breaks loose &
travels through the bloodstream, it is called
thromboembolism.

5. Venous thrombosis is the formation of a semi-solid coagulum
( Thrombus) within the venous system and when it occurs in
the deep venous system , is called deep vein thrombosis or
DVT.
5

6. Most often occurs in
the deep veins of
the legs, either
above the knee or
below it.
May also occur in
cerebral sinus & veins
of arm,retina and
mesentry.
6

7. 1969 paper by Kakker
30% of post-op patients develop clot in calf veins
35% of these lysed within 72 hrs
15% of pts with persistent thrombosis developed PE
Recent studies put incidence at 50 per
100,000 person yearly.
Incidence greatly increases with age,
18% of 80yr old patients have
asymptomatic DVT
Goldhaber SZ et al. Chest 2000;118:1680-4.

8. VTE: A Major Source of Mortality and Morbidity
Over 200,000
deaths per year due to
DVT/PE annually in
the U.S. alone.
Over 600,000
patients diagnosed with
DVT annually in the US
alone
More than HIV,
& Breast
Cancer combined
10% of Hospital Deaths
most common
preventable death
Huge Costs
and Morbidity
Recurrence of DVT, post-
thrombotic syndrome and
chronic PE / PAH are long
term sequelae
Some Causes of Death in the US Annual Number of Deaths
DVT / PE Up to 200,000
AIDS 16,371
Breast Cancer 40,580
8
Goldhaber SZ et al. Chest 2000;118:1680-4.

9. Venous Thromboembolism (VTE)
remains a major health problem
In addition to the risk of sudden death
30% of survivors
develop recurrent VTE
within 10 years
28% of survivors
develop venous stasis
syndrome within 20 years
9

10. 0 25 50 75 100 125 150 175
Other
Thoracic surgery
Orthopaedic surgery
Medical oncology
General surgery
Medical
Number of VTE events
Total VTE
PE
DVT
44
16
10
9
8
14
Total VTE (%)Patients
VTE According to Service (N=384)
Goldhaber SZ et al. Chest 2000;118:1680-4.
10

11. Proximal femoral fracture 4
(8%)
TOTAL HIP REPLACEMENT 1
(6.6%)
Major abdominal surgery 2
(8%)
HEAD INJURY 1 (2.5%)
SPINAL CORD INJURY 2 (10%)

12. The three factors( TRIAD) described by “Rudolf Virchow”
over a century ago are still relevant in the development of
venous thrombosis.
These are:
• Changes in the vessel wall
(endothelial damage);
• Alteration of normal blood flow,
• Hypercoagulability of blood
(thrombophilia).

13. Endothelial cells allow blood to flow with ease through
vessels.
Conditions/lifestyles that damage vessel walls:
*Past VTE
*Pressure Ulcers
*Smoking
*Cellulites
*High Cholesterol
*Varicose Veins

14. *Immobility
*Trauma
*Surgery
*Insertion of central line
*Varicose Veins
*Stroke
*Sepsis
Any external force that cause damage to the
vascular system can cause slow blood flow

15. It is loosely defined as any alteration of
the coagulation pathways that predisposes
to thrombosis; it can be divided into
primary (genetic) and secondary
(acquired) disorders

16. Hypercoagulability of blood
PRIMARY (GENETIC)
Common
 Factor V mutation (G1691A mutation; factor
V Leiden)
 Prothrombin mutation (G20210A variant)
 5,10-Methylene-tetra-hydrofolate reductase
(homozygous C677T mutation)
 Increased levels of factors VIII, IX, XI, or
fibrinogen
Rare
 Antithrombin III deficiency
 Protein C deficiency
 Protein S deficiency

17. SECONDARY( acquired)
High Risk for Thrombosis
Prolonged immobilization
Myocardial infarction
Tissue injury
Cancer
Prosthetic cardiac valves
DIC
Heparin-induced
thrombocytopenia
Antiphospholipid antibody
syndrome
Lower Risk for Thrombosis
Cardiomyopathy
Nephrotic syndrome
Hyperestrogenic states OCP
Sickle cell anemia
Smoking
Hypercoagulability of blood

18. The most important factor is a
HOSPITAL ADMISSION
for the treatment of medical or
surgical condition.

19. *Age
*Obesity
*Varicose veins
*Immobility
*Pregnancy
*Puerperium
*High-dose estrogen
therapy
*Previous deep vein
thrombosis or
pulmonary
*Thrombophilia
Patient factors

20. •Trauma or
surgery
•Malignancy,
especially pelvic,
and abdominal
metastatic
•Heart failure
•Recent MI
•Inflammatory
bowel disease
•Nephrotic
syndrome
•Polycythaemia
•Paraproteinaemia
•Paroxysmal
nocturnal
haemoglobinuria
•antibody or lupus
anticoagulant
•Behçet’s disease
•Homocystinaemia
Disease or Surgical Procedure

22. According to Severity Patients are classified as:
22
„HIGH-RISK:
• Age more than 40 years.
• Obesity
• Associated comorbid conditions like DM,HTN
• Malignant disease.
• History of previous DVT,MI
• Prolonged preoperative confinement to bed.
• Undergoing major surgery lasting for more than
30 minutes.
„

23. According to Severity Patients are classified as:
23
„INTERMEDIATE RISK
 Age more than 40 years.
 Debilitating illness.
 Undergoing major surgery
 No additional risk factors

24. According to Severity Patients are classified as:
24
LOW RISK
 Age less than 40 years.
 Minor surgery
 No additional risk factors.

25. Clinical Diagnosis
of DVT
25

26. A complete thrombosis history
includes
the age of onset,
location of prior thrombosis,
diagnostic studies documenting
thrombotic episodes.
A positive family history in one
or more first-degree relatives
strongly suggests the presence of
a hereditary defect.
History

27. Recent potential precipitating
conditions
Underlying conditions:
i.e. cancer,
collagen-vascular disorders
Medications
History

28. Many patients are asymptomatic
Edema, principally unilateral, is the most
specific symptom.
There may be pain & tenderness in the
thigh along
the course of the major veins
("painful deep vein syndrome").
History Symptom
& Sign

29. Tenderness on deep palpation
of the calf muscles is suggestive,
but not diagnostic.
Leg pain occurs in 50% of
patients, but this is entirely
nonspecific
-Warmth or erythema of skin
can be present over the area of
thrombosis
History Symptom
& Sign

30. -Clinical signs and symptoms of PE as
the primary manifestation occur in
10-50% of patients with confirmed
DVT.
Homan's sign is unreliable.
History Symptom
& Sign

31. Homan’s sign
This sign is present in less than
one third of patients with
confirmed DVT.
The Homan’s sign is found in
more than 50% of patients
without DVT and, therefore, is
nonspecific.
History Symptom
& Sign

33. *core 1 point if-----
• Active cancer (ongoing treatment or
treatment in the past 6month, or
palliative care)
• Paralysis, paresis, or recent plaster
immobilization of the legs
• Recently bedridden for ≥3d or major
surgery in the past 12wk (GA or regional
anaesthesia)

34. • Localized tenderness along the
distribution of the deep vein system(e.g.
back of the calf)
• Entire leg swelling
• Calf diameter of affected leg (measured
10cm below the tibial tuberosity) >3cm
greater than that of the unaffected leg.

35. • Collateral superficial veins (non-
varicose)
• Previous DVT
Take away 2 points if an alternative cause
is as/more likely than DVT
INTERPRETATION
• If score is <2—DVT is unlikely
• If score is ≥2—DVT is likely

36. In one study of 160 consecutive
patients with suspected DVT who
had negative venograms, the
following causes of leg pain were
identified:

37. •Muscle strain, tear, or twisting injury to
the leg — 40 %
•Leg swelling in a paralyzed limb — 9 %
•Lymphangitis or lymph obstruction — 7%
•Venous insufficiency (reflux) — 7 %
•Baker's cyst — 5 %
•Cellulitis — 3 %
•Knee abnormality — 2 %
•Unknown — 26 %

39. Duplex USG
D-dimers
Enhanced Helical CT Scan
MRI
Ascending Venography
Radiolabelled fibrinogen
scanning

41. Ascending
Venogram
Gold standard
(Traditional)
Identify both calf
& proximal vein
thrombosis
Negative result
almost exclude
presence of DVT.

42. D-DIMERS
Degradation product of cross-
linked fibrin
The appeal: a simple blood test
High sensitivity, low specificity
•Quantitative D-dimer < 500 ng/ml
makes PE less likely
•Elevated d-dimer common w/o clot -
especially
*Cancer/Post-op/Pregnancy/Inpatients/Prior DVT

43. MRI is the diagnostic test of choice
for suspected iliac vein or inferior
vena caval thrombosis when CT
venography is contraindicated or
technically inadequate.
In the second and third trimester of
pregnancy, MRI is more accurate
than duplex ultrasonography because
the gravid uterus alters Doppler
venous flow characteristics.
Expense, lack of general availability,
and technical issues limit its use.

45. The primary objectives of treatment of
DVT are to prevent and/or treat the following
complications:
Prevent further clot extension
Prevention of acute pulmonary embolism

46. General
Measures
Bed Rest
Elevation of affected limb
Antibiotic
Analgesic
Hydration
Compression elastic band,
etc.

47. Anti-coagulant drug therapy:
*Standard Unfractionated
heparin
Dose adjustment by daily APTT.
*Warfarin
Dose adjusted by prothrombin time
kepping INR between 2.5 to 3.5 times
the normal control value.

48. *Low molecular weight heparin(LMWH)
Enoxaparin
Dalteparin
Fondaparinux
*Direct-Acting Oral Anticoagulants (DOACs)
Riva-roxaban
Apixaban
Dabigatran
Edoxaban

49. 1st event, reversible risk factor 3-6 months
1st event, spontaneous >= 6 months
2nd event >=12 months or
lifelong
2nd spontaneous event, or 1st
spontaneous and life threatening
Lifelong
3rd event or
Ongoing risk factors
Lifelong

50. Thrombolytic therapy
In massive venous thrombosis,rapid
thrombolysis may be achieved by passing a
catheter into the vein and infusing fibrinolytic
agents like streptokinase or tissue plasminogen
activator.
Venous thrombectomy
A femoral venotomy is done and the blood clots
are cleared using a Fogarty balloon catheter.
However, the results of thrombectomy are not
encouraging.

51. Patient with suspect symptomatic DVT
Venous duplex scan NEGATIVE Low clinical probability observe
High clinical probability
Repeat scan /
Venography
negativePOSITIVE
Evaluate coagulogram /thrombophilia/ malignancy
Anticoagulant therapy
contraindication
YES IVC filter
NO
Pregnancy LMWH
OPD LMWH
Hospitalisation UFH
+ Warfarin
Compression treatment

52. oEmbolism
oPulmonary embolism
oOedema
oVenous Ulcer
oGangrene
oVaricose Vein
oPigmentation
oCalcification of Vein
oPyrexia of Unknown origin.

54. No prophylaxis + routine objective screening for DVT
Risk of DVT in Hospitalized Patients
Patient Group DVT Incidence
Medical patients 10 - 26 %
Major gyne/uro/gen
surgery
15 - 40 %
Neurosurgery 15 - 40 %
Stroke 11 - 75 %
Hip/knee surgery 40 - 60 %
Major trauma 40 - 80 %
Spinal cord injury 60 - 80 %
Critical care patients 15 - 80 %
54
Heit – Mayo Clin Proc 2001;76:1102

55. Categories of risk for venous
thromboembolism in surgical
patients
Low risk:
Minor surgery in patients <40 years of
age with no additional risk factors
present*
Risk of
calf DVT
2% Risk of
Proximal
DVT
.4%

56. Categories of risk for venous
thromboembolism in surgical
patients
Moderate risk:
Minor surgery in patients with
additional risk factor present*,
or
Surgery in patients aged 40-60
with no additional risk factor
Risk of
calf DVT
10-
20 % Risk of
Proximal
DVT
2-4%

57. Categories of risk for venous
thromboembolism in surgical
patients
High risk:
Surgery in patients >60, or
Surgery in patients aged 40-60
with additional risk factor*
Risk of
calf DVT
20-
40% Risk of
Proximal
DVT
4-8
%

58. Categories of risk for venous
thromboembolism in surgical
patients
Highest risk:
Surgery in patients >40 with multiple risk
factors*, or
Hip or knee arthroplasty, hip fracture
surgery, or
Major trauma, spinal cord injury
Risk of
calf DVT
40-
80 % Risk of
Proximal
DVT
10-
20 %

59. All patients undergoing surgery are the risk of
developing deep venous thrombosis. The
measures for prophylaxis will depend on the
risk stratification.
In low risk patients:
early ambulation,
active and passive exercise of lower limbs.
No pharmacological therapy is required.

60. In intermediate risk patients:
in addition to above measures
use of graduated elastic stockinet
intermittent pneumatic compression devise
In selected cases pharmacological therapy is
indicated.

61. In high-risk patients :
in addition to above measures pharmacological
therapy is indicated.
Low dose heparin—5000 iu s/c thrice daily.
Low molecular weight heparin—enoxaparin,
fraxiparine, etc. LMWH is preferred over heparin
Oral anticoagulants—Patient is
started on oral anticoagulants 72 hours after
surgery once the risk of bleeding is not there.

62. A.Preoperative:
Weight reduction
Stoppage of OCP 1 month before
surgery
Identify high risk group & manage
accordingly.

63. B. Peroperative:
Physical-
oElectrical stimulation of
calf muscle
oExternal intermittent
pneumatic calf compression
oPassive leg exercise ( foot
padaling machine)

64. B. Peroperative:
Chemical-
oLow dose UF Heparin
oLMWH
oDextron 70

65. C. Post operative:
Graduated Compressing stocking
Early mobilization, massage &
movement of leg
Adequate hydration
Heparin continue for 5 days( according
to justification)

66. • Acute hemorrhage from wounds or drains
or lesions
• Intracranial hemorrhage within prior 24
hours
• Heparin-induced thrombocytopenia
• Epidural anesthesia/spinal block with in
12 hours of initiation of anticoagulation
• Severe trauma
Absolute
contraindications

67. Relative contraindications
Coagulopathy (INR > 1 .5)
Intracranial lesion or neoplasm
Severe thrombocytopenia
(platelet count < 50,000/m cl)
Intracranial hemorrhage within
past 6 months
Gastrointestinal or genitourinary
hemorrhage with in past 6 months.

71. Self-care
(i.e., leg elevation, avoid
crossing legs & standing for long
periods);
anticoagulant safety issues
(avoid sharp objects & injury;
monitor common bleeding sites – gums,
nose, GI, GU, skin; actions to take if
bleeding)

72. Basic disease instruction including S/S
of DVT extension & complications.
Lifestyle modification related to
smoking and weight management.

73. Indications & actions of medications;
dose & schedule; target APTT/INR & lab
work; missed dose strategy
Medication interactions (that increase
or decrease INR); diet (foods to avoid,
limit, & eat)