This document discusses deep vein thrombosis (DVT), its causes, diagnosis, and treatment. DVT is a clinical entity that can be lethal or recurrent. It occurs in both hospitalized and non-hospitalized patients and can lead to long-term complications like pulmonary hypertension or post-thrombotic syndrome. DVT is diagnosed using tools like ultrasound, MRI, CT scans, or venography. Treatment involves anticoagulation to prevent pulmonary embolism and further complications. The duration of anticoagulation treatment depends on individual risk factors for recurrence.

2. Deep Vein Thrombosis
Hossam Bahy, MD
Venous ThromboEbolismDeep Vein Thrombosis & Pulmonary Embolism

3. Venous Thrombo-Embolism
• Clinical entity, lethal, recurrent.
• Hospitalized and non hospitalized persons.
• Long term complication:
a. Chronic thrombo-embolic pulmonary
hypertension
b. Post thrombotic syndrome

4. Pulmonary Hypertension
• Group I no known cause or inherited.
• Group II with left heart disease.
• Group III associated with lung diseases.
• Group IV thrombo-embolic
• Group V by various other diseases

5. Post thrombotic syndrome
• Due to damage of venous valves and venous
hypertension.
• Leg edema, skin changes( hyperpigmentation
lipodermatosclerosis), pain and stasis ulcer
• Compressing stocking for two years.
• Early ambulation.

7. Incidence of TVE
• 10-20 % in medical hospitalized patients.
• 15-40 % in surgical hospitalized patients.
3rd most common cuase of
hospital related death in USA

8. DVT
• Aim of management is to prevent PE & PTS.
• Popliteal vein and above 50 % estimated risk.
• Below(calf vein) 25 %

9. Virchow's Triad
• Stasis.
• Hyper-coagulability.
• Injury to vessel wall.

11. Inherited Hyper-coagulability.
• Factor V leiden
• Prothrombin gene mutation (G20210A)
• Protein C and protein S deficiency
• Anti thrombin deficiency
• Hyperhomocysteinemia
• Elevated factor VIII

12. Aquired Hyper-coagulability.
• Immobilization
• Surgery
• Trauma
• Pregnancy
• OCP & HRT
• Malignancy
• Antiphospholipid
syndrome (lupus
anticoagulant &
anticardiolipin antibodies).
• HIT
• Myeloproliferative
disorders
• Smoking
• Obesity
• Inflammatory bowel
disease
• CVP and pacemakers
• Nephrotic syndrome.

13. Clinical manifestation

14. Symptoms of DVT
• Pain
• Swelling

15. Signs of DVT
• Increased warmth
• Tenderness
• Edema
• Presence of dilated veins
• Erythema
• Cyanosis/gangrene

16. Various signs
• Homan’s sign
• Louvel’s sign
• Lowenberg’s sign

17. Phlegmasia cerulea dolens
• Complete occlusion of venous outflow.
• Malignancy, HIT, hypercoagulable state.
• Capillary bed hypertension (massive limb swelling).
• Ischemia and necrosis.
• Vascular emergency.

19. Phlegmasia cerulea dolens
TREATMENT
• Leg elevation.
• Anticoagualtion
• Thromolysis
• Thrombectomy (Surgical or cathter based).
• Fasciotomy (compartmental syndrome).

20. DVT diagnosis
• Clinical.
• Pretest probability (Wells score).

21. Pretest probability (Wells score)
Clinical feature Score
Active cancer. 1
Paralysis, paresis, recent plaster immobilization of LL. 1
Recently bed ridden > 3d or major surgery in last 4 weeks. 1
Localized tenderness along distribution of deep vein system. 1
Entire leg swollen. 1
>3cm difference in calf circumference. 1
Unilateral pitting edema. 1
Collateral non-varicose superficial veins. 1
More likely alternative diagnosis -2
-2 -1 0 /1 2 / 3 4 5 6 7 8
Add 1 if previously documented DVT
-2 -1 0 1 / 2 3 4 5 6 7 8

22. Tools
• Venography was the gold standard.
• Duplex ultrasound.
• D-Dimer.
• MRI. Pelvic, IVC, mesenteric veins
• CT. Pelvic, IVC, mesenteric veins

23. Venography
• Was/ has been/ used to be …… gold standard.
• Filling defects intra-luminal.
• Abrupt cutoff
• Non filling of the deep system
• Collaterals.
• Contrast /radiology hazards

24. Duplex ultrasound
• 95 % sensitivity and 98 % specificity.
• Non-compressibility is diagnostic but difficult
in iliac and abductor canal.
• Venous distension, decreased or absent
spontaneous flow.
• Difficult with recurrent DVT.
• Pelvic mass cause non-compressibility of
common femoral vein

25. Treatment
• Goal: relief symptoms
• Prevent PE, CTPH, PTS.
• Start anticoagulation at once
• Heparin 80 IU/Kg bolus> 18 U/kg/h IVI
• LMWH
• Fondaparinux.
• Oral anticoagulation.

26. Fondaparinux
• Indirect Xa inhibitor
• FDA approved for DVT prophylaxis.
• 2.5 mg prophylactic.
• Once daily subcutaneous injection.
• Contraindicated in less than 50 kg in
prophylaxis @ orthopedic and abdominal
surgery.

27. Fondaparinux
• FDA approved for acute DVT & PE treatment.
• < 50 kg 5 mg
• 50-100 kg 7.5 mg
• > 100 kg 10mg
• Contraindicated in severe renal impairment.

28. Thrombolytic therapy
• In only elected cases (threatened limb)
• Preferably locally via catheter.
• May be for extensive acute proximal DVT.

29. Vena caval interruption
IVC filter insertion is indicated if
 Contraindicated anticoagulation.
 Complication from anticoagulation.
 Recurrent thrombo-embolization despite
proper anticoagulation.

30. Vena caval interruption
IVC filter insertion may be indicated if
• Massive pulmonary embolism
• Ileocaval DVT.
• Free floating proximal DVT.
• Cardiac or pulmonary insufficiency.
• High risk anticoagulation as in frequent fall.
• Poor compliance.

31. Duration of treatment
Dependant on the risk of recurrence.
• Idiopathic DVT
• Hypercoagulable state.
• malignancy.

32. Duration of treatment
Dependant on the risk of recurrence.
• Old age
• Male sex
• obese
• Elevted D-dimer levels.
• Permanent IVC filter placement.

33. Duration of treatment
• 3 months of INR 2-3 for 1st DVT due to
transient cause.
• 6-12 months of INR 2-3 for 1st idiopathic DVT.
• For life if recurrent unexplained DVT.
• For life with active malignancy or gene
mutation.

34. Upper limb DVT
• Often related to CVP and pacemaker insertion.
• Thoracic outlet syndrome.
• Hyper-coagulant states including malignancy.
• Same anticoagulation duration.
• Thrombolysis for younger patients with effort
thrombosis.

35. Superficial venous thrombosis
• Frequently after IV line in upper limb.
• May occur spontaneously.
• Generally no anticoagulation.
• Unless propagated to deep system or
spontaneous.
• Heparin/ LMWH/Fondaparinux/ VKA
• Four weeks.

36. Post thrombotic syndrome
• Due to damage of venous valves and venous
hypertension.
• Leg edema, skin changes( hyperpigmentation
lipodermatosclerosis), pain and stasis ulcer
• Compressing stocking for two years.
• Early ambulation.

38. Heparin induced thrombocytopenia
• 3-5 % unfractionated heparin.
• < 1 % LMWH.
• Immunoglobulin G antibody to heparin.
platelet factor 4 complex.
• 5-14 day after exposure to heparin.
• Isolated or thrombotic.
• Stop any heparin