DVT refers to deep vein thrombosis, which is the formation of a blood clot in the deep veins, usually of the legs. Risk factors include age, immobilization, pregnancy, surgery, cancer and genetic factors. Symptoms include leg swelling, pain, redness and tenderness. Diagnosis involves a clinical probability assessment, D-dimer testing and duplex ultrasonography. Treatment includes anticoagulation medications and compression stockings to prevent complications like pulmonary embolism and post-thrombotic syndrome.

1. DVT
((Deep venous thrombosis
By
Dr- Hayam M. AL-moutary
Supervised by
Dr-Abdulla AL-goblain

2. Content
Epidemiology
Symptom& sign
Risk factor
Deferential diagnosis
Diagnosis
Management

3. DVT
• the formation of a thrombus in the deep veins
of the leg
• Virchow triad
venous stasis
vessel wall injury
hypercoagulable state

4. Epidemiology
 DVTs occur in about 1 per 1000 persons per
year.
100,000 deaths may be directly or indirectly
related to these diseases
• In pregnant women, it has an incidence of 0.5
to 7 per 1,000 pregnancies, and is the second
most common cause of maternal death in
developed countries after bleeding
Journal of Internal Medicine volume 232 Issue 2, Pages 155 - 160 •
•

5. Risk factor
– General
• Age
• Immobilization longer
than 3 days
• Pregnancy and the
postpartum period
• Major surgery in previous
4 weeks
• Long plane or car trips (>4
h) in previous 4 weeks
– Medical
• Cancer
• Previous DVT
• Stroke
• Sepsis
• Nephrotic syndrome
• Ulcerative colitis
• SLE
• Protein c & s deficiency
• Obesity

6. Risk factor
– Trauma
Multiple trauma
– Drugs/medications
OCP

7. • In a five-year case-control study (1988 to 1993) at
Assir Central Hospital (ACH), Abha (8,000 feet
above sea level), Saudi Arabia, 92 of 129 patients
suspected of deep venous thrombosis (DVT) were
studied with ascending contrast venography (CV)
(74 patients, 80.4%) or Doppler ultrasonography
(DUS) (18 patients, 19.6%). Female-to-male ratio
was 2.3 to 1. Age range of patients was twelve to
ninety years; mean age was 44.45 yrs ±17.38
years. DVT hospital incidence was 18 per 10,000
admissions
Angiology, Vol. 46, No. 12, 1107-1113 (1995)
http://ang.sagepub.com/cgi/content/abstract/46/12/1107

8. Most risk factor
• chronic diseases
(21.7%),
• trauma and surgery
(19.6%),
• pregnancy and oral
contraceptives usage
(16.3%).
most symptom and sign
• tenderness (95.6%)
• Limb swelling was noted
in 93.5% of patients.
• Pulmonary embolism
was the greatest
complication

9. clinical feature
 swelling, principally unilateral,
Leg pain occurs in 50% of patients
SOB
Clinical signs and symptoms of PE as the
primary manifestation occur in 10% of
patients with confirmed DVT
In patients with angiographically proven PE,
DVT is found in 45-70%.

10. clinical feature
• Unilateral edema
• Leg tenderness
• Redness, hotness
• Bluish discoloration
• Absent or decrease pulse

11. Clinical feature
 Phlegmasia cerulea
dolens
 leg is cyanotic from
massive ileofemoral
venous obstruction.
The leg is usually
markedly edematous,
painful, and cyanotic.
Petechiae are often
present.
Phlegmasia alba dolens
 Painful white inflammation
was originally used to
describe massive
ileofemoral venous
thrombosis and associated
arterial spasm. The affected
extremity is often pale with
poor or even absent distal
pulses

12. Phlegmasia cerulea dolens

13. Clinical feature
• Superficial thrombophlebitis is characterized by the
finding of a palpable, indurate, cordlike, tender,
subcutaneous venous segment.
• 40% of patients with superficial thrombophlebitis
without coexisting varicose veins and with no other
obvious etiology (eg, intravenous catheters,
intravenous drug abuse, soft tissue injury) have an
associated DVT

14. DVT

15. Deferential diagnosis
• Cellulitis, lymphangitis
• Lymphedema
• Postphlebitic syndrome
• Ruptured Baker cyst
• Varicose veins
• Superfical thrombophlibitis

16. Diagnosis ( work up)
History
Physical examination(work up)
Probablity scoring (well score)
Blood test
 D-dimar
Other blood test
Imaging study
MRI , U/S , venography

17. Physical examination
• Homans' test Dorsiflexion of foot elicits pain in
posterior calf. Warning: it must be noted that it is of
little diagnostic value and is theoretically dangerous
because of the possibility of dislodgement of loose
clot.
• Pratt's sign: Squeezing of posterior calf elicits pain.
• back

18. wells score) Clinical Parameter Score) Score
Active cancer (treatment ongoing, or within 6 mo or
1+
palliative)
Paralysis or recent plaster immobilization of the lower
extremities
1+
Recently bedridden for >3 d or major surgery <4 wk 1+
Localized tenderness along the distribution of the deep
venous system
1+
Calf swelling >3 cm compared with the asymptomatic
leg
1+
)Pitting edema (greater in the symptomatic leg 1+
Previous DVT documented 1+
)Collateral superficial veins (nonvaricose 1+
Alternative diagnosis (as likely or greater than that of
2-
)DVT

19. Wells score
Total of Above Score
High probability 3<
Moderate probability or 2 1
Low probability 0 >

20. case
year old female recently pregnant, now on 35
OCP, complain of 1 week unilateral right leg
swelling , no history of trauma, she has DVT
history 2year ago
On P/E
her right calf is 5 cm greater in circumference
than her left and there is tenderness when
.squeeze the gastroncemius muscle

21. Blood test
• complete blood count
• Primary coagulation studies: PT, APTT, INR
• renal function test and electrolytes
• liver function test

22. investigation
• D-dimer testing
• D-dimer antibodies account for their high sensitivity for
venous thrombo embolism.
• D-dimer level may be elevated in any medical condition
where clots form. D-dimer level is elevated in trauma, recent
surgery, hemorrhage, cancer, and sepsis.
• The D-dimer assays have low specificity for DVT; therefore,
they should only be used to rule out DVT, not to confirm the
diagnosis of DVT.

23. • D-dimer results should be used as follows:
– A negative D-dimer assay result rules out
DVT in patients with low-to-moderate risk
and a Wells DVT score less than 2.
– All patients with a positive D-dimer assay
result and all patients with a moderate-to-high
risk of DVT (Wells DVT score >2)
require a diagnostic study (duplex
ultrasonography).

24. Duplex ultrasonography
• Technological advances in ultrasonography have permitted
the combination of real-time ultrasonographic imaging with
Doppler flow studies (duplex ultrasonography).
• The absence of the normal phasic Doppler signals arising
from the changes to venous flow provides indirect evidence
of venous occlusion

25. Duplex ultrasonography

26. Duplex ultrasonography
AA ddvvaannttaaggee
 helpful to differentiate
venous thrombosis from
hematoma, Baker cyst,
abscess, and other causes
of leg pain and edema.
DDiissaaddvvaannttaaggee
 Venous thrombi proximal
to the inguinal ligament
are also difficult to
visualize
 Nonoccluding thrombi
 not be able to differentiate
between old and new clots

27. MRI
– In the second and third trimester of pregnancy,
MRI is more accurate than duplex
ultrasonography because the gravid uterus alters
Doppler venous flow characteristics.
– In suspected calf vein thrombosis, MRI is more
sensitive than any other noninvasive study.

28. MRI
• Disadvantage
Expansive
lack of general availability
 technical issues limit its use

29. (CT venography(gold stander
• The gold standard is intravenous venography, which involves
injecting a peripheral vein of the affected limb with a
contrast agent and taking CT, to reveal whether the venous
supply has been obstructed. Because of its invasiveness, this
test is rarely performed

30. ( CT venography(gold stander
• A number of small studies have compared CT
venography alone to duplex ultrasonography alone
for the diagnosis of lower extremity DVT.
• Similar high sensitivities for ultrasonography and CT
have been reported, but no large trials comparing
the two have yet been performed

31. (CT venography(gold stander
• Disadvantage
visualized veins, artifactual interference from metal
implants such as hip and knee arthroplasties .
 contraindications to the administration of contrast
dye.

32. Bilatral thrombosis

33. High clinical pretest probability- DVT likely
Doppler ultrasound
Ultrasound positive for DVT
Diagnoses of DVT confirmed
Begin treatment
Ultrasound negative
for DVT
(D-Dmer test (if available and reliable
Otherwise skip
to repeat ultrasound
D-Dimer positive Repeat
ultrasound in 1 week
D-Dimer negative
DVT ruled out
Repeat ultrasound positive for DVT
Diagnoses of DVT confirmed
Begin treatment
Suspect DVT
Low clinical pretest
probability- DVT likely
Consider starting with D-dimer
test first
(if available and reliable(
Or skip to ultrasound
D-dimer positive
D-Dimer negative
DVT ruled out
Doppler ultrasound
Ultrasound positive for DVT
Diagnose of DVT confirmed
Begin treatment
Ultrasound negative
for DVT
DVT ruled out
consider repeat(
ultrasound if
(D-dimer not available

34. Complications of deep vein thrombosis
• There are two main complications of deep vein
thrombosis (DVT):
• pulmonary embolism
• post-thrombotic syndrome
• occurs in 15% of patients with deep vein thrombosis
(DVT). It presents with leg oedema, pain, nocturnal
cramping, venous claudication, skin pigmentation,
dermatitis and ulceratiaion (usually on the medial
aspect of the lower leg).

35. management
• Non-pharmcological
• we can reduce risk of DVT by making changes to patient
lifestyle, such as:
• avoid smoking
• eating a healthy balanced diet
• getting regular exercise and
• maintaining a healthy weight or losing weight if patient obese
• Rise leg , This reduces the pressure in the calf veins

36. Travelling
• drink enough amount of water
• avoid taking sleeping pills as it can cause immobility
• perform simple leg exercises, such as regularly
flexing ankles
• take occasional short walks when possible
• wear elastic compression stockings

37. Compression stockings
• Elastic compression stockings should be routinely applied
"beginning within 1 month of diagnosis of proximal DVT and
continuing for a minimum of 1 year after diagnosis
• Most trials used knee-high stockings. A meta-analysis of
randomized controlled trials by the Cochrane Collaboration
showed reduced incidence of post-phlebitic syndrome.
•
•

38. Treatment
 The current guidelines recommend short-term
anticoagulation with LMWH SC , unfractionated heparin SC ,
(Grade 1A),
should continue for at least 5 days and until the INR is >2 for
24 hours (Grade 1C).
 Warfarin 5 mg PO daily is overlapped with heparin for 4-5
days until the international normalized ratio (INR) is
therapeutically elevated to 2-3.
For the first episode of DVT, patients should be treated for 3-
6 months. Recurrent episodes should be treated for at least 1
year
 [Guideline] American Academy of Family Physicians

39. Treatment
• A protocol for IV heparin use is as follows:
 Give an initial bolus of 80 U/kg
Initiate a constant maintenance infusion of 18
U/kg.
 Check the aPTT or Heparin Activity level 6
hours
Continue to check the aPTT until 2 successive
values are therapeutic.

40. Mangment
Heparin side effect
• heparin-induced
thrombocytopenia (HIT).
• elevation of serum
aminotransferase levels
• Hyperkalemia
• alopecia and osteoporosis
can occur with chronic use.
Werfarin side effect
• Hemorrhage
• Werfarin necrosis
• Osteoporosis
• Purple toe syndrome

41. Filters for DVT
• indications for filter placement are
• (1) severe hemorrhagic complications on
anticoagulant therapy or other absolute
contraindications to anticoagulation
• (2) failure of anticoagulant therapy, such as
new or recurrent venous thrombosis

42. Surgery for DVT
• Indication
 anticoagulant therapy is ineffective
Unsafe
Contraindication
 The major surgical procedures for DVT are
clot removal and partial interruption of the
inferior vena cava to prevent PE

43. Treatment in pregnancy
• The treatment of DVT in pregnancy is similar to the
treatment of non pregnant.
• Heparin SC or small pump infusion
• avoid warfarin in pregnancy If warfarin therapy is
essential, it should be avoided at least during the
first trimester (because of teratogenicity) and from
about 2 to 4 weeks before delivery to reduce risk of
hemorrhagic complications
• Compression stockings

44. Prevention
• Prophylaxis for DVT is required in all patients with
risk factors. DVT prophylaxis for patients scheduled
to undergo major surgery is well recognized.
• Recently, a large multicenter double-blind placebo-controlled
trial showed that a single subcutaneous
40-mg daily dose of enoxaparin achieved a 63%
reduction in the incidence of DVT/PE in general
medical patients admitted to the hospital.

45. Prevention
• In the Women's Health Study, supplementation with vitamin
E (alpha-tocopherol, 600 IU every other day) reduced the
risk of venous thrombo embolism in women, especially
those with a prior history or genetic predisposition.
• High-risk patients should also be prescribed a single
prophylactic subcutaneous 40 mg dose of enoxaparin prior
to a long plane trip (>6 h).

46. Summary
• If deal with risk factor early can be prevent DVT
• Early detect & diagnosis prevent fetal complication
• DVT is 2nd cause of death in pregnancy
• wells score& D-dimar and use of U/S can diagnosis
DVT
• PE& post thrombatic syndrom most common
complication

47. Reference
E medicine
American family physicians
Canadian family physicians
Rakel essential family medicine
Oxford handbook of clinical medicine
Swansons family medicine review

49. workshop
• CALCULATE:
• Control events rate
• Experimental event rate
• RRR(Relative Risk Reduction)
• ARR (Absolute Risk Reduction)
• RR (Relative Risk)
• NNT(Number needed to treatment)
• Comments on the curves