Deep vein thrombosis (DVT) is a condition characterized by the formation of a blood clot in deep veins, primarily in the legs, influenced by factors like venous stasis, hypercoagulable states, and endothelial damage. Symptoms include calf pain, swelling, and potential severe complications like pulmonary embolism and gangrene. Diagnosis involves clinical evaluation, D-dimer tests, and imaging, with treatment focusing on anticoagulation, thrombolytic therapy, and prevention of recurrence.

1. DEFINITION
Deep vein thrombosis is the formation of a blood clot in
one of the deep veins of the body, usually in the leg.
DEEP VEIN THROMBOSIS

2. ETIOLOGY
Starts in Lower
extremity calf veins
progressing proximally
to involve
Popliteal, Femoral, iliac
system
Virchow's triad
Describes three factors that are thought to
contribute to thrombosis
VIRCHOW TRIAD
More than 100 years ago, Rudolf Virchow
described a triad of factors of

3. Venous stasis
Hypercoagulable state
Endothelial damage

4. VENOUS STASIS
prolonged bed rest (4 days or
more)
A cast on the leg
Limb paralysis from stroke
spinal cord injury
extended travel in a vehicle

5. HYPERCOAGULABILITY
Surgery and trauma 40% of all thrombo embolic disease
Malignancy
increased estrogen
Inherited disorders of coagulation -Deficiencies of protein-S,
protein-C, anti-thrombin III.
Acquired disorders of coagulation- Nephrotic syndrome, Anti-
phospholipid antibodies

6. ENDOTHELIAL INJURY
Trauma
Surgery
Invasive procedure
Iatrogenic causes -
central venous catheters
Subclavian
Internal jugular lines
These lines cause of upper extremity DVT.

7. HYPERCOAGULABLE STATE OF MALIGNANCY
Up to 15% of cancer patients presents with VTE
VTE is not equally common in all types of cancer.
The highest incidence is found in mucin- producing
adenocarcinomas, pancreas and gastrointestinal tract,
lung cancer, and ovarian cancer.

9. PATHOPHYSIOLOGY
Vessel trauma stimulates the clotting cascade.
• Platelets aggregate at the site particularly when
venous stasis present
Platelets and fibrin form the initial clot
RBC are trapped in the fibrin meshwork

10. The thrombus propagates in the direction of the blood
flow.
Inflammation is triggered, causing tenderness, swelling,
and erythema.
Pieces of thrombus may break loose and travel through
circulation- emboli.
Fibroblasts eventually invade the thrombus, scarring vein
wall and destroying valves. Patency may be restored valve
damage is permanent, affecting directional flow.

12. • Thrombophlebitis a thrombus accompanied by inflammation of the
vein (phlebitis).
• Phlebothrombosis refers to a thrombus with minimal
inflammation.
Dislodgment and migration of a thrombus are known as
thromboembolism.
Which is common in phlebothrombosis.

13. PRESENTATION AND PHYSICAL EXAMINATION
Calf pain or tenderness, or both
Swelling with pitting oedema
Increased skin temperature and fever
• Superficial venous dilatation
Cyanosis can occur with severe obstruction

14. Less frequent manifestations of venous thrombosis include
Phlegmasia alba dolens,
Phlegmasia cerulea dolens, and
Venous gangrene.
These are clinical spectrum of the same disorder.

15. PHLEGMASIA ALBA DOLENS
Thrombosis in only major deep venous
channels sparing collateral veins
Causing painful congestion and oedema
of leg, with lymphangitis
Which further increases Oedema

16. PHLEGMASIA CERULEA DOLENS
Thrombosis extends to collateral veins.
congestions, massive fluid sequestration, edema
40-60% also have capillary involvement irreversible venous
gangrene
hydrostatic pressure in arterial and venous capillaries exceeds
the oncotic pressure
fluid sequestration in the interstitium
Circulatory shock, and arterial insufficiency which causes
gangrene.

17. c/f
sudden severe pain, swelling, cyanosis and edema of the
affected limb.
There is a high risk of massive pulmonary embolism, even
under anticoagulation.
Foot gangrene may also occur.
An underlying malignancy is found in 50% of cases. Usually, it
occurs in those

19. CLINICAL EXAMINATION
Palpate distal pulses and evaluate capillary refill to assess
limb perfusion.
Move and palpate all joints to detect acute
arthritis or other joint pathology.
• Neurologic evaluation may detect nerve root irritation;
sensory, motor, and reflex deficits should be noted

20. Homans sign: pain in the posterior calf or
knee with forced dorsiflexion of the
foot.

21. Moses sign
Gentle squeezing of the lower part of the calf from side to side.
Neuhofs sign
Thickening and deep tenderness elicited while palpating deep in
calf muscles.
Lintons sign
After applying torniquet at saphenofemoral junction patient
made to walk, then limb is elevated in supine posation
prominent superficial veins will be observed

22. Search for stigmata of PE such as tachycardia (common)
tachypnea chest findings (rare),
exam for signs suggestive of underlying predisposing
factors.

23. WELLS CLINICAL PREDICTION GUIDE
It pre-test probability score
Helps in early risk stratification and appropriate use of
laboratory tests and imaging modalities.
wells criteria is an additional tool to diagnosis rather than
being a stand-alone test.
Variable

25. Interpretation
High probability: ≥ 3 (Prevalence of DVT-53%)
Moderate probability: 1-2 (Prevalence of DVT- 17%)
• Low probability: ≤0 (Prevalence of DVT-5%)

26. DIAGNOSTIC STUDIES
Clinical examination alone is able to confirm only
20-30% of cases of DVT
Blood Tests
The D-dimer
Imaging Studies

27. D-DIMER
It specific degradation product of cross-linked fibrin.
Because concurrent production and breakdown of clot
characterize thrombosis, patients with thromboembolic
disease have elevated levels of D-dimer.
Three major approaches for measuring D-dimer
ELISA
latex agglutination
- blood agglutination test

28. PLASMIN CLEAVES FACTOR XIIIA-CROSS- LINKED FIBRIN
INTO AN ARRAY OF INTERMEDIA TE FORMS. THE D-DIMER
AND E FRAGMENTS ARE THE RESULT OF TERMINAL FIBRIN
DEGRADATIO N

31. IMAGING STUDIES Invasive venography, radiolabeled
fibrinogen noninvasive - ultrasound, plethysmography, -
MRI techniques

32. Venography
VENOGRAM:
POPLITEAL VEIN
THROMBOSIS

34. VENOGRAPHY
It detects thrombi in both calf and thigh
It can conclude and exclude the diagnosis of DVT when
other objective testings are not conclusive.
Advantages
It is useful if the patient has a high clinical probability of
thrombosis and a negative ultrasound.
It is also valuable in symptomatic patients with a history
of prior thrombosis in whom the ultrasound is non-
diagnostic.

35. DISADVANTAGE
It can primary cause of DVT in 3% of patients who
undergo this diagnostic procedure.
An invasive and expensive.
Although Venography was once considered the gold
standard for diagnosis of DVT, today it is more commonly
used in research environments and less frequently
utilized in clinical practice.

37. NUCLEAR MEDICINE STUDIES
Because the radioactive isotope incorporates into a
growing thrombus, this test can distinguish new clot from
an old clot.
Nuclear medicine studies done with P-labeled fibrinogen.
More commonly used in research.

38. PLETHYSMOGRAPHY Plethysmography measures
change in lower extremity volume in response to certain
stimuli.

39. IMPEDANCE PLETHYSMOGRAPHY
Principle- Blood volume changes in the leg lead to
changes in electrical resistance.
• Venous return in the lower extremity is occluded by
inflation of a thigh cuff, and then the cuff is released,
resulting in a decrease in calf blood volume. Any
obstruction of the proximal veins diminishes the volume
change, which is detected by measuring changes in
electrical resistance (impedance) over the calf.

40. IMPEDANCE PLETHYSMOGRAPHY
Principle- Blood volume changes in the leg lead to
changes in electrical resistance.
Venous return in the lower extremity is occluded by
inflation of a thigh cuff, and then the cuff is released,
resulting in a decrease in calf blood volume. Any
obstruction of the proximal veins diminishes the volume
change, which is detected by measuring changes in
electrical resistance (impedance) over the calf.

41. ULTRASONOGRAPHY
color-flow Duplex scanning is the imaging test of choice
for patients with suspected DVT
• inexpensive,
noninvasive,
widely available
Ultrasound can also distinguish other causes of leg
swelling, such as tumor, popliteal cyst, abscess,
aneurysm, or hematoma.

42. CLINICAL LIMITATIONS
Reader dependent
Duplex scans are less likely to detect non- occluding thrombi.
During the second half of pregnancy, ultrasound becomes less specific,
because the gravid uterus compresses the inferior vena cava, thereby
changing Doppler flow in the lower extremities.
An inability to distinguish old clots from a newly forming clot

43. MAGNETIC RESONANCE IMAGING
It detects leg, pelvis, and pulmonary thrombi and is 97% sensitive and 95%
specific for DVT.
It distinguishes a mature from an immature
clot.
MRI is safe in all stages of pregnancy.
Test may not be appropriate for patients with pacemakers or other metallic
implants, it can be an effective diagnostic option for some patients.

44. DIFFERENTIAL DIAGNOSIS
• Cellulitis
Thrombophlebitis
• Arthritis
Asymmetric peripheral edema secondary to CHF, liver disease,
renal failure, or nephrotic syndrome
lymphangitis
Extrinsic compression of iliac vein secondary to tumor,
hematoma, or abscess
Hematoma
Lymphedema

45. Muscle or soft tissue injury
Neurogenic pain
Postphlebitic syndrome
Ruptured Baker cyst
Stress fractures or other bony lesions
Superficial thrombophlebitis

46. MANAGEMENT
Using the pretest probability score calculated from the Wells
Clinical Prediction rule, patients are stratified into 3 risk
groups-high, moderate, or low.
The results from duplex ultrasound are incorporated as follows:
If the patient is high or moderate risk and the duplex ultrasound
study is positive, treat for DVT.

47. If the duplex study is negative and the patient is low
risk. DVT has been ruled out.
When discordance exists between the pretest
probability and the duplex study result, further
evaluation is required.
If the patient is high risk but the ultrasound study was
negative, the patient still has a significant probability
of DVT

48. a venogram to rule out a calf vein DVT surveillance with
repeat clinical evaluation and ultrasound in 1 week.
results of a D-dimer assay to guide management
If the patient is low risk but the ultrasound study is
positive, some authors recommend a second
confirmatory study such as a venogram before treating
for DVT

49. EMERGENCY DEPARTMANT CARE
The primary objectives of the treatment of DVT are to-
prevent pulmonary embolism,
reduce morbidity, and
• prevent or minimize the risk of developing the postphlebitic
syndrome.

50. GENERAL THERAPEUTIC MEASURES:
Bed rest.
Encourage the patient to perform gentle foot & leg exercises every hour.
Increase fluid intake upto 2 l/day unless contraindicated.
Avoid deep palpation..

51. SPECIFIC TREATMENT:
Anticoagulation
Thrombolytic therapy for DVT
Surgery for DVT
Filters for DVT
Compression stockings

52. Initial treatment of DVT is with low- molecular-weight
heparin or unfractionated heparin for at least 5 days,
followed by warfarin (target INR, 2.0-3.0) for at least 3
months.

53. ANTICOAGULATION
Heparin prevents extension of the thrombus
It is a heterogeneous mixture of polysaccharide fragments
with varying molecular weights but with similar biological
activity.

54. MECHANISM OF ACTION
Heparin's anticoagulant effect is related directly to its
activation of antithrombin III.
Antithrombin III, the body's primary anticoagulant,
inactivates thrombin and inhibits the activity of activated
factor X, factor IX in the coagulation process.

56. Side effects
Bleeding
Osteoporosis
Thrombocytopenia
Skins lesions- urticaria, papules, necrosis
Hypoaldosteronism, hyperkalemia
CONTRAINDICATIONS-
Bleeding disorders,
Severe hypertension, threatened abortion, piles,
large malignancies, tuberculosis'
Ocular surgery and neurosurgery,
Chronic alcoholics, cirrhosis, renal failure

57. DOSE
IV bolus dose of 5,000 to 10,000 units
followed by an infusion of 1,000 units per hour.
Other method of initiating therapy is to begin with
Loading dose of 50-100 units/kg of heparin followed by a
constant infusion of 15-25 units/kg/hr.

58. THROMBOLYTIC THERAPY FOR DVT
Advantages include
Prompt resolution of symptoms,
Prevention of pulmonary embolism,
Restoration of normal venous circulation,
• Preservation of venous valvular function,
• Prevention of postphlebitic syndrome.

59. DISADVANTAGE
Thrombolytic therapy does not prevent
clot propagation,
rethrombosis, or
subsequent embolization.
• Heparin therapy and oral anticoagulant therapy always
must followed after a course of thrombolysis.

60. Thrombolytic therapy is also not effective once the thrombus is
adherent and begins to organize
The hemorrhagic complications of thrombolytic therapy are about 3
times higher, including the small but potentially fatal risk of intra-
cerebral hemorrhage.
At present, therefore, thrombo-lysis should be reserved for
exceptional circumstances, such as patients with limb-threatening
ischemia caused by phlegmasia cerulea dolens.

61. SURGERY FOR DVT
Indications
when anticoagulant therapy is ineffective
unsafe,
contraindicated.
The major surgical procedures for DVT are clot removal
and partial interruption of the inferior vena cava to
prevent pulmonary embolism.

66. FILTERS FOR DVT
Indications
Contraindication to anticoagulation.
Significant bleeding complication of anticoagulation
therapy.
Pulmonary embolism with contraindication to
anticoagulation.
Recurrent thrombo-embolic complication despite
adequate anticoagulation therapy.

67. Inferior vena cava filters reduce the rate of pulmonary
embolism but have no effect on the other complications of deep
vein thrombosis. Thrombolysis should be considered in patients
with major proximal vein thrombosis and threatened venous
infarction

69. PROPHYLAXIS
Indicated in who underwent major abdominal trauma or
orthopaedic surgery or patient having prolonged
immobolization (> 3 days).
Benefits of VTE Prophylaxis
Improved patient outcomes
• Reduced costs

70. METHODS OF VTE PROPHYLAXIS
Mechanical:
• Graduated Compression Stockings (GCS)
• Intermittent Pneumatic Compression Devices (IPC)
Pharmacologic
Low molecular weight Heparin.(5000u se Shourly) It
inhibits factor Xa and IIA activity.

71. PERIPHERAL VASCULAR DISEASE
Shemil
Clinical instructor DM WIMS

72. Definition
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Peripheral vascular disease (PVD) is a circulation disorder
that causes narrowing of blood vessels to parts of the
body other than the brain and heart.

73. There are two types of PVD
Functional PVDs don't involve defects in blood vessels' structure. (The blood
vessels aren't physically damaged.) These diseases often have symptoms related
to "spasm" that may come and go.(Raynaud disease)
Organic PVDs are caused by structural changes in the blood vessels. Examples
could include inflammation and tissue damage. (peripheral artery disease)

74. Causes
1. Atherosclerosis
2. Blood clots
3. Diabetes
4. Inflammation of the arteries or arteritis
5. Infection(salmonellosis and syphilis)
6. Structural defects
7. Injury

76. Risk factors
Family history of heart disease, high blood pressure, high cholesterol,
or stroke
Older than 50 years
Overweight or obesity
Inactive lifestyle
Smoking
Diabetes
High blood pressure
High cholesterol or LDL plus high triglycerides and low HDL

77. Symptoms
Dull, cramping pain in one or both calves, thighs, or hips
when walking, called intermittent claudication
Buttock pain,
Numbness or tingling in the legs,
Weakness, burning or aching pain in the feet or toes
while resting.
A sore on a leg or a foot that will not heal,
One or both legs or feet feel cold or change color (pale,
bluish, dark reddish),
Hair loss on the legs, and
Impotence

79. 1. Edinburgh claudication questionnaire.
2. Ankle brachial index(ABI).
3. Treadmill exercise test.
4. Angiography, or arteriography
5. Doppler ultrasound flow studies
6. Magnetic resonance imaging

81. Ankle/brachial index (ABI)
This test compares the blood pressure in the arm (brachial)
with the blood pressure in the legs.
In a person with healthy blood vessels, the pressure should
be higher in the legs than in the arms.
An ABI above 0.90 is normal; 0.71-0.90 indicates mild PVD;
0.41-0.70 indicates moderate disease; and less than 0.40
indicates severe PVD.

84. Treadmill exercise test
If necessary, the ABI will be followed by a treadmill exercise
test.
Blood pressures in your arms and legs will be taken before and
after exercise (walking on a treadmill, usually until you have
symptoms).
A significant drop in leg blood pressures and ABIs after exercise
suggests PVD

85. Angiography, or arteriography
Doppler ultrasound flow studies
Magnetic resonance imaging

86. Lifestyle changes
Stopping smoking (smokers are 4 times more likely to get
PAD and have symptoms of PAD than nonsmokers.)
• Controlling diabetes
Controlling blood pressure
• Being physically active
• Eating a diet low in saturated fats

87. Medicines
Antiplatelet agents to prevent blood clots
• Cholesterol-lowering medicine.
Anti hypertensive.

88. Vascular surgery
A bypass graft using a blood vessel from another part of the body or a
tube made of synthetic material is placed in the area of the blocked or
narrowed artery to reroute the blood flow

90. Angioplasty
Balloon angioplasty (a small balloon is inflated inside the blocked
artery to open the blocked area).
Atherectomy (the blocked area inside the artery is "shaved" away by a
tiny device on the end of a catheter)
Laser angioplasty (a laser is used to "vaporize" the blockage in the
artery)
Stent (a tiny coil is expanded inside the blocked artery to open the
blocked area and is left in place to keep the artery open)

94. Complication
Amputation (loss of a limb)
Poor wound healing
Restricted mobility due to pain or discomfort with exertion
Severe pain in the affected extremity
Stroke (three times more likely in people with

95. Prevention
Smoking cessation, including avoidance of second hand smoke and use
of any tobacco products.
Dietary changes including reduced fat, cholesterol, and simple
carbohydrates (such as sweets), and increased amounts of fruits and
vegetables,
Weight reduction
Exercise plan of a minimum of 30 minutes daily
Control of diabetes
Control of high blood pressure