3. Venous Thromboembolism
• Epidemiology
– Leading preventable cause of hospital death (VTE & PE)
– A ‘spectrum’: Simple superficial thrombophlebitis to fatal PE
– Incidence: 100/100,000
• 1/3 of cases are PE
• Increase dramatically with age (>45)
– ≈80% of pt with VTE have one or more R/F
Venous Disease...Bam 3
4. • Majority of LL DVT arise from calf veins (20% from proximal VV)
• ≈20% of calf limited DVT will propagate proximally
DVT
• Only 1/3 of pts investigated for DVT have it
• ‘Silent’ PE present in 40-60% of pts with DVT
• In asymptomatic pts with proven DVT, ≈1/3 will have unDx PE
• With Rx 50% have residual clot upto 1yr
• Without Rx 50% recurrence with in 3 months
Venous Disease...Bam 4
10. Cont’d
• Phlegmasia alba dolens
– Milk leg, white leg
• Phlegmasia cerulea dolens
– Blue leg
Venous Disease...Bam 10
11. Cont’d
DDx
Muscle strain,
tear, or
twisting injury
to the leg
Leg swelling
in a paralyzed
limb
Lymphangitis
or lymph
obstruction
Venous
insufficiency
Popliteal
(Baker's) cyst
Cellulitis
Knee
abnormality
Unknown
Venous Disease...Bam 11
12. Diagnosis
– D dimer
• Highly sensitive but not specific
– Doppler U/S
• Sn & Sp >95%
– CBC, ESR
– Coagulation profile
– OFT
– Work up in line of occult maignancy
– Evaluation for hyper coagulable
states in select patients
Venous Disease...Bam 12
15. Cont’d
Inpatient
• Suspected or proven PE
• CVS and pulm. Commorbidity
• Ileofemoral DVT
• C/I for anticoagulation
• Pregnancy
• Morbid obesity
• Renal failure
• Non compliance
Whom shouldn’t we anti-
coagulate
• Severe active bleeding
• Intracranial bleeding
• Recent brain, spinal cord, ophthalmic
surgery
• ?Pregnancy
• Malignant hypertension
• ?Recent major surgery, CVA, severe
thrombocytopenia
Venous Disease...Bam 15
16. Anticoagulation
• UFH, LMWH, Fondaparinux
• Warfarin overlapped for 5 days till INR is >2
• UFH: 80u/kg IV bolus then constant 18u/kg/hr
– Check aPTT after 6 hrs bolus and adjust Q 6 hrs then after, till 2 successful
values are therapeutic (1.5* ULN)
– Monitor aPTT, PLT, HCT Q 24 hrs.
• LMWH: 1mg/kg Q 12 hrs.
• Fondaparinux: 5-10 mg sc daily. Factor Xa inhibitor. For HIT, if no
response for heparin.
Venous Disease...Bam 16
17. Cont’d
• Warfarin
– 5 mg – 10 mg adult dose and with INR of 2-3 therapeutic range.
Venous Disease...Bam 17
19. Cont’d
• Endovascular intervention
(CDT and PMCDT)
– Phlegmasia
– IVC thrombosis with poor medical response
– Ileo-femoral and femoro-popliteal DVT with low
risk of bleeding
Venous Disease...Bam 19
20. Cont’d
• Surgical thrombectomy
– Phlegmasia cerulea dolens and for those worsening on anticoag; first fasciotomy,
then thrombectomy and continue anticoagulation atleast 6 months.
• IVC Filters
– In pts. with contraindication to anti-coag
– Recurrent VTE despite intensive anticoagulation
• Compression stocking and ambulation recommended
additionally in almost all treatment modalities
Venous Disease...Bam 20
IVC Filter
23. Modified Caprini risk assessment model for VTE in
general surgical pt
Venous Disease...Bam 23
24. Cont’d
Type of surgery
Preferred modality of treatment
General/Abdmoino-pelvic
surgery
Plastic/Reconstructive
surgery
Caprini
score
0 0-2 Early and frequent ambulation
1-2 3-4 Mechanical methods
>3 >5 Pharmacologic prophylaxis
High risk surgery with multiple additional risk factors Both mechanical and pharmacologic
Venous Disease...Bam 24
25. Superficial Venous Thrombophlebitis
• Inflammation and/or thrombosis, and less commonly infection
of the superficial veins
• Benign and self limited
• Lower extremity, neck, chest, upper extremity
– GSV: 50-60%
– SSV: 11-15%
– Tributaries of GSV/SSV: 30-40%
Venous Disease...Bam 25
27. Cont’d
• C/F
– Painful, reddish and swollen superficial vein.
– The vein is hard (cord) and tender on palpation.
– Take 3-4 wks to resolve
Venous Disease...Bam 27
28. Cont’d
• Dx
– Clinical
– Doppler U/S
• Location and extent
• Exclusion of DVT (extremity edema more than expected & near SPJ/SFJ)
Venous Disease...Bam 28
29. Cont’d
• Mgt
– Aim
• Alleviate local Sx
• Prevent thrombosis spreading to DVT and PE
– Compression stocking, warm/cold compression, elevation & ambulation
– NSAID: ↓extension or recurrence
– ≥ 5 cm in length or at a distance of less than 3 cm from the saphenofemoral
junction located in the groin
• Fondaparinux (2.5 mg once daily) or a mid-treatment dose of LMWH for 6wks
– Vein ligation/excision: recurrent phlebitis
Venous Disease...Bam 29
30. Post-thrombotic syndrome
• Symptoms of CVI such as leg pain, edema, and skin ulcers that
develop and persist after an acute DVT.
• Venous thrombosis can cause permanent obstruction and
valvular damage which leads to PTS in 15–50 % of patients
within 1–2 years of an acute DVT
• Chronic venous HTN (obstruction, valvular damage)
Venous Disease...Bam 30
32. Cont’d
• Rx
– Prevention of DVT
– Properly managing DVT
– Compression stocking, leg elevation
– Percutaneous angioplasty with or without stenting
– Valvoplasty and venous bypass: rarely
Venous Disease...Bam 32
33. • In USA, 1/3 of the adult population has CVI, and 1% of adults have a
venous ulcer, the most severe manifestation of CVI
• The annual risk of developing CVI is 2.6% in women and 1.9% in men
• Combination of muscle pumps and competent valves maintains low
venous pressure and keeps venous blood flowing from distal to cephalad
and superficial to deep
• Patients with CVI have persistently high venous pressure (venous
obstruction, valvular incompetence, muscle pump weakness)
Chronic Venous Insufficiency
Venous Disease...Bam 33
38. Cont’d
• Compression stocking
– Provide graded external compression to the leg and oppose the
hydrostatic forces of venous hypertension
Venous Disease...Bam 38
39. Cont’d
• Wound and skin care
• Exercise
– rehabilitate the muscle pump action and improve symptoms.
– beneficial as supplemental therapy to medical and surgical treatment
in advanced disease.
Venous Disease...Bam 39
40. Cont’d
• Interventional Mgt
–Sclerotherapy
• treatment modality for obliterating telangiectases, varicose veins,
and venous segments with reflux
–Endovenous ablative therapy
• Radiofrequency or Laser
–Endovenous deep system therapy
• Abnormalities in venous outflow, involving iliac veins, contribute
to symptoms in 10% to 30% of patients with severe CVI
Venous Disease...Bam 40
41. Cont’d
• Surgical Mgt
–Surgery for truncal vein or venous tributaries
• GSV high ligation and stripping, ambulatory phlebectomies
–Perforator vein surgery
• Subfascial endoscopic perforator surgery
–Deep vein insufficiency
• External valvuloplasty, brachial/axillary valve transfer, and vein
transpositions
Venous Disease...Bam 41
43. Cont’d
In the thigh before entering
in the saphenous opening it
receives 6 tributaries:
Venous Disease...Bam 43
44. Introduction
• Subcutaneous dilated veins commonly in the lower extremities
which are ≥3 mm in diameter in the upright position
• Can occur in the axial superficial veins (GSV and SSV) and/or
in any of their tributaries
• As a result of
–structural weakening of the vein wall or
–secondary venous disease like DVT
Venous Disease...Bam 44
46. Cont’d
• Advancing age
• Family Hx of venous disease
• Increased BMI
• Smoking
• Hx of lower extremity trauma
• Prior venous thrombosis
• Pregnancy
• Superficial thrombophlebitis
• Specific jobs with a habit of longstanding
• Obesity
Risk Factors
Venous Disease...Bam 46
47. Cont’d
• Clinical features
– Lower extremity pain and swelling, particularly after prolonged
standing, and a feeling of heaviness in the lower extremities.
– Sx due to complications: SVT, acute bleeding originating in one of the
thin-walled varices, eczema, and skin ulceration
– Physical exam tests:
• Cough impulse test, trendelenburg’s test, multiple tourniquet test, Schwartz
test
Venous Disease...Bam 47
48. Diagnosis
• Clinical
• Duplex U/S: test of choice
– Patency & reflux of the deep veins starting from the iliac veins
– Patency and reflux of the superficial veins
– SFJ and SPJ incompetency, and marking of the saphenopopliteal
location as it is variable
– Reflux of the perforators
Venous Disease...Bam 48
56. Cont’d
• Post Op
– Dressing is removed on 24-48hr after surgery
– Analgesics (PCM, NSAID)
– Ambulation on 1st post op day
– Compression elastic bandage worn for 1-2 weeks
Venous Disease...Bam 56
