DEEP VEIN
THROMBOSIS
INTRODUCTION
• Venous thrombosis is the formation of a semisolid coagulum within
the venous system.
• It may occur in the superficial system (superficial vein thrombosis
[SVT] or 'thrombophlebitis") or the deep system (deep vein
thrombosis [DVT]).
AETIOLOGY
• The three factors described by Virchow are responsible for the
development of venous thrombosis.
• These are:
i. Contact of blood with an abnormal surface (endothelial damage)
ii. Abnormal flow (stasis)
iii. Abnormal blood (hypercoagulability).
• Immobility (and hence stasis) remains one of the most important
factors. DVT is recognized as a complication of long-hour flights and
other forms of travel.
• Postoperative thrombosis (most common cause):
- Usually seen after prostate surgery, hip, major abdominal, cancer surgeries.
- Incidence is 30% following surgeries
- In 30% of cases both legs are affected
- Bedridden for more than 3 days in the postoperative period increases the risk of
DVT.
• Spontaneous thrombosis is common in visceral neoplasm.
• Thrombosis can occur in individuals who sit with computers for long
time: Ethrombosis
SITES
• Pelvic veins – internal iliac vein
• Leg veins-
i. Veins of soleus muscle in calf
ii. Femoral vein
iii. Iliofemoral vein thrombosis is common on
left side due to its lengthy
course/compression by right iliac artery.
• Upper limb veins- Axillary vein
thrombosis
CLINICAL FEATURES
• SYMPTOMS:
i. Fever-earliest symptom.
ii. Pain and swelling in the calf and
thigh.
• SIGNS:
i. Leg is tense, tender, warm.
ii. Appears pale or bluish with
stretched and shiny skin.
iii. Positive Homan's sign
iv. Mose's sign
v. Neuhof's sign: Thickening and deep tenderness elicited while palpating deep in
calf muscles.
vi. Modified Perthes test: After applying tourniquet at saphenofemoral junction,
patient is made to walk quickly, superficial veins will become more distended in
presence of DVT.
• Phlegmasia Alba Dolens: It is the total
occlusion of deep iliofemoral venous
system causing painful congestion and
oedema of leg, with lymphangitis,
which further increases the oedema
and worsens the situation (white leg).
• Phlegmasia Caerulea Dolens: It is
occlusion of deep, collaterals, and
superficial venous systems. With
obstruction of all the main veins, the
skin becomes congested and blue (blue
leg) Later on arterial pulses may
temporarily disappear and venous
gangrene may develop.
• Most often, DVT is asymptomatic and presents suddenly with features
of pulmonary embolism like chest pain, breathlessness and
haemoptysis.
• Differential diagnosis for DVT:
i. Ruptured Baker's cyst
ii. Ruptured plantaris tendon
iii. Calf muscle haematoma
iv. Cellulitis leg
v. Superficial thrombophlebitis.
INVESTIGATIONS
• Venous Doppler with Duplex
scanning:
i. It shows noncompressible vein
which is wider than normal.
ii. On compression over calf muscles, it
does not show any augmentation of
flow.
• Venogram:
i. Contrast material is injected into
venous system after applying
tourniquet into superficial
system.
ii. Occlusive and nonocclusive
thrombus can be differentiated
by this.
• If pulmonary embolism is
suspected: CT angiography is
done.
• D-dimer test: interprets the
plasmin activity on fibrin.
Negative D-dimer test is of more
value.
TREATMENT
• Rest, elevation of limb, bandaging the
entire limb with crepe bandage.
• CONTRAINDICATIONS:
i. Associated with advanced peripheral arterial
disease
ii. Severe congestive cardiac failure
iii. Cellulitis
• INDICATION: to prevent posthrombotic
syndrome.
• Anticoagulants: Heparin/low molecular
weight heparin, warfarin.
• For fixed thrombus:
-Initially high dose of heparin of 25,000 units/day for 7 days is given.
-Later warfarin for 3-6 months is given.
-Low molecular weight heparin is preferred to heparin.
-Warfarin should be started as early as possible (same day of
heparin therapy)
-INR should be maintained between 2.0 to 3.0.
-Oral anticoagulants being teratogenic cannot be used during
pregnancy. LMWH is the drug of choice used during pregnancy and
postpartum period.
-If sensitive to heparin, Fondaparinux(factor Xa inhibitor) is given.
• For free thrombus:
i. Fibrinolysins: Streptokinase. It is commonly
infused directly into the affected vein through
a venous catheter. Urokinase or tissue
plasminogen activator may also be used to
dissolve thrombus .
ii. Thrombectomy using Fogarty's catheter
iii. IVC filter: Thrombotic emboli is prevented
from reaching the heart by filtering it at IVC
level using intracaval filters- Kim ray
Greenfield filter, Mobin Uddin umbrella filter.
PREVENTION
• Categorise the patient as low/moderate and high-risk.
i. Low-risk- young patients undergoing surgery for less than 30 minutes.
ii. Moderate-risk-patients above 40 years of age undergoing major surgery.
iii. High-risk-one who had existing cardiac diseases, stroke, previous history of
DVT, suffering from malignancy
• Mechanical methods- elastic compression bandage, elevation,
external pneumatic bandage, electrical stimulation of calf muscles
• Pharmacological-low molecular weight heparin once a day
• LOW RISK: only mechanical prophylaxis
• MODERATE AND HIGH RISK: both
EFFECTS AND SEQUELAE OF DVT
• Pulmonary embolism-15%
• Infection
• Venous gangrene
• Partial recanalization
• Chronic venous hypertension around the ankle region causing venous
ulcers
• Recurrent DVT-30%
• Propagation of thrombus proximally-20-30%
UPPER EXTREMITY DVT
• It can be primary or secondary.
• Primary upper limb DVT is Paget-Schroetter syndrome, is due to
subclavian vein compression that occurs in thoracic outlet syndrome.
It may be precipitated by exertion of arms, swimming, exercise, etc.
• Secondary upper limb DVT is due to thrombocytosis, malignancy,
surgeries, radiotherapy, etc.
• Upper limb DVT is rare compared to lower limb DVT (5% of all DVT). It
may be axillary or subclavian vein or both.
• But 30% of upper limb DVT can cause pulmonary embolism.
• Features: Unilateral arm, forearm swelling with bluish discolouration,
pain, pitting edema.
• Investigations are-
i. Duplex scan,
ii. MR venography (as clavicle obscures proper duplex evaluation),
iii. BT, CT, PT, APTT, platelet count estimation.
• Treatment is similar, with heparin/LMWH/warfarin, thrombolysis
using tissue plasminogen activator, elevation of the arm, using
compression stockings.
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