DEEP VEIN
THROMBOSIS
DEFINITION
Deep vein thrombosis is the
formation of a blood clot in one of
the deep veins of the body, usually
in the leg.
IT IS LIKE ICEBERG DISEASE
Symptomatic deep vein thrombosis is "tip of the iceberg"
VIRCHOW TRIAD
Rudolf Ludwig Carl Virchow (1821-1902) Prof Of
Pathology, Germany, Berlin
Described three factors that are thought to contribute to
thrombosis -
Venous stasis
Hypercoagulable Endothelial
state damage
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
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
ENDOTHELIAL INJURY
Trauma Surgery
Invasive procedure Iatrogenic causes –
central venous catheters
Subclavian
Internaljugular lines
These lines cause of upper extremity DVT.
PATHOLOGY OF DVT
A thrombus develops in soleal veins initially as a platelet aggregate.
Fibrin and red cells form a mesh until lumen of vein wall occludes.
Coralline thrombus then progresses as a propagated loose red fibrin
clot containing many red cells.
Extend up to next large venous branch
Possible for clot to break off
Pulmonary embolism
PRESENTATION AND PHYSICAL EXAMINATION
Calf pain or tenderness, or both
Swelling with pitting edema
Increased skin temperature and fever
Superficial venous dilatation
Cyanosis can occur with severe obstruction
Less frequent
manifestations of
venous thrombosis
include :-
a) Phlegmasia alba
dolens,
b) Phlegmasia cerulea
dolens, and
c) Venous gangrene.
These are clinical
spectrum of the
same disorder.
CLINICAL FEATURES
Sudden severe pain ,
Swelling,
Cyanosis
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.
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
Homans Sign: Pain In The Posterior Calf Or
Knee With Forced Dorsiflexion Of The Foot.
Moses sign
Gentle squeezing of the lower part of the calf from
side to side.
DIAGNOSTIC STUDIES
Clinicalexamination alone is able to
confirm only 20-30% of cases of DVT
Blood Tests The D-dimer
Imaging Studies
Imaging studies
INVASIVE
NONINVASIVE
ultrasound,
plethysmography,
MRI techniques
venography,
radiolabeled fibrinogen
ULTRASONOGRAPHY
Color-flow
duplex scanning is the
imaging test of choice for patients with
suspected DVT
Inexpensive,
Noninvasive,
Widely available
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.
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.
GENERAL THERAPEUTIC MEASURES :
Bed rest .
Encourage the patient to perform gentle
foot &
leg exercises every hour.
Increasefluid intake upto 2 l/day unless
contraindicated.
Avoid deep palpation .
SPECIFIC TREATMENT :
Anticoagulation
Thrombolytic therapy for DVT
Surgery for DVT
Filters for DVT
Compression stockings
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.
Filters for dvt
Thistiny umbrella-like device is inserted into
the vein to catch blood clots and stop them
moving up into the lungs, while allowing blood
flow to continue. It is inserted in the vena
cava.
