1. By: Dr. Nalaka Gunawansa
DVT Management
By:
Dr. Nalaka Gunawansa

2. What is DVT? Deep vein thrombosis is the formation of
a blood clot in one
of the deep veins of
the body, usually in
the leg.

3. Virchow triad
More than 100 years ago, Virchow described a triad of factors of
venous stasis,
endothelial damage, and
hypercoagulable state

4. Diagnostic investigations and diagnosis
Treatments:
pharmacological interventions
thrombolytic therapy
mechanical interventions
Patient information
verbal and written
self-management
Investigations for cancer
Thrombophilia testing

5. 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.

6. Anticoagulation
Thrombolytic therapy for DVT
Surgery for DVT
Filters for DVT
Compression stockings

7. 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.

8. 1.Anticoagulation Heparin prevents extension of the thrombus
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 in the coagulation process.

9. The optimal regimen for the treatment of DVT is anticoagulation with heparin or an LMWH followed by full anticoagulation with oral warfarin for 3-6 months
Warfarin therapy is overlapped with heparin for 4-5 days until the INR is therapeutically elevated to between 2-3.
3 LMWH preparations,
Enoxaparin,
Dalteparin, and
Ardeparin

10. Advantages of Low-Molecular-Weight Heparin Over Standard Unfractionated Heparin
Superior bioavailability
Superior or equivalent safety and efficacy
Subcutaneous once- or twice-daily dosing
No laboratory monitoring*
Less phlebotomy (no monitoring/no intravenous line)
Less thrombocytopenia
Earlier/facilitated

11. Warfarin
Interferes with hepatic synthesis of vitamin K-dependent coagulation factors
Dose must be individualized and adjusted to maintain INR between 2-3
2-10 mg/d PO
caution in active tuberculosis or diabetes; patients with protein C or S deficiency are at risk of developing skin necrosis

12. In patients with a high clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment while awaiting the results of diagnostic tests
In patients with an intermediate clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment if the results of diagnostic tests are expected to be delayed for more than 4 h (Grade 2C).
In patients with a low clinical suspicion of acute VTE, we suggest not treating with parenteral anticoagulants while awaiting the results of diagnostic tests, provided test results are expected within 24 h (Grade 2C) .

13. 2.Thrombolytic therapy for DVT
Advantages include
prompt resolution of symptoms,
prevention of pulmonary embolism,
restoration of normal venous circulation,
preservation of venous valvular function,
and prevention of postphlebitic syndrome.

14. Disadvantage include, clot propagation, rethrombosis, or
subsequent embolization.
Heparin therapy and oral anticoagulant therapy always must follow a course of thrombolysis.

15. In patients with acute PE associated
with hypotension (eg, systolic BP , 90 mm Hg)
who do not have a high bleeding risk, we suggest
systemically administered thrombolytic
therapy over no such therapy (Grade 2C) .

16. 3.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.

17. These pulmonary emboli removed
at autopsy look like casts of the
deep veins of the leg where
they originated.
This patient
underwent
a thrombectomy.
The thrombus has
been laid over the approximate
location in the leg
veins where it developed.

18. Operative Venous Thrombectomy for Acute DVT
In patients with acute proximal DVT of the leg, we suggest anticoagulant therapy alone over operative venous thrombectomy (Grade 2C) .

20. 4.Filters for DVT Indications for insertion of an inferior vena
cava filter
Pulmonary embolism with contraindication to anticoagulation
Recurrent pulmonary embolism despite adequate anticoagulation

21. Controversial indications:
Deep vein thrombosis with contraindication to anticoagulation
Deep vein thrombosis in patients with pre-existing pulmonary hypertension
Free floating thrombus in proximal vein
Failure of existing filter device
Post pulmonary embolectomy

23. Compression stockings (routinely recommended

25. PROPHYLAXIS Ideidentify any patiant who is at risk.
Prevent dehydration.
During operation avoid prolonged calf compression.
Passive leg exercises should be encourged whilst patient on bed.
Foot of bed should be elevated to increase venous return.
Early mobilization should be rule for all surgical patients.

26. Thank you