1. Deep Vein Thrombosis
DR. SRINIVAS RAJKUMAR THIRAVIARAJ

2. DVT is the formation of thrombus deep veins predominantly in the legs

3. Also
Upper Limb
Paget Schrotter Syndrome – Ax V Thrombosis
May Thurner Syndrome - LIV compression by RIA

4. contents Importance Anatomy Pathophysiology Risk Factors Diagnosis
Management
Follow Up/ Complications
Prevention

5. Venous thromboembolism (VTE),
Deep venous thrombosis (DVT) and Pulmonary embolism (PE),
One of the three major cardiovascular causes of death, along with myocardial infarction and stroke

6. PE – most common preventable cause of death among hospitalized patients. PE and DVT occurring after total hip or knee replacement are unacceptable "never events" and are no longer reimbursable.

7. The long-term effects of nonfatal VTE lower the quality of life.
Postphlebitic syndrome, which eventually occurs in more than one-half of DVT patients – No effective management possible

8. ANATOMY

9. PATHOPHYSIOLOGY Virchow’s Triad Venous Stasis Hypercoagulabilty
Endothelial Damage

10. ACQUIRED RISK FACTORS
Older age
Major surgery and orthopedic surgery
Cancers, especially of the bone, ovary, brain, pancreas, and lymphomas
Inactivity and immobilization, as with orthopedic casts, sitting, travel, bed rest, and hospitalization
Pregnancy and the postpartum period
Antiphospholipid syndrome
Trauma, minor leg injury, and lower limb amputation
Previous VTE

11. Combined oral contraceptives
Hormonal replacement therapy
Central venous catheters
Inflammatory diseases/some autoimmune diseases
Nephrotic syndrome
Obesity
Infection
HIV
Polycythemia vera
Chemotherapy
Intravenous drug use

12. INHERITED Antithrombin deficiency Protein C deficiency
Protein S deficiency (type I)
Factor V Leiden
Prothrombin G20210A
Dysfibrinogenemia
Non-O blood type

13. OTHERS:
Low free protein S
Activated protein C resistance
High factor VIII levels
Hyperhomocysteinemia
High fibrinogen levels
High factor IX levels
High factor XI levels

14. DIAGNOSIS Clinical Examination
Only 1/4th of DVT Produces Clinical Signs & Symptoms
Most important Physical Sign – Swelling of Limbs
Muscles Become Stiff & Hard – M/I than Tenderness

15. Homan’s Sign – Forcible Dorsiflexion
Moses Sign – Squeezing from side to side
May Dislodge the Clot & Increase PE Risk

17. Two-level DVT Wells score
Clinical feature
Points
Active cancer (treatment ongoing, within 6 months, or palliative) 1
Paralysis, paresis or recent plaster immobilisation of the lower extremities
Recently bedridden for 3 days or more or major surgery within 12 weeks requiring general or regional anaesthesia
Localised tenderness along the distribution of the deep venous system
Entire leg swollen
Calf swelling at least 3 cm larger than asymptomatic side
Pitting oedema confined to the symptomatic leg
Collateral superficial veins (non-varicose)
Previously documented DVT
An alternative diagnosis is at least as likely as DVT −2
Clinical probability simplified score
DVT likely
2 points or more
DVT unlikely
1 point or less
a Adapted with permission from Wells PS et al. (2003) Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. New England Journal of Medicine 349: 1227–35
A template patient record Two-level DVT Wells score, which you can print, complete and then add to patient records can be downloaded from the NICE website 

21. The sensitivity of the d-dimer is >80% for DVT (including isolated calf DVT) and >95% for PE.
With Suspected DVT, Doppler/Duplex USG should be preferred to D-Dimer

22. COMPLICATIONS

24. postphlebitic syndrome
A late effect of DVT -occurs in more than one-half of DVT patients.
Causes the venous valves of the leg to become incompetent and exude interstitial fluid.
Chronic ankle or calf swelling and leg aching, especially after prolonged standing.
Severe postphlebitic syndrome causes skin ulceration, especially in the medial malleolus of the leg. There is no effective medical therapy for this condition.

25. DVT & CANCER

26. Patients undergoing surgery for cancer have a higher risk of postoperative deep vein thrombosis (DVT) than those having surgery for nonmalignant diseases.
Longer time to recover from Surgery & Additional Functional limitation due to cancer also increases the risk.

27. Tumors Strongly Associated With Thrombosis
Autopsy studies and retrospective reviews suggest that cancers of the pancreas, lung, and stomach, and adenocarcinomas of unknown primary, are most strongly associated with thrombosis, adding to the view that mucin-producing cancers are the most often associated with VTE.

28. Lung cancer accounted for 21% of cases
Colon cancer for 18%, and
Prostate cancer for 17%

29. NON PHARMACOLOGICAL MANAGEMENT
Leg Elevation
Ambulation
Fitted Graduated Compression Stockings
Special Situations
IVC Filters
Embolectomy

31. Mini-UFH, mini-dose unfractionated heparin, 5000 units subcutaneously twice (less effective) or three times daily (more effective); LMWH, low-molecular-weight heparin, enoxaparin, 40 mg once daily, or dalteparin, 2500 or 5000 units once daily;
IPC, intermittent pneumatic compression devices.

32. Minimum distance of walking required daily to prevent venous thromboembolism was 398 m
Wayman Unit= 398m / 0.5 Miles

33. SURGICAL PROPHYLAXIS Low Dose Prophylaxis – UFH
5000 Units Deep S.C 2hrs before
5000 Units 8-12 hrs thereafter as required

34. For Active Phlebitis
Medium Dose – 20,000 to 60,000 units per day
For PTE
High Dose-60,000 to 120,000 Units/Day

35. Weight Based Dosing Regimen
Initial Therapy
Bolus – 80 U/Kg
Infusion 18U/Kg/Hr
UFH

36. LMWH & Pentasaccharide
Enoxaparin 1mg/kg/sc q12h or 1.5mg/kg/24h
Tinzaparin 175 IU/Kg SC Daily
Dalteparin 200 Iu/Kg SC Daily
Fondaparinux 5.0 mg sc daily(50 kg) 7.5mg(50-100kg) 10 mg sc (100+kg)

37. To Continue Treatment ?
Reversible risk factors – 3months Isolated Calf vein DVT – Serial Imaging 2 wks If Extension – Anticoagulation With Cancer, Decision to be Individualised Usually Active Cancer + DVT = 6 months Tx

38. It is ideal to continue OP treatment with LMWH as OD (Dalteparin 200 IU/Kg OD 1 m.o continue 150 IU/Kg for 5 months) Warfarin – INR 2.5(2-3) – Higher incidence of complications and futher VTE episodes compared to LMWH.