Deep Vein Thrombosis

Definition:

It is thrombosis of a part or all of the deep venous system in an extremity.

Its a serious life threatening condition that may lead to sudden death in the short term or to long-term
morbidity. The most frequent location of deep vein thrombosis is in the lower limbs.
The exact incidence is not well defined but it may be up to 30% after major surgeries.

Risk Factors
I.
II.

Secondary DVT occurring in the setting of a recognized risk factor.

Primary or idiopathic absence of risk factors.

The changes described by Virchow lead to clotting in the veins:

1. Changes in the vessel wall with damage to the endothelium due to injury or inflammation, this is known
to happen following previous deep vein thrombosis.
2. Diminished rate of blood flow in the veins. In modern medical practice this occurs during and after
operations, and in debil-itating conditions such as strokes and myocardial infarction.
3. Increased coagulability of the blood. This also occurs following surgery and in the presence of infection
or systemic malignancy or Thrombophilia due to deficiencies of anti-thrombin III, protein C, protein S
and factor V Leiden has been shown to lead to venous thrombosis in young patients, sometimes with
severe or fatal consequences. Immobility remains one of the most important risk factors. Recently, the
term 'ethrombosis' has been used to describe blood clots occurring in people sitting at their computer for
prolonged periods of time.
Clinical presentations:

The most significant findings are tenderness in the calf and edema at the ankle.
(Homans' sign) Pain in the calf on dorsiflexion of the toes (It should no longer be used).
Some patients with deep vein thrombosis of the lower limb may have no symptoms in the leg, but present
with severe dyspnea due to pulmonary embolism:
Swelling, Pain
Redness or no apparent signs and symptoms
Dilated superficial veins
Calf tenderness
Low-grade pyrexia
50% of the patients are asymptomatic

Diagnosis:
1.
2.
3.
4.
5.

General investigations and screening for Thrombophilia.

Doppler US & duplex imaging is most useful diagnostic tool have sensitivity a specificity up to 90%.
About 20% of pts with clinical signs and symptoms of a deep vein thrombosis have normal deep veins.
If this is not available, then ascending phlebography should be undertaken.
For diagnosis of pulmonary embolism, enhanced helical computerized tomography (CT) scanning is
considered the standard test and is replacing isotope imaging studies.

Differential diagnosis:

Ruptured Baker's cyst

Superficial thrombophlebitis
Calf muscle hematomas
Ruptured plantaris tendon
All of these diagnoses can be demonstrated on ultrasonography.

Treatment:
1. Intravenous heparin, with the dose adjusted according to the weight of the patient and controlled by the
activated partial thromboplastin time (APTT) which should be twice of the control in first 48 hrs. The
duration of heparin treatment should be at least 5 days. At the same time, the patient should be commenced
on warfarin. The aim here is to reduce the risk of a further recurrence of venous throm-bosis. Warfarin
does not remove the clot from blocked veins and the duration of treatment (usually 3-6 months) is selected
to prevent further episodes of venous thrombosis. Warfarin dosage is controlled by measuring the
international normalized ratio (INR). The INR should be prolonged to between 2.5 and 3.5 times the
control value. Patients with recurrent venous thromboembolic problems should be anti-coagulated for life.
2. Subcutaneous injections of low-molecular-weight heparin (LMWH) for the treatment of deep vein
thrombosis is an alternative method of anticoagulation. The dose is based on the patient's (100 IU/kg)
weight and treatment given without blood tests to control the dose.
3. Venous thrombectomy: Occasionally, massive venous thrombosis in the lower limb leads to severe
impairment in the blood supply to the limb, leading to ischemia and, eventually, gangrene. This is a
surgical emergency and requires rapid relief of the venous obstruction.
4. Intra-venous thrombolysis, achieved by passing a catheter into the affected vein and infusing a fibrinolytic
drug such as streptokinase or tissue plasminogen activator (TPA), is reducing the need for surgical
thrombectomy nowadays.
Prevention of deep vein thrombosis:
1. Low risk patents:
Young patients, minor illnesses, operations lasting for less than 30 minutes with no additional risk
factors; needs no specific prophylactic measure.
2. Moderate risk.
Patients over the age of 40 years with debilitating illnesses, undergoing major surgery but no
additional risk factors; these patients have up to 40% change to develop DVT and about 1% for
pulmonary embolism. They need:
o Graduated compression stockings (TED stockings)
o Heparin 5000 IU s/c bd or LMWH.
o Continued regimen until full mobilization.
3. High risk:
Patients over the age of 40 years with serious medical conditions, such as stroke and myocardial
infarction, and undergoing major surgery with additional risk factor, such as a past history of
venous thromboembolism, extensive malignant disease or obesity. These may develop DVT in
40%- 80% of the cases & 10% will complicate to pulmonary embolism. They need:
o Graduated compression stockings (TED stockings)
o Heparin 5000 IU s/c tds or LMWH.
o +/- Intra-operative pneumatic calf compression device use.
o Continued regimen until full mobilization.
Complications of DVT:

Systemic complications: pulmonary embolism, pulmonary hypertension.

Local complications:
o Post-phlebitic limb
o Phlegmasia alba dolens due to obstruction of the ilio-femoral vein this may progress to Phlegmasia
cerulea dolence (Venous gangrene) if not well treated by heparin, intravenous thrombolysis and
even some time venous thrombectomy.