VENOUS THROMBOEMBOLISM

Venous thromboembolism (VTE) is a condition in which a blood clot forms most often in

the deep veins of the leg, groin or arm (known as deep vein thrombosis, DVT) and travels
in the circulation, lodging in the lungs (known as pulmonary embolism, PE).

There are two types:

 Deep vein thrombosis (DVT) Deep vein thrombosis is a clot in a deep

vein, usually in the leg. DVT sometimes affects the arm or other veins.
 Pulmonary embolism (PE) A pulmonary embolism occurs when a DVT
clot breaks free from a vein wall, travels to the lungs and then blocks
some or all of the blood supply. Blood clots originating in the thigh are
more likely to break off and travel to the lungs than blood clots in the
lower leg or other parts of the body.

Classification[edit]
Common forms
Superficial venous thromboses cause discomfort but generally not serious
consequences, as do the deep vein thromboses (DVTs) that form in the deep veins of
the legs or in the pelvic veins. Nevertheless, they can progress to the deep veins
through the perforator veins or, they can be responsible for a lung embolism mainly if the
head of the clot is poorly attached to the vein wall and is situated near the sapheno-
femoral junction.
When a blood clot breaks loose and travels in the blood, this is called a venous
thromboembolism (VTE). The abbreviation DVT/PE refers to a VTE where a deep vein
thrombosis (DVT) has moved to the lungs (PE or pulmonary embolism).[1]
Since the veins return blood to the heart, if a piece of a blood clot formed in a vein
breaks off it can be transported to the right side of the heart, and from there into
the lungs. A piece of thrombus that is transported in this way is an embolus: the process
of forming a thrombus that becomes embolic is called a thromboembolism. An embolism
that lodges in the lungs is a pulmonary embolism (PE). A pulmonary embolism is a very
serious condition that can be fatal depending on the dimensions of the embolus. Venous
thromboembolism (VTE) refers to both DVTs and PEs.
Rare forms
While venous thrombosis of the legs is the most common form, venous thrombosis may
occur in other veins. These may have particular specific risk factors:[2]

 Cerebral venous sinus thrombosis and cavernous sinus thrombosis and jugular

vein thrombosis: thrombosis of the veins of the brain and head
 Central retinal vein occlusion and branch retinal vein occlusion
 Paget–Schroetter disease: thrombosis of the veins of the arms (axillary and
subclavian veins)
 Mesenteric vein thrombosis, which may cause mesenteric ischemia (insufficient
blood flow to the intestine)
  Budd-Chiari syndrome (thrombosis of the hepatic vein) and portal vein
thrombosis
 Splenic vein thrombosis (thrombosis of the splenic vein)
 Renal vein thrombosis (thrombosis of the veins of the kidneys
Parodoxical embolism
Systemic embolism of venous origin can occur in patients with an atrial or ventricular
septal defect, or an arteriovenous connection in the lung, through which an embolus may
pass into the arterial system. Such an event is termed a paradoxical embolism. When
this affects the blood vessels of the brain it can cause stroke

Risk Factors

VTE does not discriminate. It affects people of all ages, races and ethnicities, and
occurs in both men and women. Certain factors and situations can increase the risk
of developing potentially deadly blood clots.

Strong Risk

 Being in the hospital for an extended period of time

 Having surgery (especially hip, knee and cancer-related surgery)
o Cancer patients are at 4 times higher risk than the general population of
developing serious blood clots.
 Not moving for long periods of time (e.g., due to bedrest or long-duration
travel)

Moderate Risk

 Age (60+)
 Personal or family history of blood clots, recent stroke
 Cancer/chemotherapy
 Trauma
 Using estrogen-based medication (e.g., oral contraceptives or hormone
replacement therapy)

Other Factors

 Obesity
 Pregnancy or recent birth
 Smoking
 Alcohol consumption
 Warning Signs and Symptoms

VTE can occur without any warning signs or symptoms and can go unrecognized
and undiagnosed by a healthcare professional. Symptoms that do appear may be
associated with either DVT or PE.

Deep Vein Thrombosis (DVT)

 Pain or tenderness, often starting in the calf

 Swelling, including the ankle or foot
 Redness or noticeable discoloration
 Warmth

Pulmonary Embolism (PE)

 Unexplained shortness of breath

 Rapid breathing
 Chest pain (may be worse upon deep breath)
 Rapid heart rate
 Light headedness or passing out
Risk Assessment and Prevention

Research suggests that VTEs are often preventable, and evidence-based

prevention strategies can stop the development of clots in 'at-risk' individuals.

To identify whether a patient is 'at-risk,' healthcare professionals should conduct a

VTE risk assessment, which is tool or questionnaire that gathers information about a
patient's age, medical history, medications and specific lifestyle factors. Information
is then used to discern a patient’s potential risk (e.g., high, moderate or low risk) for
developing blood clots in the legs or lungs.

If you are admitted to a hospital and don't receive an assessment, be proactive. 

What are the most common tests my care team may order to see if I have a
blood clot?

 A blood test called a D-Dimer

  An ultrasound of the arm or leg to look for the DVT
 A CAT scan of the chest with intravenous dye to look for a PE
 For DVT: ultrasound of the leg is most often used

 For PE: Computed tomography, or CT scan, or CAT scan is most often

used. Sometimes ventilation-perfusion lung scan is used. Both tests are
able to see intravenous dyes in the arteries of the lung, looking for
blockages by clots. 

Individuals who are deemed 'at-risk' should be given appropriate prevention

(referred to as "prophylaxis"), which can include:

 Anti-clotting medications (e.g., blood thinners, referred to as "anticoagulants")

 Mechanical devices (e.g., compression stockings, intermittent pneumatic
compression devices or rapid inflation venous foot pumps)

Hospital patients may also be instructed to move around or do foot/leg exercises as

soon and as often as possible.

Pathophysiology
In contrast to the understanding for how arterial thromboses occur, as with heart attacks,
venous thrombosis formation is not well understood With arterial thrombosis, blood
vessel wall damage is required for thrombosis formation, as it initiates coagulation, but
the majority of venous thrombi form without any injured epithelium.
Red blood cells and fibrin are the main components of venous thrombi,and the thrombi
appear to attach to the blood vessel wall endothelium, normally a non-thrombogenic
surface, with fibrin.Platelets in venous thrombi attach to downstream fibrin, while in
arterial thrombi, they compose the core.As a whole, platelets constitute less of venous
thrombi when compared to arterial ones.The process is thought to be initiated by tissue
factor-affected thrombin production, which leads to fibrin deposition.
The valves of veins are a recognized site of VT initiation. Due to the blood flow pattern,
the base of the valve sinus is particularly deprived of oxygen (hypoxic). Stasis
excacerbates hypoxia, and this state is linked to the activation of white blood cells
(leukocytes) and the endothelium. Specifically, the two pathways of hypoxia-inducible
factor-1 (HIF-1) and early growth response 1 (EGR-1) are activated by hypoxia, and they
contribute to monocyte and endothelial activation. Hypoxia also causes reactive oxygen
species (ROS) production that can activate HIF-1, EGR-1, and nuclear factor-κB (NF-
κB), which regulates HIF-1 transcription.
HIF-1 and EGR-1 pathways lead to monocyte association with endothelial proteins, such
as P-selectin, prompting monocytes to release tissue factor-filled microvesicles, which
presumably initiate fibrin deposition (via thrombin) after binding the endothelial surface.

Treatment

DVT and PE are serious, life-threatening conditions that require immediate medical
attention. Treatment can differ by patient but typically includes blood thinning
medication to break up clots and prevent new ones from forming. Depending on
specific conditions, a patient might need:

 Anticoagulants (e.g., injectables such as heparin, enoxaparin, or low molecular

weight heparin, or tablets such as apixaban, dabigatran and rivaroxaban, edaxaban
and warfarin)
 Mechanical devices (e.g., compression stockings which may decrease your risk of
long term problems that can be caused from having clots or a special filter placed in
a vein)
 Thrombolytic therapy (e.g., tissue plasminogen activator)

Early diagnosis and treatment can often lead to recovery, but long-term
complications, such as post-thrombotic syndrome and chronic thromboembolic
pulmonary hypertension may occur.

Not everyone who is diagnosed with VTE needs treatment. In some cases, your doctor will
detect a clot and decide to monitor it instead of treating it right away. Doctors usually
recommend medicines to treat VTE, but a vena cava filter may be used if you cannot take the
medicine.

-Venous Thromboembolism
Catheter-assisted thrombus removal

In some cases, including emergencies, a doctor may need to do a catheter-assisted thrombus

removal. This procedure uses a flexible tube to reach a blood clot in your lung. The doctor
can insert a tool in the tube to break up the clot or to deliver medicine through the tube.
Usually you will get medicine to put you to sleep for this procedure.

of treating it right away. Doctors usually recommend medicines to treat VTE,

but a vena cava filter may be used if you cannot take the medicine.

Medicines

- Venous Thromboembolism
Catheter-assisted thrombus removal

Vena cava filter

Some people who cannot take blood thinners may need a vena cava filter to
treat their deep vein thrombosis. The filter is inserted inside a large vein
called the vena cava. The filter catches blood clots before they travel to the
lungs, which prevents pulmonary embolism. However, the filter does not stop
new blood clots from forming. A filter is not usually recommended if you
have taken blood thinners.
 Prevent a first VTE event

If you are preparing to go to the hospital for a procedure or have other risk
factors for VTE, talk with your doctor about a plan for preventing blood clots
from forming. Doctors may suggest three ways to help prevent VTE:

 Movement. Helping your blood circulate makes it harder for clots to

form. Your doctor may recommend that you move around as soon as
possible after surgery and as you heal. If you cannot get up and walk, try to
flex and stretch your feet to improve blood flow in your calves.
 Pressure. Gentle pressure keeps blood from pooling and clotting. Your
doctor may recommend applying pressure—for example, by wearing a sleeve
or boot that periodically fills with air, or by wearing graduated compression
stockings.
 Medicines. Your doctor may give you anticoagulant, or blood-thinning,
medicines to prevent clotting. Sometimes this preventive therapy starts
before surgery. Or, you may be asked to take a blood thinner during your
recovery period at home. These medicines, such as heparin, warfarin, and
direct oral anticoagulants, are also used to treat VTE.

Your doctor may recommend some combination of these preventive

treatments for a month or more after surgery. These approaches to
prevention may also be appropriate if you are admitted to the hospital for
reasons other than surgery, cannot move for an extended period, or have a
condition that makes it more likely that your blood will clot.