DVT deep venous thrombosis

Epidemiology:-
It is common disease in surgical patient of all types
estimated incidence without prophylaxis;-
22%-33% in intra-abdominal surgery.
45%66% in orthopaedic surgery
50% prostatectomy
20% trauma
3% postpartum
 Etiology and risk factors
3main factors contribute in development of
DVT
Stasis.
Endothelial injury.
Hypercoagulability.
Theses are VIRCHOW'S TRIAD
Stasis: mainly caused by heart failure,
prolonged immobility
Endothelial injury: mainly caused by
either direct trauma (severed vein) or
local irritation (by chemotherapy, past
DVT, phlebitis)
Hypercoagulability: inherited (AT III def.,
protein C, S deficiency) or acquired
(malignancy, pregnancy, AT III def.,
protein C, S deficiency as in nephritic
syndrome, DIC and liver failure.
 Other risk factors

Age>60 years
Obesity
Trauma
Use of oral contraceptive
 Pathogenesis:-

The thrombus usually originated in the

soleal venous sinuses or valvular
sinuses .the calf vein is the usual site
It may also originate in the iliac or femoral
vein.
 Symptoms:-

Dull pain, heaviness, oedema and warm limb

With extensive DVT:-massive oedema, cyanosis, dilated
superficial collateral veins and low grade fever.
With ilio-femoral DVT:-
Phlegmasia cerulea dolens (cyanosed limb due to
obstructed vein)
Phlegmasia alba dolens (pale, pulseless cold limb due to
concurrent arterial spasm)
AND THESE TWO UPPER CASES ARE LIMB
THREATENING CONDITION!!
 Signs

HOMAN'S sign (tenderness during

passive dorsiflexion of foot). And it was
contraindicated because of it’s role in
thrombus deattachment and thus
emobilization
Hotness, cyanosis, oedema (non-pitting)
 INVESTIGATIONS:
CBC for any abnormalities in Hb, WBC,
and platelet count
PT
aPTT

D-Dimer: too unspecific.

 IMAGING STUDIES:
*The standard tool for diagnosis is
phlebography using fluoroscope .the use of
this study limited by is complications which
are allergy, nephropathy and phlebitis.
*Duplex ultrasound:
Test of choice
Sensitivity and specificity >95%
Include both β-mode and Doppler studies.
Able to detect other pathology like BAKER
cyst.
 The finding are:-

Acute DVT:
Absence of spontaneous flow.
Loss of flow variation with respiration.
Failure to increase the flow after distal augmentation.
Not visible thrombi (anechoic thrombi).
Chronic DVT:
Not well established
Narrow vein
Patent collateral
Visible thrombi
The only disadvantage of duplex study is
that, it is highly operator dependant!!!
*MRV (magnetic resonance venography):-
Is promising tool for diagnosis,
100%sensitivity, 96% specificity.
 Differential diagnoses:

Unilateral limb involvement: muscular

strain, tendon rupture, cellulites,
lymphodema or retroperitoneal fibrosis
pressing over the vein.
Bilateral limb involvement: liver, heart or
renal failure or IVC obstruction.
 Complication of DVT

Recurrent DVT
Varicose vein
Chronic venous insufficiency
Post phlebitic syndrome (pain, oedema
and ulceration)
PE
 MANAGEMENT

The aim of management is:-

Prophylaxis against DVT
Treatment of ongoing DVT
 Methods of Prophylaxis:

1) Mechanical
Leg elevation
Graded compression stocking.
early ambulation
Pneumatic compression boot.
 2) Pharmacological agents:
Aspirin (anti platelet factor) not recommended
currently.
Dextran solution (40 and70) branched
polysaccharide. Decrease platelets
adhesiveness and aggregation.
Disadvantages:- Increase rate of bleeding
Pulmonary oedema (due to
overload)
Allergic reaction in 1%
Recommended dose is15-20 cc/h IV infusion
before surgery.
 Warfarine (coumadine):-
Decrease incidence of DVTby66% and PE by
80%.
Disadvantages:-
Sever hemorrhage
Must be started 2-3 days preoperative.
Require careful monitoring for PT.
Warfarine nomograph
 Heparin
Unfractionated heparin:-
Inhibits AT III and potentiate disintegration of thrombi
that form while it administered
Low dose regimen is 5000 IU twice daily SQ two
hours pre-operatively then q12hours post operative
till the patient is completely ambulating.
For morbidly obese patient: - micro-heparin drip at
1u/kg/hour
Disadvantages;-
Risk of bleeding
Thrombocytopenia (rare)
Contraindicated in patient with actively bleeding
peptic ulcer, uncontrolled HTN, bleeding disorder or
recent use of ASA
Heparin-dihydroergotamine (DHE) combination:-
Cause vasoconstriction of capacitance veins and
thus increase the venous return.
Particular effectiveness in orthopedic cases.
Contraindicated in case of hypotension, IHD and
peripheral arterial occlusive diseases.
Low molecular weight (enoxaparin):-
Lesser effect on thrombin and platelets aggregation.
Longer life time so the dose will be once daily.
More expensive than unfractionated heparin.
Heparin nomograph
 Fibrinogen-depleting compound
New class of anticoagulants but not well
known.

Prophylactic IVC filter placement.

Also known as Greenfield filter.
Used in high risk patient when other
methods are contraindicated.
Effective in preventing PE not DVT.
 An approach to Prophylaxis

1/determine patient at risk

Low risk (<40 years old, ambulating,
minor surgery)
Moderate risk (>40 years old,
abdominal, pelvic or thoracic surgery)
High risk (>60years old, prior DVTor PE
malignancy, orthopedic surgery
hypercoagulability state).
 2/prohylaxis of choice
Encourage all patients to ambulate as soon as
possible
Low risk patient don't need prophylaxis.
Moderate risk pneumatic compression boot or
low dose heparin prophylaxis.
High risk combination of pneumatic compression
boot and low dose heparin prophylaxis or
Dextran.
Coumadine or IVCfilter are considered.
Ophthalmology or neurosurgery patient are NOT
candidates for prophylaxis.
 Treatment of DVT

A: - anticoagulation
Heparin bolus 100-150 u/kg IV stat then followed
by constant infusion of 1000 u/hour with
checking aPTT q4-6hours and keeping the ratio
50-70sec.
Coumadine (Warfarine) usually started at day 3-
5 after initial heparin is given and continue for 3-
6 months .PT should be 17-20sec. and INR 2.0-
2.5.
 B:-thromolytic treatment( alteplase,
streptokinase, urokinase)
Promote rapid thrombus lysis.used in cases of
sever PE .they have more bleeding
complication.
C:-venal caval interruption. (IVC filter)
Prevent further embolism of thrombi
D:- venous thrombectomy
May be necessary in venous gangrene and
septic thrombosis.