DEEP VEIN THROMBOSIS

24 Januari 2009
KAKI BENGKAK UNILATERAL
 WHY DVT IS IMPORTANT
• DVT is serious medical problem

• Prevalence of DVT is high

• Many physicians still unrecognized DVT

SERIOUS MEDICAL
PROBLEM
Deaths caused of DVT
• Deaths caused of DVT: 543,4541
• Exceed combined deaths due to:
– AIDS 5,8602
– breast cancer 86,8312
– prostate cancer 63,6362
– transport accidents 53,5992
PULMONARY EMBOLISMS

1Cohen AT. Presented at the 5th Annual Congress of the European Federation of Internal Medicine; 2005.
2Eurostat statistics on health and safety 2001. Available from: http://epp.eurostat.cec.eu.int.
SERIOUS MEDICAL
PROBLEM

 Within 5 years of DVT, 80% of patients

developed become Post Phlebotic Syndrome
(varicose veins, ulceration veins)
 Prevalence of DVT is High
 DVT prevalence in stroke patients is one of the highest in
hospitalized patients (no prophylaxis)

Acute ischemic stroke 50

Orthopedic surgery 50

General surgery 20

Internal medicine 17

0 10 20 30 40 50 60
1Geerts WH, et al. Chest. 2004;126:338S-400S.
2Leizorovicz A, et al. Circulation. 2004;110(24 Suppl 1):IV13-9. (%)
 DVT mostly Undiagnosed

20 %
Often goes undetected until
too late

80 %
Less than half of all cases
Approximately 80% of DVT
of fatal PE are detected
are clinically silent 2,3
prior to death 1
1. Goldhaber SZ, et al. American Journal of Medicine 1982;73:822-826.
2. Lethen H, et al. American Journal of Cardiology 1997;80:1066-1069.
3. Sandler DA, et al. J. Royal Soc. Med. 1989; 82:203-205.
MECHANISME DVT
 Rudolf Ludwig Karl Virchow (1821-1902)
"Father of Pathology”

Hypercoagulability. Vascular lesion (surgical,

(Deficiency of Protein C, trauma, inflammation)
Protein S, AT III)

Thrombogenesis

Venous stasis
(Immobilization)
Chest 2002;122;1440-1456
Venous thrombosis:

Slow, turbulent blood flow in valve cusps

result in areas of local stasis

Stasis leads to the development of a

thrombus composed of red cells and fibrin

Prandoni P, et al. Haematologica 1997; 82:423–428.

Venous thrombosis:

Thrombus growth results in

proximal progression along the vein

Deep vein thrombosis Damage to veins (PTS)

Pulmonary embolism
Prandoni P, et al. Haematologica 1997; 82:423–428.
 MANY PHYSICIANS UNREGCONIZED VTE

 Symptoms : pain, redness and swelling of the leg, usually unilateral

 Within 5 years of DVT, 80% of patients develop post phlebitic syndrome,
which manifest in chronic leg discomfort and swelling, varicose veins, skin
discoloration and ulceration in severe cases.
 DOPPLER USG, VENOGRAPHY

 REMEMBER : 80-90% DVT ARE ASYMPTOMATIC (CLINACALLY SILENT)

 KRITERIA DIAGNOSA
Wells Score
• BERDASARKAN PROBALITAS KLINIK
– KANKER 1
– PARALISIS 1
– IMMOBILISASI >5 HR/PASKA BEDAH PANGGUL 1
– TERABA KEKAKUAN VENA 1
– UDEM > 3 CM DIBANDING LAIN 1
– UDEM PITTING 1
– KOLATERAL VENA SUPERFISIALIS 1
– TERDAPT DIAGNOSA BANDING -2

PROBABILITAS SEDANG : ANGKA 1 -2

PROBABALITIAS KUAT : ANGKA 3

• DIBANTU DENGAN :
– HASIL D-DIMER > 500
– COMPRESSION ULTRASONOGRAPHY POSITIP
ECHO DOPPLER
 DIAGNOSA PRAKTIS
• KLINIS
– KELUHAN KAKI BENGKAK UNILATERAL, TIDAK
NYAMAN, PANAS......LUKA BASAH SULIT SEMBUH
– PITTING EDEMA, TERABA HANGAT
• LAB :
– D-DIMER MENINGKAT
• DOPPLER VASKULAR :
– COMPRESSION ULTRASONOGRAPHY NEGATIP
 PENANGANAN DVT
a. Oral antikoagulan : warfarin
Minimal 5 hari (sebaiknya 3 bulan)
target INR 2-3
Dosis 1-3 mg /hari

b. Parenteral antikoagulan
Heparin
UFH : bolus 5000 IU lanjut 1000 IU/jam
(target PT/APTT 2-3 x normal
LMWH : fondaparinux / enoxaparine
Mulai hari pertama + oral antikoagulan
Lama pemberian minimal 5-7 hari
 Pertimbangkan obat-obat tambahan
• Terdapat Chronic Venous Insufisiensi / HT
Venous
• Terdpt Lymphangitis/Lympedema

– Obat Phlebotropik (Diosmin)

– Kadang diuretik
– Obat Hemorheological:
• Pentoxifilin , cilostazol
FOTO 3 MINGGU
POST TERAPI
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