PENYAKIT THROMBOEMBOLI VENA

dr. Ismon Kusasi, SpB(K)V

 economy class
Deep venous
thrombosis
Formation of a blood
clot ("thrombus") in
a deep vein
Deep vein thrombosis commonly affects the
leg veins (such as the femoral vein or the
popliteal vein) or the deep veins of the pelvis.
 Occasionally the veins of the
arm are affected (if spontaneous,
this is known as Paget-Schrötter disease).
A
N
A
T
O
M
Y
Venous Endothelial
stasis injury

Hyper-
coagulability

VIRCHOW’S TRIAD
Pain, unilateral limb swelling,
redness, Homan sign, Moses
sign
Homan sign
 DVT – Wells Score
Cancer Entire leg swollen

Paralysis or plaster Calf > 3cm larger

immobilization than unaffected leg

Bedrest > 3 d or Pitting edema

surgery in past 4 greater than
wks unaffected leg
Localized Collateral
tenderness superficial veins

Probability High (≥ 3), Moderate (1-2) or Low (0 or less)

 Score of 2 or higher - deep vein
thrombosis is likely. Consider imaging the
leg veins.
Score of less than 2 - deep vein
thrombosis is unlikely.Consider blood test
such as d-dimer test to further rule out deep
vein thrombosis.
Venography– Gold standard investigation:
with pedal vein cannulation, intravenous contrast
injection, and serial limb radiographs. Identification of
venous filling defects is diagnostic for venous thrombosis.
However, the invasive nature and significant consumption
of resources are only 2 of its many limitations.
Venous duplex ultrasound—investigation of choice.
Non-invasive nature, wide availability, sensitivity/specificity
of 97% and 94%. However, duplex is limited by operator
experience and body habitus.
D-dimers
are degradation products of
cross-linked fibrin by plasmin
that are detected by
diagnostic assays. Highly
sensitive, up to 97%, not
specific (35%). Many other
clinical situations can result in
elevated D-dimer levels,
including infection, trauma,
postoperative states, and
malignancy
Intermittent pneumatic leg compression devices work by
effectively increasing venous blood flow and activating the
fibrinolytic system.
Subcutaneous heparin of 5000 units given twice
daily has been shown to not only decrease the
incidence of deep venous thromboses (DVTs)
but also prevents fatal PE
warfarin in high-risk patients. Therapy is initiated the night prior to
surgery; the anticoagulation effects of warfarin do not begin until
the third day of use, preventing postoperative bleeding
complications
Low-molecular weight heparin (LMWH) has been
shown to be superior to both heparin and warfarin in
high-risk patients such as those suffering from
multitrauma and postorthopedic surgery
 TREATMENT
Enoxaparin 1mg/kg sq every 12 hours for 5 days
Warfarin started day 1 at 5 mg a day
Warfarin continued to keep INR at 2.5
(2.0-3.0 range) for 3 months
COMPLICATIONS
Dyspnea, pleuritic pain and cough most
common symptoms. Tachypnea, rales and
Tachycardia most common signs
Post venous thrombotic syndrome--- pain, swelling, skin
changes due to destruction of veins