VTE-DVT

How to Diagnose
and Management it

Edited :
dr.Dairion Gatot.M.Ked.,Sp.PD,K-HOM

Hematology-Medical Onkology Division

Internal Departement of Medical Faculty of Sumatera Utara University /
Haji Adam Malik General Hospital,
Medan 2020
 INTRODUCTION
VTE is deep vein thrombosis and pulmonary embolism
PE occurs when parts of the clot
 Thrombosis is the formation or detach and travel in the blood
presence of a thrombus that to block vessels in the lungs
may obstruct blood flow PE
through a vein or artery1
Migration Embolus
 VTE occurs when thrombosis
obstructs blood flow through a
vein
 The term VTE encompasses:
 DVT Thrombus

 PE As the venous
 VTE is a serious health issue2 clot grows, it
extends along
the vein

DVT, deep vein thrombosis; PE, pulmonary embolism

1. Anderson FA, et al. Center for Outcomes Research, University of Massachusetts Medical Center; 1998
2. Goldhaber SZ. J Am Coll Cardiol 1992
 VTE:
deep vein thrombosis and pulmonary embolism

Migration
PE

Embolus

Thrombus

DVT
 Potential complications and goal of treatment

 DVT complications:1,2
· PE
· Damage to valves in the deep veins
· Venous reflux
· Post-thrombotic syndrome (PTS)
 Goal of treatment
· Prevent embolization to the lungs
· Prevent extension into larger veins
· Prevent recurrence
· Avoid the chronic complications

1. Kearon C. Circulation 2003; 2. Ginsberg JS, et al. Arch Intern Med 2000
 Post-thrombotic syndrome
 Occurs in nearly one-third of
patients within 5 years after
idiopathic DVT1
 PTS is characterized by:2
· Pain
· Oedema
· Hyperpigmentation
· Eczema
· Varicose collateral veins
· Venous ulceration
 Severe PTS can lead to
intractable, painful venous
leg ulcers requiring ongoing
nursing and medical care3
Reproduced with permission from Dr AT Cohen and Dr T Urbanek
1. Prandoni P et al. Ann Intern Med 1996; 2. Kahn SR. J Thromb Thrombolysis 2006;
3. Kahn SR, et al. J Gen Intern Med 2000
 DEEP VEIN THROMBOSIS
DVT PROBLEM IS NOT DEATH

SEQUALE
& COMPLICATION

PERMANENT BLOOD VESSEL

DAMAGE OF INFERIOR EXTREMITY
POST THROBOSIS OF VEIN INSUFISIENCY

POST PHLEBITIS SYNDROMA

PULMONAL EMBOLI
PULMONAL HIPERTENSION
 DVT: PATOGENESIS

Thrombus Generation and Extension

Pathogenesis of Thromboembolism
 Pulmonary embolism
can occur at any site in the lung vascularisation

Small VTE & large VTE ???  PE

 DVT
How to diagnose it ?
KASUS
 Diagnosis of DVT
1. History of illness: Symptoms (+) or (-)
Risk Factors: Medical & Surgery
2. Physical examination:
• Pitting edema of the leg
• Pain
• No clear signs or symptoms (subocclusive
thrombus)
3. Laboratory : D-dimer
& Radioimaging examinations:
• Veno/Phlebo-graphy (“Gold Standard”)
• Compression/ Dupplex ultrasonography (96 – 97 %)
for sympt. Prox. DVT
• Duplex scan
• Impedance Plethysmography

(http://guidance.nice.org.uk/CG144/EducationResource/DVTTrainingPlan/doc/English).
 Clinical presentations of DVT

 DVT occurs when clots form in the deep veins within the muscles of the leg1
 Less commonly, clots may form in the upper extremities as well2
 DVT-related symptoms may include:1,3
· Leg pain
· Tenderness of the leg
· Cramping that intensifies over several days
· Erythema
· Warmth at the site of DVT
· Edema
· No clear signs or symptoms (subocclusive thrombus)
 DVT is often asymptomatic, sometimes revealed only after diagnostic tests4

1. Blann AD, Lip GY. BMJ 2006; 2. Spencer FA. J Gen Intern Med 2006 3. Goldhaber SZ, Morrison RB. Circulation 2002;
4. Anderson FA et al. Center for Outcomes Research, University of Massachusetts Medical Center 1998
 DVT: DIFFERENTIAL DIAGNOSIS
CAUSES of EDEMA of the LOW
EXTREMITIES (differential diagnosis)
ACUTE EDEMA CHRONIC EDEMA

Deep vein thrombosis (DVT) Venous abnormalities:

Superficial Thrombophlebitis - post thrombotic syndrome/
Cellulitis post phlebitic syndrome
Joint effusion/Haemarthrosis - chronic vein insufisiency
Fractures - lipodermatosclerosis
Arthritis - venous obstruction / suppression
Dermatitis Lymphedema: - tumors
- infections
- trauma, dll
Diseases : - hemangioma
- congenital
Others: = heart failure
- idiopathic edema in women
 DVT >< AIL
Diagnotic: Symptom and Sign

DVT AIL
• Symtom (stasis) (ischemia)
- edema pain:
usually unilateral - thromboemboli: onset akut
- silent DVT - thrombotic: slowly
- pain dan hard (intermittent claudication)

• Simtom & - pain - “6 Ps”: pain, pallor, pares-

sign - pitting edema thesia,paralysis,pulseless-
- flebitis:inflamasi ness, poikylothermia
- dilatasi v.superfisial - awal: nyeri & parestesia
- sianosis (ileofemoral) - palpasi : arteri pulse (-)
 RISK FACTORS of
SUSPECTED DVT
• Risk factor scoring systems:
- the Wells score for suspected DVT
(7 objective + 1 subjective factors)
- the Geneva score for suspected DVT
(objective factors: blood gases analysis)

• Low risk group

• Intermediate risk group
• High risk group
 The WELLS SCORE for patients
clinically SUSPECTED DVT
Factor Points
Active cancer (treatment within last six months or palliative) 1
Calf swelling ≥3 cm compared to asymptomatic calf (measured 10 1
cm below tibial tuberosity)  
Collateral superficial veins (non-varicose)  1
Pitting oedema (confined to symptomatic leg)  1
Swelling of entire leg 1
Localised tenderness along distribution of deep venous system  1
Paralysis, paresis, or recent cast immobilisation of lower extremities 1
Recently bedridden ≥3 days, or major surgery requiring regional or 1
general anesthetic in the previous 12 weeks 
Previously documented deep-vein thrombosis  1
Alternative diagnosis at least as likely as DVT -2

Interpretation: For dichotomised evaluation (likely v unlikely)

score of 2 or higher - DVT is “likely”
score of less than 2 - DVT is “unlikely” (2)
(1) Tovey C, Wyatt S. Diagnosis, investigation, and management of deep vein thrombosis. BMJ. 2003;326(7400):1180-4
(2) Scottish Intercollegiate Guidelines Network (SIGN) 2010. Prevention and Management of Venous Thromboembolism
 LABORATORY TESTS for DVT

A. D-dimer (cutoff value 500 ug/L):

- D-dimer < 500 ng/ml  excluding acute DVT or PE
- negative predictive value for DVT & PE: 98 %
- especially in low & intermediate risk groups
- highly sensitive, but no specific: post surgery, DIC,
inflamation, infection, necrosis, cancers, etc 
D-dimer (+)
- ELISA VIDAS DD: quick & accurate result
(sensitivity:98–100%)
B. Other hemostasis lab tests:
- underlying disease:hereditary/acquired thrombophilia
(AT III & Protein C deficiencies , APS, etc)
 to determine the duration of anticoagulants
 Radio-Imaging examinations

• PLETHYSMOGRAFI

• VENOGRAFI CONTRAS (Golden standard)

• USG (USG Kompresi, Duplex USG, Colour flow doppler

imaging)

-DUPLEX ULTRASOUND:
Sensitiviti 93%, spesificiti 98% (average 97%)

• SPIRAL COMPUTED TOMOGRAFI VENOGRAFI & MRI.

Wells score DVT (Diagnosis Suspect)

If DVT suspected use the

two-level DVT Wells score

(http://guidance.nice.org.uk/CG144/EducationResource/DVTTraining
Plan/doc/English).
 •Wells score = DVT unlikely

•Offer a D-dimer test and if the result is positive offer either:

– proximal leg vein ultrasound scan (within 4 hours of request) or

– if proximal leg vein scan not available within 4

hours, interim 24-hour dose of a parenteral
anticoagulant followed by proximal leg vein
ultrasound within 24 hours of request

(http://guidance.nice.org.uk/CG144/EducationResource/DVTTrainingPlan/doc/English)
.
 •Wells score = DVT likely

Offer
– proximal leg vein ultrasound scan (within 4 hours of request), if
negative, a D-dimer test or
– if proximal leg vein scan not available within 4
hours, D-dimer test and an interim 24-hour
dose of a parenteral followed by proximal leg
vein ultrasound within 24 hours of request
Repeat proximal leg vein ultrasound scan 6–8 days later for all patients
with positive D-dimer test and negative proximal leg vein ultrasound
scan

(http://guidance.nice.org.uk/CG144/EducationResource
/DVTTrainingPlan/doc/English).
 MANAGEMENT
A. Acute Treatment of DVT
• B. Duration of Anticoagulant Administration
 to prevent recurrent DVT (localized DVT)
 to prevent acute distant consequences (PE)
 to prevent chronic local consequences:
- venous valve damage / destruction
- chronic valve insufficiency (CVI)
- Post thrombotic / Post phlebitic syndrome
(PTS / PPS)
C. Treatment of Underlying Causes (Risk/ Trigger Factors)
 MANAGEMENT
1. General Measures:
- elevation of the feet
- compression with elastic stocking
& intermittent pneumatic compression
- early mobilization

2. Medications:
a. Heparin: UF-heparin or LMWH
b. Warfarin (oral anticoagulant)
c. Fibrinolytic agents
c. Others
3. Surgery: in recurrent / chronic DVT
ROLE OF ANTICOAGULANT THERAPY
1. Anticoagulant are considered potential
treatment for thrombosis
2. Anticoagulant is not without risk

 Every medicine has a benefit vs risk profile – the

balance between the benefit of treatment and the side
effects or risks associated with the drug
 Principle of anticoagulant are safe and effective
MEDIKAMENTOSA ANTICOAGULAN

Evolution of Anticoagulation
1930s
Heparin 1980s
1950s 1990s DTI 1990s Xa
• Parenteral LMWH 2010
• Narrow
Warfarin • Parentera
• Parenteral inhibitors ORAL
• Narrow • Monitoring
• therapeutic
l • Parenteral DTI/Xa
• Limited
therapeuti index • HIT • ?????
c index • Unpredictable • Must use to • Must
• Drug HIT/CV transition
transition
interactions
• Unpredict • Monitoring to to warfarin
warfarin • Must
able • Bleeding risk
transition • Fondafarin
to warfarin ux
• Monitoring
• Argatroba
• HIT n
(Novastan
• Bleeding ®
®

risk • Lepirudin
(Refludan)
 Time to Market for New Anti-Thrombotic
Agents

Apixaban
Dabigatran
Otomaxiban

Idraparinux
Rivaroxaban
biotinylated

2010 2011 2012 2013

TERIMAKASIH