Deep Vein Thrombosis

Introduction
• Venous system of lower limb can be divided
anatomically into
1. Superficial venous system – located within
superficial tissues
2. Deep venous system – beneath deep fascia of
leg, accompanying the arterial tree
• Superficial vein drain into deep vein at
junction or via fascial perforating vein and
then dep vein returns blood to Right atrium
 Deep vein of lower limb
• Includes three pairs of venae commitantes, which
accompany 3 crural arteries (anterior, posterior tibial
artery and peroneal arteries) which inter
communicate and come together in popliteal fossa
to form Popliteal vein.
• Popliteal vein passes through Adductor haitus to
enter Subsartorial canal as Femoral Vein, which
receives the deep femoral vein in femoral triangle
before passing behind inguinal ligament to become
External iliac vein.
 Deep Vein thrombosis
• Venous thrombosis is the formation of a semi
solid coagulum within the venous system and
may occur in superficial system (Superficial
thrombophlebitis) or deep system (DVT).
• Venous thrombosis of deep veins of leg may
be complicated by immediate risk of
pulmonary embolus and sudden death.
 Etiology

• Three factors described by Virchow

1. Contact of blood with abnormal surface
(endothelial damage)
2. Abnormal flow (stasis)
3. Abnormal blood (thrombophilia)
Risk factors for venous thromboembolism
• Pateint factors:
1. Age
2. Obesity
3. Varicose veins
4. Immobility
5. Pregnancy
6. Puerperium
7. High dose oestrogen therapy
8. Previous deep vein thrombosis/ pulmonary embolism
9. Thrombophila
Risk factors for venous thromboembolism
• Disease or Surgical procedure:
1. Trauma or Surgery (pelvis, hip and lower limb)
2. Malignancy (Pelvic and Abdominal metastasis)
3. Heart Failure
4. Recent myocardial infarction
5. Paralysis of lower limb
6. Infection
7. Inflammatory bowel disease
8. Nephrotic syndrome
9. Polycythemia
10. Paraproteinemia
11. Paroxysmal nocturnal hemoglobinuria antibody of lupus anticogulant
12. Behcet’s disease
13. Homocystinaemia
 Pathology
• Thrombus commences as platelet aggregates
• Subsequently Fibrin and Red cells form a mesh until
lumen of vein wall occludes.
• Embolus from lower leg veins detach and pass
through large lower limb vein and vena cava reach
Right atrium and lodges in Pulmonary artery
occluding perfusion to all or part of one or both lung.
• Results in Tachycardia, pain, respiratory failure to
cardiac collapse and death.
 DIAGNOSIS
• Most common presentation of DVT is pain and
swelling especially in one leg, however
bilateral DVT are common (occuring upto
30%).
• DVT differentiated from other causes of
systemic edema such as Hypoproteinaemia,
renal failure and heart failure.
• Clinical examination for DVT is unreliable,
physical signs may also absent.
• Mild pitting edema of ankle, dilated surface
veins, a stiff calf and tenderness over the course
of the veins should be sought.
• Leg pain occurs in about 50% of patients with
DVT but is non specific.
• Homan’s sign – resistant of calf muscles to
forcible dorsiflexion – is not specific and should
not be elicited.
• Tenderness occurs in 75% of patients but is also
found in 50% of patient without objectively
confirmed DVT
 Investigation
• Modified Wells Criteria for predicting DVT:
Variables Score
Lower limb trauma/ surgery/ immobilisation in plaster cast 1
Bedridden for > 3days / surgery in last 4 weeks 1
Tenderness along line of Femoral / Popliteal veins 1
Entire limb swollen 1
Calf >3cm larger circumference than the other side
10cm below the tibial tuberosity 1
Pitting edema 1
Dilated collateral superficial veins (not varicose vein) 1
Previous DVT 1
Malignancy (including treament upto 6 months ago) 1
Intravenous drug abuse 3
Alternative diagnosis more likely than DVT -2
 Investigation (cont..)
• Venous duplex ultrasound is commonly
performed to look for evience of thrombosis
throughout the Deep or Superficial venous
system.
• Under normal circumstances vein will
compress tightly shut but in presence of DVT
they will not fully compress, it is rapid to
perform but not ideal and mostly misses calf
vein thrombosis.
 Duplex doppler

Compressible with no evidence of DVT Non Compressible shows evidence of DVT

Mickey Mouse Sign represent Normal anatomy of Common Femoral Artery ,

Common Femoral Vein and Great Saphenous Vein
 Investigation (cont..)
• Ascending venography shows Thrombus as
filling defect.
• MR venography may also be used.
• Differential diagnosis of DVT:
 Ruptured Baker’s cyst
 Calf muscle hematoma
 Ruptured plantaris muscle
 Thrombosed popliteal aneurysm
 Arterial Ischemia
 Prophylaxis of DVT
• Divided into Mechanical and Pharmacological.
 Mechanical methods:
 Use of grduted elastic compression stockings and
external pneumatic compression can reduce
incidence of thrombosis.
 Electronic nerve stimulators

• Compression based prophylactic measures should

be avoided in patients with Peripheral vascular
disease.
 Prophylaxis of DVT (Cont..)
 Pharmacological methods:
Are more effective than mechanical methods at
risk reduction, although they carry increased risk
of bleeding
• Low dose unfractionated heparin was used both
intravenously and subcutaneously.
• In absence of renal impairment low molecular
weight heparin can be given subcutaneously, this
is given once daily hence low risk of bleeding
complication
 Treatment
• Patient who are confirmed with duplex imaging
should be anticogulated with treatment dose of
subcutaneous LMWH, but patient with renal
impairment should be started with intrvenous
unfractionated heparin.
• Patient who are sensitive to heparinoids should
commence on Fondaprinux, Bivalirudin.
• Typically patient will be commence on Warfarin for
atleast 3 months
• Patient who cannot be sfely anticoagulated should be
considered for temporary venacava filter.
 Treatment (Cont.)
• During thrombolysis, an agent such as tissue
plasminogen activator is administered directly into
thrombus either via popliteal vein or direct puncture
to groin.
• Some thrombus can be compressed by stent grafting
allowing venous lumen to be opened
• These treament can result in significant reduction in
Post Thrombotic Syndrome at 5 years but at cost of
an increased risk of significant bleeding
complications.