Deep Vein Thrombosis In

Surgery
Presenter: Abhirami
Sunita Kaur
Supervisor: Mr. Tan Jih Huei
Superficial venous trunk
• Greater (long) and small (short)
saphenous vein.
• GSV join femoral vein at
saphenofemoral junction
• SSV joins the popliteal vein at
saphenopopliteal junction in
popliteal fossa
Deep veins of lower limb
• 3 pair of venae comitantes – peroneal vein, posterior
tibial and anterior tibial vein – intercommunicate and join
in the popliteal fossa to form popliteal vein (also receives
the soleal and gastrocnemius veins).
• Popliteal vein pass up through adductor hiatus to enter
adductor canal as superficial femoral vein + profunda
femoral vein —> common femoral vein
• Internal and external iliac vein join in the pelvis to form
common iliac vein
Deep Venous Thrombosis
• VTE is the third most common cardiovascular disease after myocardial
infarction and stroke.
• The overall VTE rates are 100 per 100,000 population per year
• 70% are hospital acquired.
• Risk factors
• >60 years old
• Prolonged immobility/long distance travel/major or orthopaedic surgery
• Medical – cancer, varicose veins, thrombophilia, pregnancy
• Drugs – chemo, OCP, HRT
• Obesity, smoking
Pathophysioloy
Clinical Features
• History
• Pain
• Sudden
• Radiates to groin/buttocks (iliofemoral dvt)
• Leg swelling
• Below knee – distal dvt
• Up to groin – proximal dvt
• Aggravated by ambulation
• Relieved by rest
Clinical Features
Symptoms Signs Mechanism
Asymmetric Pitting edema on - Caused by venous obstruction.
leg/calf affected side - Calf circumference is measured 10cm below the tibial tuberosity.
swelling - Normal difference between the 2 legs should be <1cm, if >3cm
difference is considered significant.

Pain, Localized tenderness - Caused by vascular inflammation.

tenderness, along deep venous - Recruitment of inflammatory cells to thrombus and venous stasis
erythema system causes phlebitis.

Dilated Palpable cord - Caused by obstruction of the deep venous system.

superficial Cord-like vein - Palpable cord refers to palpable superficial veins, which is a sign
veins of superficial thrombophlebitis.

Abnormal skin Lipodermatosclerosis - - Oedema above and a narrow atrophic ankle below
and LL changes ‘champagne-bottle leg’
Champagne bottle leg
Wells Score
DVT Pulmonary Embolism
MANAGEMENT
Investigations
Full blood count
D dimer
Coagulation profile
Doppler ultrasonography
• Noninvasive, comprehensive
and without any risk of
reaction to contrast
angiography
Duplex Sonography
Contrast Venography
MRI Venography
Investigations
Chest xray
CT Angiography of lower limb
CT Pulmonary Angiography
• Filling defects within the segmental
branch of ascending and descending
pulmonary arteries bilaterally.
Normal pulmonary trunk
• Filling defect with hypodense
thrombus noted within the right
atrium of the heart extending to SVC
Management
1. Analgesia
2. Anticoagulant therapy – 3-12 months depending on site of
thrombosis and risk factors. Starts LMWH or fondaparinux and
continue for at least 5 days (until INR is 2)
• Tinzaparin dose is 175 IU/kg once daily
• Enoxaparin dose 1mg/kg twice daily
• Fondaparinux dose is 7.5mg daily
4. Vitamin K antagonist – Warfarin 5mg daily within 24h of diagnosis,
continue for 3 months for provoked DVT and longer if unprovoked
Management
5. Thrombolysis – alteplase, recombinant tissue-type
plasminogen activator (r-tPA)
6. Cathether-directed thrombectomy
• Aspiration catheter
• Lytic delivery catheter
• Mechanical thrombectomy
7. Inferior vena cava filter – for patient with proximal
DVT or PE who cannot have anticoagulant therapy
• A mechanical barrier to the flow of emboli larger
than 4mm in the major vein
DVT Prophylaxis
• Early mobilization – walking
Mechanical prophylaxis
• Graduated compression stockings – calf pressure of
14-15mmHg day and night
• Intermittent pneumatic compression
• A-V impulse foot pump
DVT Prophylaxis
Pharmacological
• Low molecular weight heparin – enoxaparin (40mg daily, for kidney
impaired 20mg daily), tinzaparin (3500U-4500U)
• Fondaparinux – 2.5mg daily, contraindicated in severe renal
impairment (eGFR <30ml/min)
• Oral direct thrombin inhibitor – dabigatran etexilate – 110mg to
220mg daily
• Oral direct factor Xa antagonist – rivaroxaban, apixaban – 10mg daily
• Unfractionated heparin – for severe renal impairment - 5000 units BD
Complications
• Chronic venous insufficiency – lower extremity
discomfort and oedema
• Post-phlebitic/Post-thrombotic syndrome – occurs
in 40% - chronic swelling, chronic pain, skin
hardening, dryness or itching, dark pigmentation,
visible spider veins, ulcers
• Pulmonary embolism – dyspnea, chest pain,
haemoptysis - lead to ventilations-perfusion defect
and cardiac strain – arrhythmia, cardiac dysfunction
• Pulmonary hypertension
References
• CPG Prevention and Treatment of Venous Thromboembolism.
Ministry of Health Malaysia
• NICE guidelines on Venous Thromboembolism.
https://www.nice.org.uk/guidance/ng89
• , Mattock K, Waltham M, Evans CE, Ahmad A, Patel AS, Premaratne S,
Lyons OT, Smith A. Leukocytes and the natural history of deep vein
thrombosis: current concepts and future directions. Arteriosclerosis,
thrombosis, and vascular biology. 2011 Mar;31(3):506-12.