II. Epidemiology

  1. Deep Vein Thrombosis (DVT) represents 66% of Venous Thromboembolism (VTE)
    1. Pulmonary Embolism (PE) represents the remaining 33% of VTE
    2. Pulmonary Embolism accompanies proximal DVT in 40% of cases
    3. Deep Vein Thrombosis is identified in 70% of those with Pulmonary Embolism
  2. Venous Thromboembolism
    1. General population: 0.1% (100 per 100,000 person years)
      1. Effects 300,000 to 600,000 patients per year in U.S.
    2. Elderly: 1%
    3. Hospitalized patients: 15%
    4. VTE annual mortality in U.S.: estimated at 60,000 to 100,000 per year

IV. Signs

  1. Clinical exam is unreliable for DVT
  2. Homans' Sign (no predictive value)
    1. Homans' Sign: Relaxed foot abnormally plantar flexed
    2. Pseudo-Homans': Pain on passive dorsiflexion of foot
  3. Other unreliable signs
    1. Tenderness
    2. Distal extremity edema
    3. Palpable cord

V. Differential Diagnosis

VI. Diagnosis

  1. Images
    1. deepVeins.jpg
  2. Precautions
    1. See DVT in Pregnancy
    2. Exercise caution in pregnancy
      1. Pregnancy is higher risk of pelvic DVT (which is higher risk of PE and more difficult to detect)
  3. Step 1: Assess DVT Probability
    1. See Wells Clinical Prediction Rule for DVT
    2. If moderate to high probability, goto step 3
  4. Step 2: Low Probability for DVT
    1. Obtain D-Dimer
    2. Negative D-Dimer: Excludes DVT in a low probability patient
      1. However, D-Dimer Test Sensitivity is 95%, and will miss 5% of DVTs
    3. Positive D-Dimer: Lower Extremity DopplerUltrasound
      1. Negative Ultrasound
        1. Excludes DVT
      2. Positive Ultrasound
        1. Treat as DVT
  5. Step 3: Moderate to high Probability for DVT
    1. Obtain Lower Extremity DopplerUltrasound (Test Sensitivity approaches 95%)
    2. Negative Compression Ultrasound: Obtain D-Dimer
      1. Negative D-Dimer
        1. Excludes DVT
      2. Positive D-Dimer
        1. Repeat Compression Ultrasound in one week or venography
    3. Positive Compression Ultrasound
      1. Treat as DVT
  6. References
    1. Bockenstedt (2003) N Engl J Med 349:1203-4 [PubMed]

VII. Associated Conditions

  1. See Thrombophilia
  2. Idiopathic DVT associated with undiagnosed malignancy

VIII. Evaluation: Unprovoked Venous Thromboembolism

  1. Thrombophilia
    1. See Thrombophilia for testing indications
    2. Consider directed screening in unprovoked VTE when diagnosis impacts management
  2. Malignancy
    1. Associated with a higher VTE recurrence rate (esp. brain, myeloproliferative, ovarian, lung and non-rectal GI cancer)
    2. Present in 20% of patients with VTE
      1. Relative Risk of malignancy diagnosis in 2 years: 3.0
        1. Oudega (2006) Brit J Gen Pract 56:693-6 [PubMed]
      2. Prevalence of occult malignancy in unprovoked VTE: 3.9%
        1. Carrier (2015) N Engl J Med 373(8): 697-704 [PubMed]
    3. Perform age and gender appropriate routine malignancy screening
      1. No other occult malignancy testing recommended (unless dictated by signs and symptoms)
      2. Atypical location (e.g. splenic or cerebral vein) may warrant additional testing
      3. Recurrence despite Anticoagulation, Family History and weight loss may also prompt evaluation

IX. Management: General

  1. See DVT in Pregnancy
  2. See Pulmonary Embolism Management
    1. Anticoagulation protocols are the same for DVT and PE
  3. Consider Thrombophilia work-up
    1. See Thrombophilia
    2. Reserve blood for tests prior to Anticoagulation
  4. Anticoagulation Protocol
    1. Anticoagulation in Thromboembolism
  5. Disposition
    1. Hospitalization and Heparin for high risk patients
    2. Consider home management with LMWH (see below)
  6. Local measures
    1. Early ambulation
      1. Replaces prior recommendations to minimize activity for first few days
    2. Elevate affected limb to reduce swelling
    3. Apply heat to affected limb
    4. Graded elastic Compression Stockings (20-30 mmHg)
      1. Reduce risk of Postphlebitic Syndrome (Postthrombotic Syndrome)
      2. Kolbach (2004) Cochrane Database Syst Rev (1): CD004174 [PubMed]
  7. Superficial Venous Thrombosis Anticoagulation indications
    1. See Superficial Venous Thrombosis
    2. Proximal superficial clot (upper thigh) especially within 5 cm of deep system
    3. Clot >7 cm long in leg
    4. Lack of improvement after 1 week
    5. Hypercoagulable state

X. Management: Distal DVT (Calf-vein DVT)

  1. Option 1: Anticoagulation (standard strategy since 2001)
    1. Anticoagulation recommended for 6 to 12 weeks
      1. Initiate with LMWH and then to oral Warfarin (or other Anticoagulant - see above)
    2. Justification (based on risk of untreated calf DVT complications)
      1. Risk of propogation to proximal DVT is 5-20% (NNT 16)
      2. Recurs in 30% of untreated patients
      3. Post-Thrombotic Syndrome occurs in 20% if untreated
      4. Pinede (2001) Circulation 103:2453-60 [PubMed]
      5. Utter (2016) JAMA Surg 151(9): e161770 +PMID:27437827 [PubMed]
  2. Option 2: 2015 Chest Guidelines recommend serial Ultrasound instead of Anticoagulation
    1. Assumes lower risk patient
      1. Asymptomatic
      2. No cancer history or other underlying Coagulopathy
      3. DVT not unprovoked and not recurrent
    2. Preferred strategy if Anticoagulation contraindicated or increased bleeding risk
    3. Safe even in symptomatic patients, with similar outcomes to Anticoagulation, but without the 4% bleeding risk
      1. Righini (2016) Lancet Hematol 3(12): e556-62 +PMID: 27836513 [PubMed]
    4. Repeat Doppler Ultrasound twice weekly for 2 weeks
    5. Monitor for extension of distal DVT to proximal DVT
    6. Kearon (2016) Chest 149(2): 315-52 +PMID:26867832 [PubMed]

XI. Management: Anticoagulation

XII. Management: Home Deep Vein Thrombosis Protocol

  1. Criteria for home management
    1. No massive Deep Vein Thrombosis
      1. No entire Leg Swelling, acrocyanosis or ischemia
      2. No DVT extension into iliofemoral vein or IVC
    2. No symptomatic Pulmonary Embolism
      1. Oxygen Saturation >95% on room air
    3. No significant bleeding risks on Anticoagulants
      1. Active bleeding or bleeding in last 4 weeks
      2. Recent surgery or Trauma
      3. Platelet Count <70, INR >1.4 or PTT >40 sec
      4. Metastatic disease involving liver or brain
    4. No significant comorbidities
      1. No severe liver or Kidney disease
      2. Impaired cognition or mobility
      3. Pain requiring parenteral Narcotics
    5. References
      1. Douketis (2005) Can Fam Physician 51:217-23 [PubMed]
  2. Efficacy
    1. Safe and effective management of proximal DVT
    2. Spyropoulos (2002) Chest 122:108-14 [PubMed]
  3. Review Contraindications
    1. Use only in otherwise low risk patients
    2. See Low Molecular Weight Heparin for contraindication
  4. Patient Education
    1. Demonstrate self-administered Subcutaneous Injections
    2. Review sterile technique
    3. Review risks of bleeding and infection
    4. Emphasize precautions against Trauma
  5. Consider home health referral
  6. Anticoagulation
    1. See Anticoagulation in Thromboembolism

XIII. Management: Intervention Radiology directed Thrombolysis (with benefit)

  1. Ileofemoral DVT (typically within last 14 days)
    1. High risk of comorbidity
      1. Post-Thrombotic Syndrome: >50%
      2. Venous Claudication at 5 years in nearly half of patients
    2. Efficacy data (some studies question longterm benefit)
      1. Normal vein after Catheter Thrombolysis: 45% (contrast with 0% after Heparin alone)
      2. Decreases risk of long term Venous Insufficiency, Post-Phlebitic Syndrome, stasis ulcers
      3. Best outcome if performed early (within 2 weeks)
      4. Poor efficacy if prior Deep Vein Thrombosis
    3. References
      1. (2009) J Thromb Haemost 7:1268-75 [PubMed]
  2. Other indications
    1. Massive proximal extremity DVT with severe symptoms or Limb Threatening Ischemia

XIV. Complications

  1. Pulmonary Embolism (PE)
    1. PE is an increased risk in the first 2 weeks after DVT diagnosis and Anticoagulation start
  2. Post-Thrombotic Syndrome (Postphlebitic Syndrome)
    1. Reduced with below knee graded Compression Stockings
      1. Prandoni (2004) Ann Intern Med 141:249-56 [PubMed]
    2. Encourage 30 minute walk per day
      1. Kahn (2011) CMAJ 183(1):37-44 +PMID:21098066 [PubMed]
  3. Breakthrough Venous Thromboembolism (2 to 3% of VTE patients on Anticoagulation for 6 months)
    1. Considered Breakthrough VTE if occurs at least 2 weeks after consistent Anticoagulation initiated
  4. Phlegmasia (Milk Leg)
    1. Phlegmasia Alba Dolens
      1. Painful, white leg following ileo-femoral deep vein obstruction
    2. Phegmasia Cerulea Dolens
      1. Painful, cyanotic, edematous leg following ileo-femoral deep and superficial vein obstruction
      2. Venous Gangrene (capillary obstruction) results if not promptly managed

XV. Prognosis

  1. Mortality: 6% within 1 month of DVT diagnosis
  2. Recurrence when not on Anticoagulation
    1. See Thromboembolism Risk Factors
    2. Provoked VTE with transient risk factors: 3.3% recurrence rate in first year
    3. Unprovoked VTE: 10.3% recurrence rate in first year (30% in first 10 years)
    4. Proximal DVT has a 4 fold higher risk of recurrence than distal DVT
    5. Central Pulmonary Embolism has higher risk of recurrence than peripheral PE
    6. Elevated D-Dimer 3 weeks after stopping Anticoagulation is associated with higher risk of VTE recurrence
      1. Eichinger (2003) JAMA 290(8): 1071-4 [PubMed]

XVII. Resources

  1. CDC: Venous Thromboembolism
    1. https://www.cdc.gov/ncbddd/dvt/data.html

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Thromboembolism (C0040038)

Definition (NCI) Occlusion of the lumen of a vessel by a thrombus that has migrated from a distal site via the blood stream.
Definition (NCI_CTCAE) A disorder characterized by occlusion of a vessel by a thrombus that has migrated from a distal site via the blood stream.
Definition (CSP) obstruction of a blood vessel with thrombotic material carried by the blood stream from the site of origin to plug another vessel.
Definition (MSH) Obstruction of a blood vessel (embolism) by a blood clot (THROMBUS) in the blood stream.
Concepts Disease or Syndrome (T047)
MSH D013923
ICD9 453.9
SnomedCT 134356002, 13713005, 371039008
English Thromboembolisms, Embolism and thrombosis of unspecified site, Thromboembolism, thromboembolic disease (diagnosis), thromboembolic disease, Thromboembolism NOS, Thromboembolic Event, Venous thrombosis NOS, Thromboembolism [Disease/Finding], diseases thromboembolic, thromboembolus, thromboembolisms, thromboembolic disorder, disease thromboembolic, Other venous embolism and thrombosis of unspecified site, Thromboembolism - lesion (disorder), THROMBOEMBOLISM, Thromboembolic event, Thromboembolus, Thromboembolism - lesion, Thromboembolic disease, Thromboembolic disorder (disorder), Thromboembolic disorder, Thromboembolus (morphologic abnormality), thromboembolism, embolism; thrombus, thromboembolic; disorder, thrombus; embolism
Portuguese TROMBOEMBOLISMO, Trombembolismo NE, Embolismo e trombose de localização NE, Tromboembolia, Tromboembolismo
Spanish TROMBOEMBOLISMO, Embolia y trombosis de localización no especificada, Tromboembolia NEOM, Tromboembolia, Tromboembolismo, enfermedad tromboembólica, trastorno tromboembólico (trastorno), trastorno tromboembólico, tromboembolia, tromboembolismo, tromboémbolo (anomalía morfológica), tromboémbolo
German THROMBOEMBOLIE, Thromboembolie NNB, Embolie und Thrombose an unspezifischer Stelle, Thromboembolie
Dutch embolie en trombose op niet-gespecificeerde plaats, trombo-embolie NAO, trombo-embolie, embolie; trombus, trombo-embolisch; aandoening, trombus; embolie, Embolie, trombo-, Trombo-embolie
French Thromboembolie SAI, Embolie et thrombose d'un site non précisé, MALADIE THROMBO-EMBOLIQUE, Thromboembolie, Embolie cruorique, Thrombo-embolie
Italian Embolia e trombosi di sede non specificata, Tromboembolia NAS, Tromboembolia
Japanese 血栓塞栓症NOS, 血栓塞栓症, ケッセンソクセンショウNOS, ケッセンソクセンショウ
Swedish Blodproppssjukdomar
Finnish Tromboembolia
Czech Tromboembolismus NOS, Embolizace a trombóza blíže neurčené lokalizace, Tromboembolismus, tromboembolie, tromboembolismus, TEN, tromboembolická nemoc
Polish Choroba zakrzepowo-zatorowa, Tromboembolizm
Hungarian Thromboembolisatio k.m.n., Thromboembolisatio, Meghatározatlan elhelyezkedésű embolisatio és thrombosis
Norwegian Tromboembolisme, Blodproppsykdommer, Tromboembolisk sykdom

Ontology: Deep Vein Thrombosis (C0149871)

Definition (MEDLINEPLUS)

Deep vein thrombosis, or DVT, is a blood clot that forms in a vein deep in the body. Most deep vein clots occur in the lower leg or thigh. If the vein swells, the condition is called thrombophlebitis. A deep vein thrombosis can break loose and cause a serious problem in the lung, called a pulmonary embolism.

Sitting still for a long time can make you more likely to get a DVT. Some medicines and disorders that increase your risk for blood clots can also lead to DVTs. Common symptoms are

  • Warmth and tenderness over the vein
  • Pain or swelling in the part of the body affected
  • Skin redness

Treatment includes medicines to ease pain and inflammation, break up clots and keep new clots from forming. Keeping the affected area raised and applying moist heat can also help. If you are taking a long car or plane trip, take a break, walk or stretch your legs and drink plenty of liquids.

Definition (NCI_NCI-GLOSS) The formation of a blood clot in a deep vein of the leg or lower pelvis. Symptoms may include pain, swelling, warmth, and redness in the affected area.
Definition (NCI) A blood clot in a deep vein, predominantly in the lower extremity, but may include the pelvis or upper extremity.(NICHD)
Definition (NCI_CDISC) A blood clot (thrombus) in a deep vein in the lower extremity.
Concepts Disease or Syndrome (T047)
MSH D020246
ICD10 I82.40
SnomedCT 128053003, 128057002, 195403006, 266328001, 155454004
LNC MTHU020788, LA7425-7
English DVT, THROMBOSIS VENOUS DEEP, Deep Vein Thrombosis, Thrombosis venous deep, Deep Vein Thromboses, Deep-Vein Thromboses, Deep-Vein Thrombosis, Thromboses, Deep Vein, Thromboses, Deep-Vein, Thrombosis, Deep Vein, Thrombosis, Deep-Vein, Vein Thromboses, Deep, Vein Thrombosis, Deep, Deep Venous Thromboses, Deep Venous Thrombosis, Deep-Venous Thromboses, Deep-Venous Thrombosis, Thromboses, Deep Venous, Thromboses, Deep-Venous, Thrombosis, Deep Venous, Thrombosis, Deep-Venous, Venous Thromboses, Deep, Venous Thrombosis, Deep, DVT NOS, Deep vein thrombosis NOS, Thrombosis;deep venous, deep vein thrombosis (DVT), deep venous thromboses, deep vein thromboses, deep-vein thrombosis, Deep venous thrombosis NOS, Venous thrombosis -deep, deep vein thrombosis, Deep venous thrombosis (diagnosis), venous thrombosis deep, Deep venous thrombosis, Deep venous thrombosis (disorder), DVT - Deep vein thrombosis, Deep vein thrombosis, deep; thrombosis, thrombosis; deep, deep venous thrombosis
Dutch diepe veneuze trombose NAO, trombose diep veneus, DVT, diep; trombose, trombose; diep, diepe veneuze trombose, Diep-veneuze trombose, Trombose, diepe veneuze
French Thrombose veineuse profonde SAI, TVP, Thrombose veineuse profonde, THROMBOSE VEINEUSE PROFONDE
German Tiefe Venentrombose NNB, DVT, Thrombose venoes tief, Tiefe Venenthrombose, VENENTHROMBOSE TIEF, tiefe Beinvenenthrombose, Thrombose, tiefe Venen
Italian Trombosi venosa profonda NAS, Trombosi venosa profonda, Trombosi della vena profonda
Portuguese Trombose venosa profunda NE, Trombose venosa profunda, TVP, Trombose de Veias Profundas, TROMBOSE VENOSA PROFUNDA, Trombose de veia profunda, Trombose de Veia Profunda
Spanish TVP, Trombosis venosa profunda NEOM, Trombosis de Venas Profundas, TROMBOSIS VENOSA PROFUNDA, trombosis venosa profunda (trastorno), trombosis venosa profunda, Trombosis venosa profunda, Trombosis de Vena Profunda
Japanese 深部静脈血栓症, 深部静脈血栓症NOS, シンブジョウミャクケッセンショウ, シンブジョウミャクケッセンショウNOS
Czech Hluboká žilní trombóza, Hluboká žilní trombóza NOS, hluboká žilní trombóza
Hungarian Mélyvena thrombosis, Mélyvénás thrombosis k.m.n., Visszérő mélyvénás trombózis, Mélyvenás thrombosis
Norwegian Dyp venetrombose

Ontology: Venous Thromboembolism (C1861172)

Definition (NCI_CDISC) Occlusion of the lumen of a vein by a thrombus that has migrated from a distal site via the blood stream.
Definition (NCI) Occlusion of the lumen of a vein by a thrombus that has migrated from a distal site via the blood stream.
Definition (MSH) Obstruction of a vein or VEINS (embolism) by a blood clot (THROMBUS) in the blood stream.
Concepts Pathologic Function (T046)
MSH D054556
LNC LA20775-5
English Venous thromboembolism, Thromboembolism, Venous, Venous Thromboembolism [Disease/Finding], Venous Thromboembolism
Dutch veneuze trombo-embolie
French Thromboembolie veineuse, Maladie veineuse thromboembolique, MVTE, Thromboembolisme veineux, Maladie veineuse thrombo-embolique, Thrombo-embolisme veineux
German venoese Thromboembolie, Thromboembolie, Venöse, Venöse Thromboembolie
Portuguese Tromboembolismo venoso, Tromboembolia Venosa, Tromboembolismo Venoso
Spanish Tromboembolismo venoso, Tromboembolia Venosa, Tromboembolismo Venoso
Japanese ジョウミャクケッセンソクセンショウ, 静脈血栓塞栓症, 血栓塞栓症-静脈
Finnish Laskimoiden tromboembolia
Italian Tromboembolia venosa
Swedish Venös tromboemboli
Czech Venózní tromboembolie, venózní tromboembolismus, žíly - tromboembolismus, žilní tromboembolie, žilní tromboembolismus
Polish Choroba zakrzepowo-zatorowa żylna, Żylna choroba zakrzepowo-zatorowa
Hungarian Venás thromboembolisatio
Norwegian Venøs tromboembolisme