CV
Deep Vein Thrombosis
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Deep Vein Thrombosis
, Venous Thromboembolism, DVT, VTE, Thromboembolism
See Also
Pulmonary Embolism
DVT Prevention
Deep Vein Thrombosis in Pregnancy
Upper Extremity DVT
Epidemiology
Deep Vein Thrombosis (DVT) represents 66% of Venous Thromboembolism (VTE)
Pulmonary Embolism
(PE) represents the remaining 33% of VTE
Pulmonary Embolism
accompanies proximal DVT in 40%
Deep Vein Thrombosis is identified in 70% of those with
Pulmonary Embolism
Incidence
: Venous Thromboembolism
Gene
ral population: 0.1% (100 per 100,000 person years)
Elderly: 1%
Hospitalized patients: 15%
Annual mortality in U.S.: estimated at 60,000 to 100,000 per year
Risk Factors
See
Deep Vein Thrombosis Risk Factors
(includes
Recurrent Thromboembolism Risk
s)
See
Thrombophilia
Signs
Clinical exam is unreliable for DVT
Homans' Sign (no predictive value)
Homans' Sign: Relaxed foot abnormally plantar flexed
Pseudo-Homans': Pain on passive dorsiflexion of foot
Other unreliable signs
Tenderness
Distal extremity edema
Palpable cord
Differential Diagnosis
See
Leg Edema
Extremity
Trauma
Cellulitis
Peripheral Arterial Disease
Baker's Cyst
(Pseudo-thrombosis)
Superficial Thrombophlebitis
Diagnosis
Precautions
See
DVT in Pregnancy
Exercise
caution in pregnancy
Pregnancy is higher risk of pelvic DVT (which is higher risk of PE and more difficult to detect)
Step 1: Assess
DVT Probability
See
Wells Clinical Prediction Rule for DVT
If moderate to high probability, goto step 3
Step 2: Low Probability for DVT
Obtain
D-Dimer
Negative
D-Dimer
: Excludes DVT in a low probability patient
However, D-Dimer
Test Sensitivity
is 95%, and will miss 5% of DVTs
Positive
D-Dimer
:
Lower Extremity Doppler
Ultrasound
Negative
Ultrasound
Excludes DVT
Positive
Ultrasound
Treat as DVT
Step 3: Moderate to high Probability for DVT
Obtain
Lower Extremity Doppler
Ultrasound
(
Test Sensitivity
approaches 95%)
Negative
Compression Ultrasound
: Obtain
D-Dimer
Negative
D-Dimer
Excludes DVT
Positive
D-Dimer
Repeat
Compression Ultrasound
in one week or venography
Positive
Compression Ultrasound
Treat as DVT
References
Bockenstedt (2003) N Engl J Med 349:1203-4 [PubMed]
Management
Gene
ral
See
DVT in Pregnancy
See
Pulmonary Embolism Management
Anticoagulation
protocols are the same for DVT and PE
Consider
Thrombophilia
work-up
See
Thrombophilia
Reserve blood for tests prior to
Anticoagulation
Anticoagulation
Protocol
Anticoagulation in Thromboembolism
Disposition
Hospitalization and
Heparin
for high risk patients
Consider home management with
LMWH
(see below)
Local measures
Early ambulation
Replaces prior recommendations to minimize activity for first few days
Elevate affected limb to reduce swelling
Apply heat to affected limb
Graded elastic
Compression Stockings
(20-30 mmHg)
Reduce risk of postphlebitic syndrome (postthrombotic syndrome)
Kolbach (2004) Cochrane Database Syst Rev (1): CD004174 [PubMed]
Superficial Venous Thrombosis
Anticoagulation
indications
See
Superficial Venous Thrombosis
Proximal superficial clot (upper thigh) especially within 5 cm of deep system
Clot >7 cm long in leg
Lack of improvement after 1 week
Hypercoagulable
state
Management
Distal DVT (Calf-vein DVT)
Option 1:
Anticoagulation
(standard strategy since 2001)
Anticoagulation
recommended for 6 to 12 weeks
Initiate with
LMWH
and then to oral
Warfarin
(or other
Anticoagulant
- see above)
Justification (based on risk of untreated calf DVT complications)
Risk of propogation to proximal DVT is 5-20% (NNT 16)
Recurs in 30% of untreated patients
Post-thrombotic syndrome occurs in 20% if untreated
Pinede (2001) Circulation 103:2453-60 [PubMed]
Utter (2016) JAMA Surg 151(9): e161770 +PMID:27437827 [PubMed]
Option 2: 2015
Chest
Guidelines recommend serial
Ultrasound
instead of
Anticoagulation
Assumes lower risk patient
Asymptomatic
No cancer history or other underlying
Coagulopathy
DVT not unprovoked and not recurrent
Preferred strategy if
Anticoagulation
contraindicated or increased bleeding risk
Safe even in symptomatic patients, with similar outcomes to
Anticoagulation
, but without the 4% bleeding risk
Righini (2016) Lancet Hematol 3(12): e556-62 +PMID: 27836513 [PubMed]
Repeat
Doppler Ultrasound
twice weekly for 2 weeks
Monitor for extension of distal DVT to proximal DVT
Kearon (2016) Chest 149(2): 315-52 +PMID:26867832 [PubMed]
Management
Anticoagulation
See
Anticoagulation in Thromboembolism
Management
Home Deep Vein Thrombosis Protocol
Criteria for home management
No massive Deep Vein Thrombosis
No entire
Leg Swelling
, acrocyanosis or ischemia
No DVT extension into iliofemoral vein or IVC
No symptomatic
Pulmonary Embolism
Oxygen Saturation
>95% on room air
No significant bleeding risks on
Anticoagulant
s
Active bleeding or bleeding in last 4 weeks
Recent surgery or
Trauma
Platelet Count
<70, INR >1.4 or PTT >40 sec
Metastatic disease involving liver or brain
No significant comorbidities
No severe liver or
Kidney
disease
Impaired cognition or mobility
Pain requiring parenteral
Narcotic
s
References
Douketis (2005) Can Fam Physician 51:217-23 [PubMed]
Efficacy
Safe and effective management of proximal DVT
Spyropoulos (2002) Chest 122:108-14 [PubMed]
Review Contraindications
Use only in otherwise low risk patients
See
Low Molecular Weight Heparin
for contraindication
Patient Education
Demonstrate self-administered
Subcutaneous Injection
s
Review sterile technique
Review risks of bleeding and infection
Emphasize precautions against
Trauma
Consider home health referral
Anticoagulation
See
Anticoagulation in Thromboembolism
Management
Intervention Radiology
directed
Thrombolysis
(with benefit)
Ileofemoral DVT (typically within last 14 days)
High risk of comorbidity
Post-thrombotic syndrome: >50%
Venous
Claudication
at 5 years in nearly half of patients
Efficacy data (some studies question longterm benefit)
Normal vein after Catheter
Thrombolysis
: 45% (contrast with 0% after
Heparin
alone)
Decreases risk of long term
Venous Insufficiency
, post-phlebitic syndrome, stasis ulcers
Best outcome if performed early (within 2 weeks)
Poor efficacy if prior Deep Vein Thrombosis
References
(2009) J Thromb Haemost 7:1268-75 [PubMed]
Other indications
Massive proximal extremity DVT with severe symptoms or
Limb Threatening Ischemia
Complications
Pulmonary Embolism
Post-thrombotic syndrome (postphlebitic syndrome)
Reduced with below knee graded
Compression Stockings
Prandoni (2004) Ann Intern Med 141:249-56 [PubMed]
Encourage 30 minute walk per day
Kahn (2011) CMAJ 183(1):37-44 +PMID:21098066 [PubMed]
Phlegmasia
(
Milk Leg
)
Phlegmasia Alba Dolens
Painful, white leg following ileo-femoral deep vein obstruction
Phegmasia Cerulea Dolens
Painful, cyanotic, edematous leg following ileo-femoral deep and superficial vein obstruction
Venous Gangrene
(capillary obstruction) results if not promptly managed
Associated Conditions
See
Thrombophilia
Idiopathic DVT associated with undiagnosed malignancy
Initiate evaluation for underlying malignancy in the first month of unprovoked DVT
Directed history and physical
Consider
Chest XRay
,
Colonoscopy
,
Mammogram
, PSA
Relative Risk
of malignancy diagnosis in 2 years: 3.0
Oudega (2006) Brit J Gen Pract 56:693-6 [PubMed]
Prevalence
of occult malignancy in unprovoked VTE: 3.9%
Carrier (2015) N Engl J Med 373(8): 697-704 [PubMed]
Prognosis
Mortality: 6% within 1 month of DVT diagnosis
VTE recurs in 33% of patients within 10 years
Prevention
See
DVT Prevention
See
DVT Prophylaxis
See
DVT Prevention in Travelers
Resources
CDC: Venous Thromboembolism
https://www.cdc.gov/ncbddd/dvt/data.html
References
Feied in Marx (2002) Rosen's Emergency Med, p. 1210-33
AbuRahma (2001) Ann Surg 233(6):752 [PubMed]
Forster (2001) Chest 119(2):572-9 [PubMed]
Hull (2000) Arch Intern Med 160:229-36 [PubMed]
Hyers (2001) Chest 119:176S-93S [PubMed]
Lensing (1999) Lancet 253:479-85 [PubMed]
Merli (2001) Ann Intern Med 134:191-202 [PubMed]
Ramzi (2004) Am Fam Physician 69:2841-8 [PubMed]
Wells (2001) Thromb Haemost 86(1):499-508 [PubMed]
Wilbur (2012) Am Fam Physician 86(10):913-9 [PubMed]
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