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Deep Vein ThrombosisAka: Venous Thromboembolism, DVT

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Epidemiology: Incidence Venous Thromboembolism
1. General population: 0.1%
2. Elderly: 1%
3. Hospitalized patients: 15%
Risk Factors
1. Deep Vein Thrombosis Risk Factors
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
Diagnosis
1. Step 1: Assess DVT Probability
  1. See Wells Clinical Prediction Rule for DVT
  2. If moderate to high probability, goto step 3
2. Step 2: Low Probability for DVT
  1. Obtain D-Dimer
  2. Negative D-Dimer: Excludes DVT
  3. Positive D-Dimer: Lower Extremity Doppler ultrasound
    1. Negative ultrasound: Excludes DVT
    2. Positive ultrasound: Treat as DVT
3. Step 3: Moderate to high Probability for DVT
  1. Obtain Lower Extremity Doppler ultrasound
  2. Negative Ultrasound: Obtain D-Dimer
    1. Negative D-Dimer: Excludes DVT
    2. Positive D-Dimer: Repeat ultrasound or venography
  3. Positive Ultrasound: Treat as DVT
4. References
  1. Bockenstedt (2003) N Engl J Med 349:1203
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. Distal DVT (Calf-vein DVT)
  1. Treated now due to risks (not treated in past)
    1. Risk of propogation to proximal DVT is 20%
    2. Recurrs in 30% of untreated patients
    3. Post-thrombotic syndrome occurs in 20% if untreated
  2. Now Anticoagulation recommended for 6 to 12 weeks
    1. Initiate with LMWH and then to oral Warfarin
  3. If Anticoagulation contraindicated
    1. Repeat doppler ultrasound twice weekly for 2 weeks
    2. Monitor for proximal DVT
  4. Pinede (2001) Circulation 103:2453
5. Anticoagulation Protocol
  1. Anticoagulation in Thromboembolism
6. Disposition
  1. Hospitalization and Heparin for high risk patients
  2. Consider home management with LMWH (see below)
7. Local measures
  1. Minimize activity for first few days
  2. Elevate affected limb
  3. Apply heat to affected limb
  4. Graded elastic Compression stockings
    1. Reduce risk of postphlebitic syndrome
Management: Anticoagulation
1. See Anticoagulation in Thromboembolism
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 <100, INR >1.4 or PTT >40 sec
    4. Metastatic disease involving liver or brain
  4. No significant comorbidities
    1. Impaired cognition or mobility
    2. Pain requiring parenteral Narcotics
  5. References
    1. Douketis (2005) Can Fam Physician 51:217
2. Efficacy
  1. Safe and effective management of proximal DVT
  2. Spyropoulos (2002) Chest 122:108
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
Management: Intervention Radiology directed Thrombolysis
1. Indication: Massive ileofemoral thrombus
  1. Not recommended in other cases
2. Efficacy data
  1. Normal vein after Heparin: 0%
  2. Normal vein after Catheter Thrombolysis: 45%
  3. Prevents long term Venous Insufficiency
  4. Prevents stasis ulcers
  5. Best outcome if performed early (within 2 weeks)
  6. Poor efficacy if prior deep vein thrombosis
  7. Some studies question long-term benefit
Complications
1. Pulmonary Embolism
2. Post-thrombotic syndrome (postphlebitic syndrome)
  1. Reduced with below knee graded Compression stockings
  2. Prandoni (2004) Ann Intern Med 141:249
Precautions
1. Idiopathic DVT associated with undiagnosed malignancy
  1. Relative Risk of malignancy diagnosis in 2 years: 3
  2. Oudega (2006) Brit J Gen Pract 56:693
Prevention
1. See DVT Prevention
2. See DVT Prophylaxis
3. See DVT Prevention in Travelers
References
1. Feied in Marx (2002) Rosen's Emergency Med, p. 1210-33
2. AbuRahma (2001) Ann Surg 233(6):752
3. Forster (2001) Chest 119(2):572
4. Hull (2000) Arch Intern Med 160:229
5. Hyers (2001) Chest 119:176S
6. Lensing (1999) Lancet 253:479
7. Merli (2001) Ann Intern Med 134:191
8. Ramzi (2004) Am Fam Physician 69:2841
9. Wells (2001) Thromb Haemost 86(1):499

Deep Vein Thrombosis (C0149871)
Definition (NCI)	A blood clot (thrombus) in a deep vein in the thigh or leg.
Concepts	Disease or Syndrome (T047)
ICD9	453.40
MSH	D020246
English	Deep Vein Thromboses, Deep Vein Thrombosis, Deep Venous Thromboses, Deep venous thrombosis, Deep-Vein Thromboses, Deep-Vein Thrombosis, Deep-Venous Thromboses, Deep-Venous Thrombosis, DVT, DVT - Deep vein thrombosis, THROMBOSIS VENOUS DEEP
Spanish	trombosis venosa profunda
Parent Concepts	Thrombosis (C0040053), Venous Thrombosis (C0042487)
Sources	AOD, COSTAR, CSP, CST, DXP, LNC, MEDLINEPLUS, MSH, MTH, MTHICD9, NCI, OMIM, SCTSPA, SNOMEDCT Derived from the NIH UMLS (Unified Medical Language System)

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Deep Vein ThrombosisAka: Venous Thromboembolism, DVT

Deep Vein Thrombosis (C0149871)

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