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Deep vein thrombosis

Deep vein thrombosis. David Hughes. Pathophysiology. normal deep pelvic/leg veins thrombus (red cells, fibrin) around valves propagation Virchow’s triad (endothelium, coagulability, stasis). Symptoms. asymptomatic warm, red, swollen leg unilateral pain, improved by elevation

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Deep vein thrombosis

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  1. Deep vein thrombosis David Hughes

  2. Pathophysiology • normal deep pelvic/leg veins • thrombus (red cells, fibrin) around valves • propagation • Virchow’s triad (endothelium, coagulability, stasis)

  3. Symptoms • asymptomatic • warm, red, swollen leg • unilateral pain, improved by elevation • gradual onset • superficial venous distension • pitting oedema • mild fever • tachycardia

  4. Wells criteria • active Ca (Rx last 6/12 or palliative) +1 • calf swelling >3cm compared to other calf +1 • distended non-varicose superficial veins +1 • pitting oedema +1 • previous DVT +1 • swelling of entire leg +1 • localised pain along deep venous system +1 • paralysis/paresis/recent cast immobilisation lower limbs +1 • recently bedridden > 3/7 or major surgery in past 4/52 +1 • alternative diagnosis at least as likely -2

  5. Wells interpretation • ≥2 - DVT likely, consider imaging leg veins • <2 - DVT unlikely, consider D-dimer to further rule out DVT

  6. Other predisposing factors • age (>40) • smoking • obesity • pregnancy • oral contraceptive • HRT • thrombophilia • long-distance flight • cardiac failure • dehydration

  7. Prophylaxis • early mobilisation • elevation of legs • compression stockings • LMW heparin • weight loss

  8. Differential diagnosis • cellulitis • ruptured Baker’s cyst

  9. Investigation • calf circumference (calf >3cm than other 10cm below tibial tuberosity) • D-dimer (not diagnostic, suggestive but not conclusive) • Homan’s sign ill-advised • Doppler ultrasonography (iliofemoral) • venography (definitive, calf)

  10. Treatment • bed rest initially • elevate leg • analgesia • compression stocking (post-thrombotic) • anticoagulation • Rx-dose heparin (1.5mg/kg/24h SC) • warfarin for 3-6/12 (INR 2-3) • thrombolysis/surgery (extensive, limb-threatening)

  11. Complications • PE (~10%) • post-thrombotic syndrome • recurrence DVT (~20%)

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