Deep Venous Thrombosis

Definition The presence of thrombus within a deep vein Risk Factors Surgery -Orthopedic, thoracic, abdominal, and genitourinary procedures Neoplasms -Pancreas, lung, ovary, breast, stomach Trauma -Fractures of spine, pelvis, femur, or tibia ,Spinal cord injuries mmobili!ation -"cute myocardial infarction ,#ongestive heart failure ,Stro$e postoperative convalescence %ecent travel with e&tended time in seated position Pregnancy 'strogen use -(ormone replacement or contraception (ypercoagulable states -%esistance to activated protein # )factor * +eiden, antithrombin , protein #, and protein S deficiencies ,"ntiphospholipid syndrome ,(yperhomocysteinemia ,Systemic lupus erythematosus *enulitis -Thromboangiitis obliterans ,-eh.et/s disease ,(omocysteinuria Previous 0*T Obesity Etiology Predisposing factors include vascular stasis, vascular damage, and hypercoagulability1 2sually, 0*T is due to multiple ris$ factors1 Thrombus is composed principally of platelets and fibrin1 nflammatory response in the vessel wall may be minimal Symptoms & Signs a, 0*T of the iliac, femoral, or popliteal veins #alf pain 2nilateral leg swelling 3armth ,erythema Tenderness along the course of the involved veins "ppearance of prominent venous collaterals ncreased resistance or pain during dorsifle&ion of the foot )(omans/ sign, Phlegmasia cerulea dolens 4 Phlegmasia alba dolens1 b, 2pper-e&tremity 0*T Occurs less fre5uently than in the lower e&tremity ncidence is increasing because of greater use of indwelling central venous catheters1 Differential Diagnosis 0isorders that cause unilateral leg pain or swelling #ellulites 6uscle rupture (emorrhage

 %uptured popliteal cyst +ymphedema Laboratory Tests a, nvestigation for diagnosis 7,0uple& venous ultrasonography --mode8 9-dimensional imaging and pulse-wave 0oppler interrogation The noninvasive test used most often to diagnose 0*T -y imaging the deep veins, thrombus can be detected by direct visuali!ation or by inference when the vein does not collapse on compressive maneuvers1 Sensitivity of duple& venous ultrasonography approaches :;< for pro&imal 0*T and =;< for symptomatic calf vein thrombosis1 9, 6% " noninvasive means of imaging 0*T directly 0iagnostic accuracy for assessing pro&imal 0*T is similar to that of duple& ultrasonography1 2seful in patients with suspected thrombosis of the superior and inferior venae cavae or pelvic veins >, *enography #ontrast medium is injected into a superficial vein of the foot and directed to the deep system by the application of tourni5uets1 Presence of a filling defect or absence of filling of the deep veins is re5uired to ma$e the diagnosis Investigation for etiology -aseline blood urea nitrogen and creatinine measurement, complete blood counts "PTT and PT- nternational normali!ed ratio ) N%, before staring treatment Protein #, protein S, or antithrombin deficiency ,antiphospholipid antibodies Treatment Prevention of pulmonary embolism is the most important reason for treating 0*T1 n early stages, thrombus may be loose and poorly adherent to the vessel wall1 "nticoagulants prevent thrombus propagation and allow the endogenous lytic system to operate1 nticoagulant therapy a! "nfractionate# heparin ? nitial therapy should include unfractionate# heparin or low-molecularweight heparin1 2nfractionated heparin should be administered intravenously1 #ommon side effects are bleeding1 "ntidote is protamine1 n @ ;< of patients, heparin therapy may cause thrombocytopenia1-heparin induced thrombocytopenia)( T, b! Lo$%molecular%$eight )A,BBB to C,BBB 0a, heparins can also be used

e1g 'no&aparin, 0alteparin "s effective as or better than conventional, unfractionated heparin in preventing e&tension or recurrence of venous thrombosis "dministered subcutaneously, in fi&ed doses, once or twice daily ncidence of thrombocytopenia is less with low-molecular-weight heparin than with conventional preparations1 No need to monitor PTT c! Direct thrombin inhibitor, -ivalirudin or argatroban, may be used as initial anticoagulant therapy for patients in whom heparin is contraindicated because of heparin-induced thrombocytopenia1 #! &arfarin "dministered during the first wee$ of treatment with heparin and may be started as early as the first day of heparin treatment if the activated PTT is therapeutic1 t is important to overlap heparin treatment with oral anticoagulant therapy for at least A?; days because the full anticoagulant effect of warfarin is delayed1 The dose of warfarin should be adjusted to maintain the prothrombin time at an N% of 91B?>1B1 e! Thrombolytic #rugs '&amples8 strepto$inase, uro$inase, tissue plasminogen activator Denerally only used for patients with+imb-threatening thrombosis an# Symptoms for @ = days an# +ow ris$ of bleeding 'onitoring Platelet count should be chec$ed after > days of heparin therapy1 Once a therapeutic N% )E91;, has been achieved, N% should be chec$ed8 0uration of anticoagulation therapy Patients with major transient ris$ factor8 > months diopathic 0*T8 C months ndefinite treatment -Protein #, protein S, or antithrombin deficiency ,Persistent antiphospholipid antibodies, %ecurrent idiopathic thromboembolism (omplications Pulmonary embolism Post-thrombotic syndrome )chronic pain and swelling, #hronic venous insufficiency 6ajor bleeding secondary to anticoagulation treatment )revention Prophyla&is should be considered in clinical situations where the ris$ of 0*T is high1

 +ow-dose unfractionated heparin 0ose8 ;,BBB 2 9 h before surgery and then ;,BBB 2 every F?79 hours postoperatively or +ow-molecular-weight heparins '&ternal pneumatic compression devices

)ulmonary Thromboembolism
Definition " condition in which venous thrombi dislodge from their site of formation and emboli!e to the pulmonary arterial circulation Etiology #aused by dislodgement of venous thrombi traveling to pulmonary arterial circulation "bout half of patients with pelvic vein thrombosis or pro&imal leg 0*T have P'1 solated calf vein thrombi pose a lower ris$ of P'1 %is$ factors are discussed in 0*T chapter Symptoms & Signs Pulmonary embolism is important cause for sudden death
Substernal pain indistinguishable from the pain of coronary artery disease

0yspnea )most fre5uent symptom,

Pleuritic chest pain and haemoptysis due pulmonary infarction

Tachycardia )most fre5uent sign,,Tachypnea Nec$ vein distention "ccentuated pulmonic component of the second heart sound due to pulmonary hypertension 6assive P' is often indicated by8 0yspnea ,Syncope ,(ypotension ,#yanosis Small P' located distally near the pleura is often indicated by8 Pleuritic pain #ough (emoptysis1 Differential Diagnosis "cute coronary syndrome, Pneumonia, #ongestive heart failure Pericarditis %ib fracture, Nonthrombotic pulmonary embolism -Fat embolism from blunt trauma ,+ongbone fracture ,Tumor embolism ,"ir embolism "mniotic fluid embolism Laboratory Tests *! )lasma D%#imer ELIS +

 'levated level )E;BB ngGm+, in more than :B< of patients with P', but nonspecific +evels increase in patients with myocardial infarction, sepsis, or almost any systemic illness1 Therefore, the test has no useful role for people who are already hospitali!ed1 #an be used to help e&clude P'8 negative predictive value of up to ::1C< ,! -. shows type 7 respiratory failure /! (hest ra#iography Normal or near-normal result in a dyspneic patient occurs in P'1 Focal oligemia )3estermar$/s sign, ,Peripheral wedge-shaped density above the diaphragm )(ampton/s hump, ,'nlarged right descending pulmonary artery )Palla/s sign, 0!Venous ultrasonography #onfirmed 0*T is usually an ade5uate surrogate for P'1 1! (hest (T #T with intravenous contrast is superseding lung scanning as the principal diagnostic imaging test for P' 'ffectively diagnoses large, central P' n patients without P', lung parenchymal images may establish alternative diagnoses not apparent on chest radiography1 2! Lung scanning Perfusion scan defect indicates absent or decreased blood flow, possibly due to P' *entilation scans, obtained with radiolabeled-inhaled gases such as &enon or $rypton, improve the specificity of the perfusion scan1 "bnormal ventilation scans indicate an abnormal nonventilated lung, providing possible e&planations for perfusion defects other than acute P'1 (igh probability of P' is defined as H 9 segmental perfusion defects in the presence of normal ventilation1 3! 'RI Dadolinium-enhanced magnetic resonance pulmonary angiography is not nephroto&ic1 %esults are similar compared with first-generation chest #T16% also assesses %* function1 4! Echocar#iography E;B< of patients with P' have normal echocardiograms1 (elps with rapid triage of e&tremely ill patients -"cute myocardial infarction,Pericardial tamponade ,0issection of the aorta ,P' complicated by right-heart failure 5! )ulmonary angiography Selective pulmonary angiography is the most specific e&amination available for definitively diagnosing P'1 0etects emboli as small as 7?9 mm

*6!Electrocar#iography #lassic abnormalities -Sinus tachycardia New-onset atrial fibrillation or flutter S wave in lead , a I wave in lead , and an inverted T wave in lead Treatment %is$ stratification is crucial in determining treatment strategy1 (igh-ris$ patients -(emodynamic instability ,%* dysfunction ", Primary therapy Primary therapy should be reserved for patients at high ris$ of an adverse clinical outcome1 #lot dissolution with thrombolysis %emoval of P' by embolectomy -, Secondary prevention of recurrent P' Secondary prevention is usually ade5uate when %* function remains normal in a hemodynamically stable patient1 "nticoagulation with heparin and warfarin Placement of an inferior vena caval filter )rimary therapy a, Thrombolysis %ecombinant tissue plasminogen activator, 7BB mg as a continuous peripheral * infusion over 9 hours b, 'mbolectomy ? Open surgical or #atheter 1"voids ris$ of intracranial hemorrhage associated with thrombolysis in patients with massive P' Pulmonary thromboendarterectomy -Patients with chronic pulmonary hypertension due to prior P' with severe pulmonary symptoms may benefit1 #7unctive therapy Pain relief )especially with NS" 0s, Supplemental o&ygenation Psychological support 0obutamine -6ay be effective in the treatment of %* failure and cardiogenic shoc$ *olume loading Should be underta$en cautiously to avoid further reductions in left ventricular forward output Secon#ary prevention a! heparin follo$e# by $arfarin +#etails #iscusse# in DVT chapter b! Inferior vena caval filters In#ications "ctive bleeding that precludes anticoagulation %ecurrent venous thrombosis despite intensive anticoagulation Prevention of recurrent P' in patients with right-heart failure who are not candidates for thrombolysis

(omplications #aval thrombosis with mar$ed bilateral leg swelling The filter may fail, permitting passage of small to medium-si!ed clots or large thrombi emboli!e to the pulmonary arteries via collateral veins1 -y providing a nidus for clot formation, filters double the 0*T rate in the 9 years after placement1 )revention Prophyla&is against P' is of paramount importance1 Same as 0*T