DVT

-current advancement in diagnosis

and management
2077/8/7

Moderator: Dr Dinesh Chapagain

Presenter: Dr Vimal K Yadav
THE ANATOMY OF THE VENOUS SYSTEM
OF THE LOWER LIMB
 Incidence of VTE
• Approx 100 persons/100,000 each year in the US.
• 500 persons/100,000 at 80 years of age.

• > 2/3rd of these patients have DVT alone, and the

rest have evidence of PE.

• The recurrence rate with anticoagulation:

– 6% to 7% in the ensuing 6 months.
 Acute DVT
• Major cause of morbidity and mortality in the surgical
patient.
• Venous thromboembolism (VTE)
– autopsy studies suggest that it is the mc direct cause of death in
surgical patients.

• DVT of the leg may be complicated by the immediate risk of

PE and sudden death.

• The triad of
– venous stasis
– endothelial injury
– hypercoagulable state, proposed by Virchow in 1856.
 CLINICAL PRESENTATION
• Features of lower extremity DVT are nonspecific and many
patients are asymptomatic.

• History :
DVT should be suspected in patients who present with leg
swelling, pain, warmth, and erythema.

• In one series, the sensitivity and specificity of these findings

were:
o Swelling or edema – 97 and 33 percent
o Pain – 86 and 19 percent
o Warmth – 72 and 48 percent
Clinical examination for DVT is unreliable Physical signs may also be absent.

Homans’ sign
• Resistance (not pain) of the calf muscles to forcible
dorsiflexion
• Not specific
• Should not be elicited.

Calf pain/tenderness:
– Only 25% of those with these symptoms actually have DVT.
– Does not correlate with the size, location or extent of the
thrombus.
Physical Examination
What should be sought for:
o Dilated superficial veins
o Unilateral edema or swelling with a difference in calf or thigh
diameters
o Unilateral warmth, tenderness, erythema
o Pain and tenderness along the course of the involved major
veins
o Local (eg, inguinal mass) or general signs of malignancy

Among these, a larger calf diameter is the most useful

finding.
One meta-analysis reported that patients with a difference in calf
diameter were twice as likely to have DVT.
A number of conditions are associated with increased
coagulability of the blood (thrombophilia)

Thrombophilia should be excluded in:

oPt with family history of DVT
oPt with no other predisposing factor.
 Thrombophilias
• They may also be associated with increased risk of recurrence.

• Some types of thrombophilias may increase the risk of recurrence

up to 80 fold.

• Crowther and Kelton proposed a classification system for inherited

thrombophilias.

• They divided the defects into three groups:

o Group 1: Deficiencies of natural coagulation inhibitors
o Group 2: Disorders a/w increases in the levels or function of the
coagulation factors
o Group 3: Other disorders: Conditions such as hyperhomocysteinemia,
plasminogen deficiency and increased TAFI.
 Sometimes the leg appears cellulitic
very occasionally it may be white or cyanosed:

Phlegmasia alba dolens:

• Massively swollen leg
• Pitting edema pain
• Blanching.

Phlegmasia cerulea dolens:

• Massive edema
• Arterial inflow
compromised
• Painful blue leg
 Complications of DVT
• Early complications:
o proximal propagation of thrombus
o acute pulmonary embolus (PE)
o major bleeding (from anticoagulation)
o death.
• Late complications:
o recurrent clot
o post-thrombotic (post phlebitic) syndrome
o chronic thromboembolic pulmonary hypertension.
 Alternative diagnosis of a DVT
• The following causes of the leg pain were identified in 160
consecutive patients with suspected DVT who had negative
venograms :

o Muscle strain, tear, or twisting injury to the leg – 40 percent

o Leg swelling in a paralyzed limb – 9 percent
o Lymphangitis or lymph obstruction – 7 percent
o Venous insufficiency – 7 percent
o Popliteal (Baker's) cyst – 5 percent
o Cellulitis – 3 percent
o Knee abnormality – 2 percent
o Unknown – 26 percent
 Risk factors for DVT
Modifiable(Odds ratio) Non modifiable(Odds ratio)
• Cigarette smoking(2.82) • Age(1.99-2.46)
• Oral contraceptive • Trauma(12.7)
pills(3.8) • Pregnancy(4.29)
• Hormone • Previous DVT(15.6)
replacement(2.5) • Surgical procedures(21.7)
• Prolonged • Malignancy(6.5)
immobilisation(2.46)
• Idiopathic
• Obesity(3.92)
• Long distance travel (2.0)
• Medical disorders(1.99)
 How to improve diagnostic accuracy
• Combination of clinical signs/symptoms and risk
factors to improve diagnostic accuracy.

• Various scoring systems have been devised to

quantify the risk of DVT.

• The most well known among the probability scores is

the Wells’ scores.
 Suspected First DVT
(Risk Stratification)
• The total score denotes:
o 0 or less points – Low probability
o 1 to 2 points – Moderate probability
o 3 to 8 points – High probability

• The incidence of DVT:

o Low probability – 3 percent
o Moderate probability – 17 percent
o High probability – 50 to 75 percent
The American Academy of Family Physicians (AAFP)/American
College of Physicians (ACP) recommendations for workup of
patients with probable DVT
Investigations for DVT include:
• D-dimer assay
• Plethysmography
• Compression ultrasonography
• Doppler ultrasound
• Venography
CT Venography
MR Venography
Conventional Contrast Venography
• The indications for this “Gold Standard” are dwindling;
– Invasive nature
– Radiation hazard
– Contrast allergy
– Nephrotoxicity,
– Thrombophlebitis
– Lack of repeatability

• In clinical setting it may be indicated in patients with

– equivocal Doppler results
– distal thrombosis, non occlusive thrombosis and recurrent
thrombosis.
 CT Venography
• CT imaging after injection of contrast into the dorsal
vein.

• The thrombus in the veins can be inferred from filling

defects.

• Drawbacks include
– inability to be performed at bed side
– necessity for a larger volume of iodinated contrast
agent(150 ml)
– radiation exposure
– streak artefacts due to metallic prostheses.
 Signs in CT venography:
• ‘Polo-mint’ sign, in cross-sectional imaging.
• ‘Railway’ or ‘Tram-track’ sign in reconstructed images.

• Dilation of the involved veins up to twice its normal size.

• Contrast in the vasa vasorum 🡪dense rim around the involved

segment.

• CT pulmonary angiography/CT Venography (CTPA/CTV) can be

used as a single first-line diagnostic test in ICU patients with
suspected VTE.
• However,its routine use in the diagnosis of suspected DVT is not
recommended.
 Magnetic Resonance Venography
• Methomoglobin formed by oxidation of hemoglobin in the
thrombus.

• Methomoglobin by virtue of its paramagnetic

properties,generates a signal which is picked by MRV.

• Sequences used to image DVT:

o Spin-echo(SE)
o Gradient recall echo (GRE)
o Time of flight (TOF)
o Contrast enhanced 3D MRV
o Direct thrombus imaging.
Advantage:
• avoiding ionizing radiation
• accuracy comparable to ultrasound
• high accuracy in distal thrombosis .
• Useful for imaging the iliac veins and IVC, where the
use of duplex ultrasound is limited

Problems:
• metallic prostheses
• prolonged acquisition times
• higher costs
• claustrophobia
• interpretation of images requires substantial
experience.
 Plethysmography
• Plethysmography records the changes in the volume of tissue due
to variations in blood flow or tissue fluid.

• This change can be measured by means such as

o Photoplethysmography
o Stain gauze plethysmography
o Impedance plethysmography.

• Digital photo plethysmography(DPPG)

– uses the light absorptive properties of hemoglobin to assess the
changes in the venous blood.

• Impedance Plethysmography (IPG): Measures changes in electrical

conductivity of blood with fluctuations in flow.
 Plethysmography
• Computerisation has made its calibration and
standardisation simple.

• The accuracy of plethysmography has been modest at

best.

• It cannot be used as confirmatory test for DVT.

• Alongside clinical scores or D-dimer assay it may be

used to screen pts for the necessity of a more accurate
test.
 Impedance plethysmography.
• A cuff is inflated around the upper thigh until the electrical
signal has plateaued.

• Measures the rate of emptying of the venous volume.

• Cuff is deflated: rapid outflow and reduction of volume.

• Venous thrombosis: prolongation of the outflow wave.

• It is not useful clinically for the detection of calf venous

thrombosis and of patients with prior venous thrombosis.
Compression Ultrasonography and Doppler
Ultrasound.
• Ultrasonography is tool for confirmation of DVT.

• USG is useful in ruling out other conditions which mimic DVT.

– (Baker’s cyst,lymphadenopathy,hematomas, abscesses, femoral
artery aneurysms,etc).

• It is highly operator dependent.

• The methods used to detect DVT are

– compression ultrasonography(CUS)
– pulsed wave doppler, color Doppler, continious wave doppler
– duplex and triplex imaging.
 Duplex ultrasound
• It superimposes color coded images of blood flow
over a real time B-mode ultrasound.

• The flow velocity is color coded.

– can discriminate segments of thrombosis where there is
no flow.

• Triplex ultrasound is duplex scanning combined with

continuous wave doppler.
 Duplex ultrasound.
(Doppler ultrasound and color flow imaging)
• The current test of choice for the diagnosis of DVT is
duplex ultrasound.

• Principle: impairment of an accelerated flow signal

caused by an intraluminal thrombus.

• Advantage:
– noninvasive
– no risk of reaction to contrast angiography.

• Disadvantage: highly operator dependent.

 The accuracy of ultrasound is less for:
• in asymptomatic DVT in patients after orthopedic
procedures or those in ICUs
– Sensitivity, Specificity and PPV of 62%, 97% and 66%.
– The reasons cited are smaller, fresh and more easily
compressible thrombus.

• distal thrombosis with a sensitivity of only 36%.

• in recurrent thrombosis
– can not distinguish between an acute or chronic thrombus,
unless a prior scan has revealed complete resolution of
DVT.
 Two point Compression ultrasonography
(CUS)
• A normal vein is easily compressed.
• Presence of a thrombus: resistance to compression.

• Distal compression: augmentation of flow

• Proximal compression: interruption of flow.

• Suspected venous thrombosis:

– failure to demonstrate augmentation on compression.

• Chronicity of the thrombus: increased echogenicity

and heterogeneity.
• However, proximal CUS has limited utility and lower
sensitivity in patients with the following:

• Calf vein thrombus

– Veins in the calf are harder to assess than proximal veins.
– Whole leg US images both the proximal and calf veins.

• Iliac vein thrombus

– The iliac vein often cannot be assessed for compressibility.
– These veins are assessed with Doppler imaging or
computed tomography (CT) venography.
 Single comprehensive duplex ultrasound
• Stevens et al;
– explored the feasibility of a single comprehensive
duplex ultrasound to guide anticoagulation.

• The deep veins were evaluated from the inguinal

region to the medial malleolus at 2 cm intervals
for compressibility.

• This was followed with supplmentary doppler.

 D-Dimer assay
• In the process of coagulation:

– Thrombin acts on fibrinogen to form fibrin molecules.

– Factor XIIIa then introduces a linkage between the D

domains of two adjacent fibrin molecules.

– During fibrinolysis plasmin acts on fibrin polymer to

produce D-Dimers.
• D-Dimer value is proportional to the extent of DVT
– more with proximal than distal,size of the clot and its
surface area.

• Normal D-Dimer values (< 0.5 mg/L i.e. <500ng/ml)

• Negative D-dimer test result in patients with suspected

DVT.
– high negative predictive value (97% to 99%).
• D-Dimers return back to normal levels by two weeks
post thrombosis.

• Hence tests are useful only during this period.

• There are four basic methods for estimating D-Dimer

concentrations-
– latex agglutination
– micro plate ELISA
– membrane ELISA
– whole blood agglutination.
• Modern assays for D-dimer are monoclonal antibody
based.

• ELISA is highly sensitive but takes longer time.

• Latex and whole blood agglutination although less

sensitive are rapid to perform.

• Recently, a number of rapid, point-of-care D-dimer

assays have been developed for acute care settings.
• Other biochemical markers of thrombosis are:
o soluble fibrin monomers
o fibrinogen degradation products
o thrombin-antithrombin complex
o fibrinopeptide A and B
o prothrombin fragments 1+ 2
o thrombus precursor protein
o activated protein C-protein c inhibitor complex and
o myeloperoxidase.

• In recent reviews there is attention to C-reactive

protein(CRP) in the pathogenesis of DVT and its role in
diagnostic evaluation.
 Prophylaxis
• The methods of prophylaxis can be mechanical or pharmacologic.

• Mechanical prophylaxis methods include graduated compression

stockings (GCSs), pneumatic compression devices (PCDs), and A-V
foot pumps

• The simplest method is for the patient to walk.

• Activation of the calf pump mechanism is an effective means of

prophylaxis.

• A patient who is expected to be up and walking within 24 to 48

hours is at low risk for development of venous thrombosis.
 ANTICOAGULATION
• Options include
– subcutaneous low molecular weight (LMW)
heparin
– subcutaneous fondaparinux
– oral factor Xa inhibitors rivaroxaban or apixaban
– unfractionated heparin (UFH).
 Low-dose unfractionated heparin.
• The dosage traditionally used was 5000 units of
unfractionated heparin every 12 hours.

• However, dose of 5000 units subcutaneously every

12 hours is no more effective than placebo.

• Dosing regimen of every 8 hours rather than every 12

hours, is effective in VTE.
• LMWH has a longer plasma half-life and significantly
higher bioavailability.

• The consistent bioavailability and clearance of LMWH

do not require monitoring of factor Xa levels.

• Dosing is merely based on the patient’s weight.

• There is a more predictable anticoagulant response

than with unfractionated heparin.

• No laboratory monitoring is necessary because the

partial thromboplastin time (PTT) is unaffected.
• Dual therapy
– LMW heparin overlapped with warfarin
– Pre-treatment with LMW heparin followed by
either dabigatran or edoxaban

• Monotherapy; ie, no need for heparin pre-

treatment
– anticoagulation with rivaroxaban or apixaban
• Absolute contraindications to anticoagulation
include:
– Active bleeding
– Severe bleeding diathesis
– High bleeding-risk surgery/procedure
– Major trauma
– Acute intracranial hemorrhage (ICH)
• Relative contraindications to anticoagulation include:
– Recurrent bleeding from multiple gastrointestinal
telangiectasias
– Intracranial or spinal tumors
– Large abdominal aortic aneurysm with concurrent
severe hypertension
– Stable aortic dissection
– Low bleeding-risk surgery/procedure

• Thrombocytopenia is not always a contraindication to

anticoagulation (eg, those with counts
>50,000/microL).
Copyrights apply
 Management
Treatment options for DVT include the following:

• Anticoagulation (mainstay of therapy) - Heparins, warfarin,

factor Xa inhibitors, and various emerging anticoagulants

• Pharmacologic thrombolysis

• Endovascular and surgical interventions

• Physical measures (eg, elastic compression stockings and
ambulation)
 Management
• Untreated lower extremity DVT carries a 30%
recurrence rate.

• Traditionally, the treatment of DVT has

centered around
– heparin treatment to maintain the PTT at 60 to 80
seconds
– followed by warfarin therapy to obtain an INR of
2.5 to 3.0.
• Patients with sensitivity towards heparinoids,
such as heparin-induced thrombocytopenia:
↓
Alternative anticoagulant;
– fondaparinux (an indirect factor Xa inhibitor) or
– bivalirudin (a direct thrombin inhibitor)

• There is a range of newer or ‘novel’ anticoagulants

(NOACs).

• These oral agents either directly inhibit

– factor Xa (rivaroxaban and apixaban) or
– thrombin (dabigatran).
 Subcutaneous Unfractioned Heparin
• The incidence of recurrent venous thromboembolism
increases if the time to therapeutic anticoagulation is
prolonged.

• Therefore, it is important to reach therapeutic levels within

24 hours.

• An initial bolus of 80 units/kg or 5000 units IV bolus is

administered, followed by 18 units/kg/hr.

• The rate is dependent on a target PTT corresponding to an

anti–factor Xa level of 0.3 to 0.7 unit/mL.
• The PTT needs to be checked 6 hours after any
change in heparin dosing.

• Warfarin is started on the same day.

• If warfarin is initiated without heparin, the risk for

a transient hypercoagulable state exists.

• A minimum treatment time of 3 months is

advocated in most cases.
• If the patient has a known hypercoagulable
state:
– lifetime anticoagulation is required in the absence
of contraindications.

• The accepted INR range is 2.0 to 3.0.

Thrombolytic therapy and thrombectomy
• Thrombolytic therapy:systemic and catheter-directed.
– tissue plasminogen activator is administered directly into the
thrombus
• Thrombectomy:surgical or catheter-directed.

• For most patients with acute lower extremity DVT, anticoagulant

therapy alone is sufficient.

• Thrombolysis and/or thrombectomy are usually reserved for:

– phlegmasia cerulea dolens
– massive iliofemoral DVT
– patients who fail therapeutic anticoagulation.
 Thrombolysis
• The purported benefit is preservation of valve function,
with a subsequently lesser chance for development of CVI.

• Phlegmasia cerulea dolens:

– Thrombolysis is advocated for relief of significant venous
obstruction.
– Better relief of symptoms and fewer long-term sequelae than
heparin anticoagulation alone.
– The alternative for this condition is surgical venous
thrombectomy.

• No matter which treatment is chosen, long-term

anticoagulation is indicated.
• Additionally, suitable candidates for
thrombolysis:
– symptoms for <14 days (ie, fresh clot; organized
clot will not undergo lysis)
– good functional status
– low bleeding risk
Risk factors for bleeding with anticoagulant therapy
 Endovascular reconstruction
• Chronic proximal venous occlusion of the iliofemoral
system is a challenging clinical problem.

• Endovascular reconstruction removes the need for

surgical bypass and has been used successfully.

• Recanalization of the occluded iliac vein is performed

endovascularly.

• Balloon dilation of the lesion is then performed, and a

stent is placed across the dilated segment.
 Vena cava filter
• The most worrisome and potentially lethal complication of DVT is
pulmonary embolism.

• The gold standard remains pulmonary angiography.

• Pulmonary angiography is increasingly displaced by computed

tomography angiography.

• Adequate anticoagulation is usually effective for stabilizing venous

thrombosis.

• However,if a patient develops a PE in the presence of adequate

anticoagulation, a vena cava filter is indicated.
Modern filters are placed percutaneously over a guidewire.

The Greenfield filter, most extensively used and studied, has a 95%
patency rate and a 4% recurrent embolism rate.

This high patency rate allows safe suprarenal placement if there is

involvement of the IVC up to the renal veins.
Copyrights apply
 Retrievable vena cava filters
• Although they are generally safe, IVC filters are not
without risk and significant morbidity.

• Retrievable filters for the patient with temporary

indications for pulmonary embolus prophylaxis.
•
• Retrievable filters can be deployed from the internal
jugular vein or femoral vein.

• They can be retrieved from the right jugular vein or

right femoral vein.
• Before retrieval:
– venography is performed to ensure that there is
no nidus of IVC thrombus in the filter.
• Insertion complications reported include
– vena cava perforation
– filter migration
– venous thrombosis at the insertion site.

• Retrieval complications include

– failure to retrieve the filter
– thrombus embolization from the filter
– vein retrieval site thrombus
– groin hematoma.
 MONITORING AND FOLLOW-UP
• Patients should be monitored for the complications of deep
vein thrombosis (DVT) as well as those of anticoagulation.

• Warfarin is monitored using prothrombin time (PT) ratio

usually expressed as the international normalized ratio
(INR).

• The goal INR is 2 to 3 (target 2.5).

• Low molecular weight heparin, fondaparinux, and the factor

Xa and direct thrombin inhibitors do not require routine
laboratory monitoring
Algorithm for the treatment of lower extremity deep
venous thrombosis (DVT)
Algorithm for the treatment of lower extremity deep
venous thrombosis (DVT)
 References
• Sabiston’s Textbook of Surgery,20th edition
• Bailey & Love’s Surgery,27th edition
• Roshan Lall Gupta’s Recent Advances in
Surgery Volume 13
• Pubmed articles/www.ncbi.nlm.nih.gov
• USMLE First AID Step 1 2020 30th edition
• www.uptodate.com