: ''This article is about Deep-vein thrombosis. For other uses of DVT, see
DVT (disambiguation).''
'Deep-vein thrombosis' (also known as 'deep-venous thrombosis' or 'DVT' and colloquially as 'economy class syndrome') is the formation of a
blood clot ("thrombus") in a
deep vein. It commonly affects the
leg veins, such as the
femoral vein or the
popliteal vein or the deep veins of the pelvis. Occasionally the veins of the
arm are affected (known as ''
Paget-Schrötter disease'').
Thrombophlebitis is the more general class of pathologies of this kind. IT CAN BE FATAL!
Signs and symptoms
There may be no symptoms referrable to the location of the DVT, but the classical symptoms of DVT include
pain,
swelling and redness of the
leg and dilation of the surface veins. In up to 25% of all hospitalized patients, there may be ''some'' form of DVT, which often remains clinically inapparent (unless
pulmonary embolism develops).
There are several techniques during physical examination to increase the detection of DVT, such as measuring the circumference of the affected and the contralateral limb at a fixed point (to objectivate
edema), and palpating the
venous tract, which is often tender. Physical examination is unreliable for excluding the diagnosis of deep vein thrombosis.
In phlegmasia alba dolens, the leg is pale and cool with a diminished arterial pulse due to spasm. It usually results from acute occlusion of the iliac and femoral veins due to DVT.
In phlegmasia cerulea dolens, there is an acute and nearly total venous occlusion of the entire extremity outflow, including the iliac and femoral veins. The leg is usually painful, cyanosed and oedematous. Venous gangrene may supervene.
It is vital that the possibility of pulmonary embolism be included in the history, as this may warrant further investigation (''see''
pulmonary embolism).
A careful history has to be taken considering ''risk factors'' (see below), including the use of estrogen-containing methods of
hormonal contraception, recent long-haul flying, and a history of
miscarriage (which is a feature of several disorders that can also cause thrombosis). A family history can reveal a
hereditary factor in the development of DVT.
Cause/Etiology
Main articles: Thrombosis
Virchow's triad is a group of 3 factors known to affect clot formation: rate of flow, the consistency (thickness) of the blood, and qualities of the vessel wall. Virchow noted that more deep venous thrombosis occurred in the left leg than in the right and proposed compression of the left common iliac vein by the overlying right common iliac artery as the underlying cause (see
May-Thurner syndrome).
[1]
The most common risk factors are recent surgery or hospitalization.
[2] 40% of these patients did not receive heparin prophylaxis. Other risk factors include advanced age, obesity, infection, immobilization, female sex, use of combined (estrogen-containing) forms of
hormonal contraception, tobacco usage and
air travel ("
economy class syndrome", a combination of immobility and relative dehydration) are some of the better-known causes.
[3] Thrombophilia (tendency to develop thrombosis) often expresses itself with recurrent thromboses.
It is recognized that thrombi usually develop first in the calf veins, "growing" in the direction of flow of the vein. DVTs are distinguished as being above or below the
popliteal vein. Very extensive DVTs can extend into the
iliac veins or the
inferior vena cava. The risk of pulmonary embolism is higher in the presence of more extensive clots.
Diagnosis
The
gold standard is ''intravenous venography'', which involves injecting a peripheral
vein of the affected limb with a
contrast agent and taking
X-rays, to reveal whether the
venous supply has been obstructed. Because of its invasiveness, this test is rarely performed.
Physical examination
#
Homan's test: Dorsiflexion of foot elicits pain in posterior calf
#
Pratt's sign: Squeezing of posterior calf elicits pain
However, these
medical signs do not perform well and are not included in
clinical prediction rules that combine best findings in order to diagnose DVT.
[4]
Probability scoring
In
2006, Scarvelis and Wells overviewed a set of
clinical prediction rules for DVT,
[5] on the heels of a widely adopted set of clinical criteria for pulmonary embolism.
[6][7]
'Wells score or criteria':
(Possible score -2 to 9)
:1) Active cancer (treatment within last 6 months or palliative) -- 1 point
:2) Calf swelling >3cm compared to other calf (measured 10cm below tibial tuberosity) -- 1 point
:3) Collateral superficial veins (non-varicose) -- 1 point
:4) Pitting edema (confined to symptomatic leg) -- 1 point
:5) Swelling of entire leg - 1 point
:6) Localized pain along distribution of deep venous system -- 1 point
:7) Paralysis, paresis, or recent cast immobilization of lower extremities -- 1 point
:8) Recently bedridden > 3 days, or major surgery requiring regional or general anesthetic in past 12 weeks -- 1 point
:9) Previously documented DVT -- 1 point
:10) Alternative diagnosis at least as likely -- Subtract 2 points
'Interpretation':
: Score of 2 or higher - deep vein thrombosis is likely. Consider imaging the leg veins.
: Score of less than 2 - deep vein thrombosis is unlikely. Consider blood test such as
d-dimer test to further rule out deep vein thrombosis.
Blood tests
D-dimer
Main articles: d-dimer
In a low-probability situation, current practice is to commence investigations by testing for
D-dimer levels. This cross-linked
fibrin degradation product is an indication that
thrombosis is occurring, and that the
blood clot is being dissolved by
plasmin. A low D-dimer level should prompt other possible diagnoses (such as a ruptured
Baker's cyst, if the patient is at sufficiently low clinical probability of DVT.
[8][9]
Other blood tests
Other blood tests usually performed at this point are:
★
complete blood count
★ Primary
coagulation studies:
PT,
APTT,
Fibrinogen
★
liver enzymes
★
renal function and
electrolytes
Imaging the leg veins
Impedance plethysmography,
Doppler ultrasonography, compression
ultrasound scanning of the leg veins, combined with duplex measurements (to determine blood flow), can reveal a
blood clot and its extent (i.e. whether it is below or above the
knee).
Therapy
Hospitalization should be considered in patients with more than two of the following risk factors as these patients may have more risk of complications during treatment
[10]:
★ bilateral DVT, renal insufficiency, body weight <70 kg, recent immobility, chronic heart failure, and cancer
Anticoagulation
Main articles: Anticoagulation
Anticoagulation is the usual treatment for DVT. In general, patients are initiated on a brief course (i.e., less than a week) of
heparin treatment while they start on a 3- to 6-month course of
warfarin (or related
vitamin K inhibitors).
Low molecular weight heparin (LMWH) is preferred,
[11] though unfractionated
heparin is given in patients who have a contraindication to LMWH (e.g., renal failure or imminent need for invasive procedure). In patients who have had ''recurrent DVTs'' (two or more), anticoagulation is generally "life-long." The
Cochrane Collaboration has meta-analyzed the risk and benefits of prolonged anti-coagulation.
[12]
Thrombolysis
Main articles: Thrombolysis
Thrombolysis is generally reserved for extensive clot, e.g. an iliofemoral thrombosis. Although a
meta-analysis of
randomized controlled trials by the
Cochrane Collaboration shows improved outcomes with
thrombolysis,
[13] there may be an increase in serious bleeding complications.
Compression stockings
Elastic
compression stockings should be routinely applied "beginning within 1 month of diagnosis of proximal DVT and continuing for a minimum of 1 year after diagnosis".
Starting within one week may be more effective.
[14] The stockings in almost all trials were ''stronger than routine anti-embolism stockings'' and created either 20-30 mm Hg or 30-40 mm Hg. Most trials used knee-high stockings. A
meta-analysis of
randomized controlled trials by the
Cochrane Collaboration showed reduced incidence of post-phlebitic syndrome.
[15] The
number needed to treat is quite potent at 4 to 5 patients need to prevent one case of post-phlebitic syndrome.
[16]
Inferior vena cava filter
Main articles: Inferior vena cava filter
Inferior vena cava filter reduces pulmonary embolism
[17] and is an option for patients with an absolute contraindiciation to anticoagulant treatment (e.g., cerebral hemorrhage) or those rare patients who have objectively documented recurrent PEs while on anticoagulation, an
inferior vena cava filter (also referred to as a ''
Greenfield filter'') may prevent pulmonary embolisation of the leg clot. However these filters are themselves potential foci of thrombosis,
[18] IVC filters are viewed as a temporizing measure for preventing life-threatening pulmonary embolism.
[19]
Prognosis
Post-phlebitic syndrome occurs in 10% of patients with deep vein thrombosis (DVT). It presents with leg oedema, pain, nocturnal cramping, venous claudication, skin pigmentation, dermatitis and
ulceration (usually on the medial aspect of the lower leg).
Prophylaxis (Prevention)
Clinical practice guidelines by the American College of Chest Physicians (ACCP) provide recommendations on DVT prophylaxis in hospitalized patients
[20].
General Medical Inpatients
Regarding general medical inpatients the guidelines state, "In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, including active cancer, previous VTE,
sepsis, acute neurologic disease, or inflammatory bowel disease, we recommend prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A)
[21]." Enoxaparin or unfractionated heparin may be used.
[22] LMWH may be more effective than UFH. If UFH heparin is used, 5000 U 3 times daily may be more effective.
[23]
Since publication of the ACCP guidelines, an additional
randomized controlled trial [24] and
meta-analysis [25] including the trial have been published. The
meta-analysis concluded " Anticoagulant prophylaxis is effective in preventing symptomatic venous thromboembolism during anticoagulant prophylaxis in at-risk hospitalized medical patients. Additional research is needed to determine the risk for venous thromboembolism in these patients after prophylaxis has been stopped." With regards to which patients are at risk, most studies in the meta-analysis were of patients with
New York Heart Association Functional Classification (NYHA) III-IV heart failure. Regarding patients at lesser risk of DVT, the trial above
[26] and an earlier trial
[27] are relevant yet inconclusive.
Chronic renal dialysis patients may be at increased risk of thromboembolism
[28], but
randomized controlled trials have not addressed the risk benefit of prophylaxis.
Surgery Patients
In patients who have undergone
surgery,
low molecular weight heparins (LMWH) are routinely administered to prevent thrombosis. LMWH can only currently be administered subcutaneously by injection. Prophylaxis for pregnant women who have a history of thrombosis may be limited to LMWH injections or may not be necessary if their risk factors are mainly temporary.
Early and regular ambulation (walking) is a treatment that predates anticoagulants and is still recognized and used today. Walking activates the body's muscle pumps, increasing venous velocity and preventing
stasis.
Intermittent pneumatic compression (IPC) machines have proven protective in bed- or chair-ridden patients at very high risk or with contraindications to heparins. IPC machines use air bladders that are wrapped around the thigh and/or calf. The bladders alternately inflate and deflate, squeezing the muscles and increasing blood velocity by as much as 500%. IPC machines have been proven effective on knee and hip surgery patients (a population with a risk as high as 80% with no prophylactic treatment) of developing DVT and PE.
Alternatively, between 150-300mg of aspirin can be taken.
Travelers
Main articles: Economy class syndrome
There is clinical evidence to suggest that wearing compression socks while travelling also reduces the incidence of thrombosis in people on long haul flights. A randomised study in 2001 compared two sets of long haul airline passengers, one set wore travel compression hosiery the others did not. The passengers were all scanned and blood tested to check for the incidence of DVT. The results showed that asymptomatic DVT occurred in 10% of the passengers who did not wear compression socks. The group wearing compression had no DVTs. The authors concluded that wearing elastic compression hosiery reduces the incidence of DVT in long haul airline passengers. J Scurr et al. 2001 Lancet.
[29].
Epidemiology
DVTs occur in about 1 per 1000 persons per year. About 1-5% will die from the complications (i.e.
pulmonary embolism).
DVT is much less common in the pediatric population. About 1 in 100,000 people under the age of 18 experiences deep vein thrombosis, possibly due to a child's high rate of heartbeats per minute, relatively active lifestyle when compared with adults, and fewer comorbodities (e.g. malignancy).
See also
★
Venogram (medical)
References
1. Virchow R. Ueber die Erweiterung kleinerer Gefäfse. Arch Pathol Anat Physiol Klin Med 1851;3:427-62.
2. Venous thromboembolism in the outpatient setting, Spencer FA, Lessard D, Emery C, Reed G, Goldberg RJ, , , Arch. Intern. Med., 2007
3. Cardiovascular risk factors and venous thromboembolism incidence: the longitudinal investigation of thromboembolism etiology., Tsai A, Cushman M, Rosamond W, Heckbert S, Polak J, Folsom A, , , Arch Intern Med, 2002
4. Does this patient have deep vein thrombosis?, Wells PS, Owen C, Doucette S, Fergusson D, Tran H, , , JAMA, 2006
5. Diagnosis and treatment of deep-vein thrombosis., Scarvelis D, Wells P, , , CMAJ, 2006
6. Neff MJ. ACEP releases clinical policy on evaluation and management of pulmonary embolism. ''American Family Physician''. 2003; '68'(4):759-?. Available at: http://www.aafp.org/afp/20030815/practice.html. Accessed on: December 8, 2006.
7. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer., Wells P, Anderson D, Rodger M, Ginsberg J, Kearon C, Gent M, Turpie A, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J, , , Thromb Haemost, 2000
8. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis, Wells PS, Anderson DR, Rodger M, ''et al'', , , N. Engl. J. Med., 2003
9. A diagnostic strategy involving a quantitative latex D-dimer assay reliably excludes deep venous thrombosis, Bates SM, Kearon C, Crowther M, ''et al'', , , Ann. Intern. Med., 2003
10. Predicting adverse outcome in outpatients with acute deep vein thrombosis. findings from the RIETE Registry, Trujillo-Santos J, Herrera S, Page MA, ''et al'', , , J. Vasc. Surg., 2006
11. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians, Snow V, Qaseem A, Barry P, ''et al'', , , Ann. Intern. Med., 2007
12. Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism, Hutten BA, Prins MH, , , Cochrane database of systematic reviews (Online), 2006
13. Thrombolysis for acute deep vein thrombosis, Watson L, Armon M, , , Cochrane Database Syst Rev,
14. Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial, Prandoni P, Lensing AW, Prins MH, ''et al'', , , Ann. Intern. Med., 2004
15. Non-pharmaceutical measures for prevention of post-thrombotic syndrome, Kolbach D, Sandbrink M, Hamulyak K, Neumann H, Prins M, , , Cochrane Database Syst Rev,
16. Review on the value of graduated elastic compression stockings after deep vein thrombosis, Kakkos S, Daskalopoulou S, Daskalopoulos M, Nicolaides A, Geroulakos G, , , Thromb Haemost, 2006
17. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group, Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral F, Huet Y, Simonneau G, , , N Engl J Med, 1998
18. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d'Embolie Pulmonaire par Interruption Cave) randomized study, , , , Circulation, 2005
19. Vena caval filters for the prevention of pulmonary embolism, Young T, Aukes J, Hughes R, Tang H, , , Cochrane database of systematic reviews (Online), 2007
20. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
Chest. 2004 Sep;126 (3 Suppl):338S-400S. http://www.chestjournal.org/cgi/content/full/126/3_suppl/338S PMID 15383478
21. .
22. Twice vs three times daily heparin dosing for thromboembolism prophylaxis in the general medical population: A metaanalysis, King CS, Holley AB, Jackson JL, Shorr AF, Moores LK, , , Chest, 2007
23. Pharmacological Venous Thromboembolism Prophylaxis in Hospitalized Medical Patients: A Meta-analysis of Randomized Controlled Trials, Wein L, Wein S, Haas SJ, Shaw J, Krum H, , , , 2007
24. Lederle FA, Sacks JM, Fiore L, Landefeld CS, Steinberg N, Peters RW, Eid AA, Sebastian J, Stasek JE Jr, Fye CL. The prophylaxis of medical patients for thromboembolism pilot study. Am J Med. 2006;119:54-9. PMID 16431185
25. Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med. 2007;146:278-88. PMID 17310052
26. .
27. Gardlund B. Randomised, controlled trial of low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases. The Heparin Prophylaxis Study Group. Lancet. 1996 May 18;347(9012):1357-61. PMID 8637340
28. Chronic dialysis patients have high risk for pulmonary embolism, Tveit DP, Hypolite IO, Hshieh P, ''et al'', , , Am. J. Kidney Dis., 2002
29. Scurr JH, Machin SJ, Bailey-King S, Mackie IJ, McDonald S, Smith PD. Frequency and prevention of symptomless deep-vein thrombosis in long-haul flights: a randomised trial. ''Lancet 2001;12(9267):1485-9. PMID 11377600.
External links
★
Deep Vein Thrombosis (DVT) Prevention, Treatment, Diagnosis, & Related Issues - ClotCare.com
★
Deep Vein Thrombosis (DVT) Blood Clot Prevention, Treatment, and More - DVT.net
★
Paget-von Schrötter disease - whonamedit.com
★
DVT - emedicine.com
★
AntiCoagulation Europe - AntiCoagulation Europe is a charity providing information and advice to people on oral anticoagulation therapy
★
Prevent DVT Coalition
★
North American Thrombosis Forum - NATF is a nonprofit organization that aims to promote public education, policy and advocacy for clotting diseases of the cardiovascular system.
★
J Scurr Lancet study summary
★
mediUK DVT prevention during travel, the clinical evidence
★
Victims of Air Related DVT Association
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