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DEEP VEIN THROMBOSIS

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

DEFINITION: - thrombi at the level of deep veins of the leg or even abdominal (including inferior cava vein, portal vein)

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

Virchows triad - blood stasis - parietal venous lesion (endothelial damage) - hypercoagulability

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

MORPHOPATHOLOGY

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

CLINICS
Asymptomatic Unilateral edema Leg pain and tenderness Phlegmatia cerulea dolens-cyanotic from
massive iliofemural venous obstruction

Phlegmatia alba dolens white from massive


iliofemural+arterial compression/spasm

CLINICS
Homanss sign dorsiflexion Lowenbergs sign tensiometer 60Hg Ramirezs sign Liskers sign veins from bone. Louvels sign caugh Mikaeliss sign <38,5 AB/frison Mahlers sign FC.

SUPERFICIAL LEG THROMBOSIS .


Venous distension Proeminence of subcutaneous veins Palpable, indurated cord-like, tender subcutaneous venous segment extension

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

D-dimer
Fibrin degradation product Elevated in any madical condition with clots:
Trauma Recent surgery Hemorrhage Cancer Sepsis

Low specifity for DVT only to rule out DVT, not co confirm

LAB TESTS in young patients.


. . . . . .

LAB TESTS in young patients


Antithrombin III deficiency Protein C deficiency Protein S deficiency Prothrombin 20210A mutation Factor V Leiden

Homocisteine Antiphospholipidic syndrome


Lupus anticoagulant Anticardiolipine antibodies

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

PARACLINICAL EXAMINATION
Ultrasonography MRI CT Venogram

PARACLINICAL EXAMINATIONS
CT venogram
For suspected iliac vein thrombosis For suspected IVC thrombosis

MRI
for suspected iliofemoral DVT, IVC, SVC. When venography is contraindicated Iodine allergy, renal failure

VENOGRAPHY
Obese patients with important edema Non-invasive evaluation-not clear

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

DIFFERENTIAL DIAGNOSIS
Acute limb ischemia Artritis Limphangitis Celulitis Hematoma Limphedema Baker chist Post-trombotic sindrome, varicose veins.

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

DVT PREVENTION

DVT TREATMENT.
PHARMACOLOGICAL INTERVENTIONAL SURGICAL

PHARMACOLOGICAL
ANTICOAGULANT HEPARINE LMWH FONDAPARINUX

WARFARIN NEW: DABIGATRAN

PHARMACOLOGICAL
HEPARINE
bolus 80U/kg 18 U/kg/hour APTT 2-3

LMWH
Same eficacity as Heparine 1 mg/kg x2/day

FONDAPARINUX
Same eficacity as Heparine 7,5 mg 5 mg<50kg 10 mg>100kg

PHARMACOLOGICAL
At least 5 days + vitamin K antagonist: Warfarin Until INR >=2 for 24 hours.

WARFARIN -initial transient hypercoagulable state

WARFARIN
II, VII, IX, X, protC, protS. X, II t1/2 24-72 hours.

Agravation with Warfarin

WARFARIN-duration
Calf DVT 3 months Proximal DVT- 6 months Upper extremity DVT- 3 months Recurrent episodes- 1 year.

PHARMACOLOGICAL
THROMBOLYSIS:
1. Massive iliofemoral DVT

2. Young patients with phlegmatia alba

dolens (limb ischemia)

INTERVENTIONAL
IVC filter: To block any clots which might embolize
Contraindications to anticoagulants Severe hemorrhagic complications to anticoagulants Failure to anticoagulant therapy (recurrent DVT, PE)

SURGERY
Massive ileofemoral DVT (phlegmatia cerulea dolens)
+contraindications to thrombolysis The clot can be removed

TREATMENT
Compression stockings
Reduces leg edema Assist the calf muscle pump From the first day of treatment

Ambulation:
day 2 after initiation of anticoagulation therapy + compression

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

DEEP VEIN THROMBOSIS What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

COMPLICATIONS
Post thrombotic syndrome Pulmonary embolism

POST THROMBOTIC SYNDROME

POSTTHROMBOTIC SYNDROME AND CHRONIC INSUFFICIENCY

Varicose veins Abnormal pigmentation Venous ulcerations

Which of the following are clinical findins in deep vein thrombosis?


PR segment depression Unilateral edema Phlegmatia cerulea dolens Palpable, indurated cord-like, tender subcutaneous venous segment Homanss sign pain at dorsiflexion

PULMONARY EMBOLISM

Carto + semne EKG

CASE PRESENTATION
ACUTA DYSPNEEA

ANAMNESYS
Male, 67 ani, Sanpaul jud. Cluj

Dyspneea
Dry cough

ANAMNESYS
5 days ago Dyspneea: brutal, rapid onset during effort

Generalist- Sanpaul
Ambulance-Cluj-Emergency Department

ANTECEDENTS
HTA-2007 max 160/100 Hypercolesterolemia-2007

MEDICATIONS
Prestarium 5 mg 1-0-0 tb/zi. Simvastatin 20mg 0-0-1 tb/zi.

CLINICAL FINDINGS

T=37,4 C; pale, mild finger cianosis;

PHYSICAL EXAMINATION
Respiratory: no rales

C-V: tachycardia 120/min, nu murmurs, TA=135/95mmHg. Hepatomegaly 3cm , +jugular distension.

CLINICAL INTERPRETATION
.
.

.
.

CLINICAL INTERPRETATION
CARDIAC TAMPONADE?
PULMONARY EMBOLISM? METABOLIC DYSPNEEA ACIDOSIS ? ANEMIA ?

LAB TESTS
I line tests
CBC

Second line tests


Thrombophylia tests

Biochemistry
Coagulation

ABG
Ddimers

LAB TESTS
Gli=92mg/dl Col=157mg/dl Tgl=56mg/dl Ac. Uric=7,2 mg/dl Na=144mEq/l K=3,8mEq/l Ca=4,9 azot=33mg/dl creat=1,1mg/dl ASAT=15U/l ALAT=10U/l LDH=411U/l Bilirubina=0,5mg/dl TQ=14,6 INR=1,21 Troponina I <0,2g/ml CPK=74U/l

ESR=14-37 Hb= 14,5 g/dl L= 14800/mm3 Tr= 131000/mm3

LAB TESTS
I line tests
CBC

Second line tests


Thrombophylia tests

Biochemistry
Coagulation

ABG
Ddimers

GAZE SANGUINE .

SaO2=87,5% paO2=51,4 paCO2=29,3 pH=7,495 HCO3=18

LAB TESTS
I line tests
CBC

Second line tests


Thrombophylia tests

Biochemistry
Coagulation

ABG

Ddimers

D dimers +2g/ml

(V.N. <0,2g/ml)

ANALIZE DE LABORATOR

D dimeri +2g/ml

Troponine I <0,2g/ml BNP=74U/l

PARACLINICAL EXAMINATIONS
First line
EKG

Second line
Venous ultrasound

Rx
Ecocardiography

Pulmonary scintigraphy
CT angiogram IRM

Amgiography

PARACLINICAL EXAMINATIONS
First line Second line
Venous ultrasound

EKG
Rx Ecocardiography

Pulmonary scintigraphy
CT angiogram IRM

Amgiography

EKG

EKG

EKG

EKG

EKG

EKG

PARACLINICAL EXAMINATIONS
First line
EKG

Second line
Venous ultrasound

Rx
Ecocardiography

Pulmonary scintigraphy
CT angiogram IRM

Amgiography

RX PULMONAR

PARACLINICAL EXAMINATIONS
First line
EKG

Second line
Venous ultrasound

Rx

Pulmonary scintigraphy
CT angiogram IRM

Ecocardiography

Angiography

ECOCARDIOGRAPHY
RV=31
IVS TR - paradoxical movement -PAP=40-45mmHg

PARACLINICAL EXAMINATIONS
First line
EKG

Second line

Rx
Ecocardiography

Venous ultrasound Pulmonary scintigraphy CT angiogram IRM Angiography

LIMB ULTRASOUND

PARACLINICAL EXAMINATIONS
First line
EKG

Second line
Venous ultrasound

Rx
Ecocardiography

Pulmonary

scintigraphy
CT angiogram IRM Angiography

PULMONARY SCINTIGRAPHY

PULMONARY SCINTIGRAPHY

PULMONARY SCINTIGRAPHY

DIAGNOSYS
MODERATE BILATERAL PULMONARY THROMBOEMBOLISM. DEEP VEIN THROMBOSIS RIGHT LEG

ARTERIAL HYPERTENSION GRADE 2 (ESC).

TREATMENT
Oxygen
Clexane 2x80 mg/zi Omeran 20mg/zi Cefort 1 grx2/zi Codeine phosphate tbx2/zi Atacand 16 mg dimineata Simvastatin 20mg/zi

EVOLUTION

EKG

EKG

EKG

EKG

EKG -at 2 months

CHEST X-ray

CHEST X-ray

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

PULMONARY EMBOLISM

Complication of DVT Obstruction of one or more branches of the pulmonary artery through an embolus migrating from a deep vein thrombosis

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

CLINICS
Acute dyspneea with normal pulmonary examination

CLINICS
Dyspneea with normal lungs severe chest pain SBP (+/- cardiogenic shock) cyanosis (respiratory failure) tachycardia later: right sided heart failure

CLINICS
Massive pulmonary embolism Submassive PE Low risk PE

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

LAB TESTS
Ist line tests
CBC

Second line tests


Thrombophylia tests

Biochemistry
Coagulation

ABG
Ddimers

LAB TESTS
I line tests
CBC

Second line tests


Thrombophylia tests

Biochemistry
Coagulation

ABG
Ddimers

LAB TESTS
I line tests
CBC

Second line tests


Thrombophylia tests

Biochemistry
Coagulation

ABG

Ddimers

D-dimers

D-dimers

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

PARACLINICAL EXAMINATIONS
First line
EKG

Second line
Venous ultrasound

Rx
Ecocardiography

Pulmonary scintigraphy
CT angiogram IRM

Amgiography

PARACLINICAL EXAMINATIONS
First line Second line
Venous ultrasound

EKG
Rx Ecocardiography

Pulmonary scintigraphy
CT angiogram IRM

Amgiography

EKG
clockwise rotation S1Q3. Right axis deviation Ischemic signs Conduction troubles:RBBB Arrythmias: ST, ExA, ExV, AF, AfT.

PARACLINICAL EXAMINATIONS
First line
EKG

Second line
Venous ultrasound

Rx
Ecocardiography

Pulmonary scintigraphy
CT angiogram IRM

Amgiography

PARACLINICAL EXAMINATIONS
First line
EKG

Second line
Venous ultrasound

Rx
Ecocardiography

Pulmonary scintigraphy
CT angiogram IRM

Amgiography

CHEST X-Ray
Westermark sign Atelectasis Small pleural effusion Elevated diaphragm Triangular radioopacity with the base towards the pleura

PARACLINICAL EXAMINATIONS
First line
EKG

Second line
Venous ultrasound

Rx

Pulmonary scintigraphy
CT angiogram IRM

Ecocardiography

Angiography

PARACLINICAL EXAMINATIONS
First line
EKG

Second line

Rx
Ecocardiography

Venous ultrasound Pulmonary scintigraphy CT angiogram IRM Angiography

PARACLINICAL EXAMINATIONS
First line
EKG

Second line
Venous ultrasound

Rx
Ecocardiography

Pulmonary

scintigraphy
CT angiogram IRM Angiography

PARACLINICAL EXAMINATIONS
First line
EKG

Second line
Venous ultrasound

Rx
Ecocardiography

Pulmonary scintigraphy

CT angiogram IRM Angiography

PARACLINICAL EXAMINATIONS
First line
EKG

Second line
Venous ultrasound

Rx
Ecocardiography

Pulmonary scintigraphy
CT angiogram IRM

Angiography

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

DIFFERENTIAL DIAGNOSIS
Myocardial ischemia: RV infarction
Pericarditis: cardiac tamponade Anemia Metabolic acidosis Cardiogenic shock Aortid dissection COPD Penumothorax Cor pulmonale Musculoskeletal pain

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

TREATMENT OF PE
Pharmacological Interventional Surgical

TREATMENT OF NON-MASSIVE PULMONARY EMBOLISM

Pharmacological
HEPARINE

LMWH
FONDAPARINUX

Pharmacological
HEPARINE: 80 U/kg or 5000 bolus
infusion: 18 U/kg/h or 1300 U/kg APTT Renal impairment CrCl<20-30ml/min

LMWH no monitoring

FONDAPARINUX anti-X a

aPTT=activated partial thromboplastin time, with therapeutic range-60-80 seconds.

LMWH

FONDAPARINUX=anticoagulant that specifically inhibits activated


factor X.

WARFARIN
Vit K antagonist After 5 days of Heparine/LMWH or Fondaparinux 2 consecutive days of INR 2-3

INR-2-3.

DURATION OF TREATMENT
Calf DVT 3 months Proximal DVT- 6 months Upper extremity DVT- 3 months Pulmonary embolism- 6 months Pulmonary embolism+cancer -lifelong Recurrent PE lifelong
Pulmonary embolism + AT III deficiency/Leiden mutation, prot C, prot S deficiency life-long.

TREATMENT OF MASSIVE PULMONARY EMBOLISM

THROMBOLYSIS
Streptokinase Urokinase Alteplase Reteplase Tenecteplase Heparine+Thrombolysis+Volume 500-1000ml

THROMBOLYSIS
Streptokinase 1,5 mil U/2h Urokinase 3 milU/2 h Alteplase 100mg/2h Reteplase 10U+10U (30 min) Tenecteplase 30 mg bolus50mg Heparine+Thrombolysis+Volume 500-1000ml 14 days

INTERVENTIONAL

INTERVENTIONAL
IVC FILTERS:
1. CI to anticoagulants

2. Massive PE who survived recurrent may

be fatal. 3. Recurrent venous thromboembolism under anticoagulants

SURGICAL
Pulmonary endarterectomy

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

PULMONARY EMBOLISM
What you should know

DEFINITION

ETIOLOGY

MORPHOPATHOLOGY

CLINICS

LAB TESTS

PARACLINICAL EXAMINATIONS

DIFFERENTIAL DIAGNOSIS

TREATMENT

COMPLICATIONS

COMPLICATIONS
Sudden cardiac death Shoc PEA Atrial/Ventricular arrythmias Secondary PAH Cor pulmonale Severe hypoxemia Right-to-left intracardiac shunt Lung infarction

In case of a pulmonary embolism, which are the possible complications ?


Ventricular septal defect Sudden cardiac death Secondary pulmonary arterial hypertension Pneumothorax Renal carcinoma

The pharmacological treatment of non massive pulmonary embolism can be made with:
Heparine Enoxaparine Streptokinase Vitamin K agonists (Fitomenadione) Surgery