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(DVT)
Definition
Thrombus: A solid mass of platelets
and/or fibrin (and other components
of blood) that forms locally in a
vessel.
Embolus: Detached intravascular
solid, liquid, or gaseous mass that is
carried by the blood to a site distant
from its point of origin.
2
Virchows Triad
Endothelial Injury
Hypercoagulabilit
y
Venous Stasis
Virchows Triad
1. Endothelial Injury
Physical loss of epithelium
subendothelial extracellular matrix
exposure, platelet adhesion, TF
release, PGI2 & PAs depletion
Eg. Trauma/ surgery, haemodynamic
stress of hypertension, turbulent flow
over scarred valves
4
Virchows Triad
2. Hypercoagulability
Any alteration of the coagulation
pathways that predisposes to
thrombosis
1 (Congenital): Factor V Leiden, Anti
thrombin III def., protein C & protein S
def.
2 (Acquired): Preganacy, puerperium,
malignancy
5
Virchows Triad
3. Venous stasis
Immobility, Obesity, Pregnancy,
Paralysis, Operation, Trauma
Fate of Thrombus
1. Propagation
2. Embolization
3. Dissolution: Removed by fibrinolytic
activity
4. Organization: To fibrinnous thrombus
5. Recanalization: Capillary channels
formed in the organized thrombus
6. Culture medium for bacteria
8
DVT Pathology
DVT Pathology
10
Clinical Features
Symptoms
Signs
a. Asymptomatic
c. Mild fever
d. Symptoms of PE
12
Complications of DVT
Pulmonary embolism
Post thrombotic syndrome
Phlegmasia alba & caerulea dolens
Post Thrombotic
Syndrome
Characterised by:
Oedema
Hyperpigmentation
Venous ectasia
Redness
Pain during
compression
Skin induration
Ulcer
Further reading : http://circ.ahajournals.org/content/121/8/e217.full
Post Thrombotic
Syndrome
18
19
DVT Investigation
Screening
Diagnostic
D-dimer test
not in Malaysia. Why?
DVT Investigation
Screening
1. Lack standardisation and cut off
value
2. Blood agglutination for D-dimer
test for most lab in Malaysia is
not sensitive to rule out VTE
not in Malaysia. Why?
3. Other causes of raised DVT
which limits the exclusion of VTE
D-dimer test
D-dimer test
Quick, non-invasive screening for
abnormal or excess clotting
Normal or negative D-dimer
result no acutecondition or
disease causing abnormal clot
formation and breakdown
Positive D-dimer - indicates
significant blood clot formation and
breakdown in the body, but it does
not tell the location or cause
Elevated levels may be seen in
recent surgery, trauma,
infection,myocardiac infarction,
malignancy or liver diease.
Further reading : https://labtestsonline.org/understanding/analytes/d-dimer/tab/test/
DVT Investigation
Screening
D-dimer test
not in Malaysia. Why?
Diagnostic
Contrast Compression
venography ultrasound
Why not???
DVT Investigation
Diagnostic
1. Invasive
Contrast Compression
2. Higher cost
venography ultrasound
3. Limited availability
(equipments, skilled
Why not???
professionals,
software)
Further
reading : Malaysian
CPG on Venous Thromboembolism, August 2013
Contrast Venography vs
Compression Ultrasound
Contrast
venography
Gold standard
Better in
identifying calf
vein thrombosis
Increased risk of
phlebitis and
contrast related
problems
Invasive and
painful
Compression
ultrasound
Non-invasive
Poor visualization of
iliac, and pelvic
veins
Requires skilled
operator
Can be repeated
serially to monitor
suspected DVT
Poor sensitivity in
identifying calf vein
urther reading : http://www.lumen.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/DVT1.ht
thrombi
Contrast Venography
Shows presence of
intraluminal filling
defect.
Venogram showing
a popliteal deep
vein thrombosis
Compression Ultrasound
compression
compression
transducer
(Normal)
transducer
(DVT)
Normal or not?
Normal or not?
Duplex Ultrasonography
Treatment of DVT
Principle of treatment
Prevent thrombus extension
Prevent thrombus embolisation
LMWH
Enoxaparin 1
mg/kg twice daily
Tinzaparin dose is
175 IU/kg once
daily
Fondaparinux
Fondaparinux- 7.5
mg daily
(5 mg if <50
kg,7.5mg if 50100 kg , 10 mgif
>100 kg)
continue for at least 5 days or until the INR is
2 for at least 24 hours
Duration of
Anticoagulant
DVT Prophylaxis
Mechanical
1. Compression stockings
2. Intermittent pneumatic
compression
3. Venous foot pump
Pharmacological
1. UFH
2. LMWH
3. Fondaparinux
Gradient compression
stockings
Gradient compression
stockings (GCS) provide
pressure that is strongest
around the foot and ankle
and looser as it moves up the
leg
Systematic review of
randomized, controlled trials
Sajid MS, Desai M, Morris RW, in 2012 found that knee- and
Hamilton G. Knee length versus
thigh-high GCS do not
thigh length graduated compression
stockings for prevention of deep vein significantly differ in their
thrombosis in postoperative surgical
patients.Cochrane Database Syst effectiveness in reducing the
Rev. 2012 May 16. 5:CD007162.
incidence of deep venous
Intermittent pneumatic
compression
In use, an inflatable cuff
encloses the limb requiring
treatment, and pressure
lines are connected between
the cuff and the air pump.
IPC devices have the
advantage of requiring no
monitoring, with no increase
in bleeding.
In a study of the efficacy of
IPC in multiple postoperative
patient groups versus no use
of prophylaxis, Urbankova et
al reported that the
Comparison
Method
Graduated
compression
stockings
Function
Provide circumferential pressure
that gradually decreases from the
ankle to the thigh to promote
venous blood flow
Intermittent
Leggings repeatedly inflated and
pneumatic
deflated by a pneumatic pump with
compression
the goal of mimicking natural calf
muscle contractions that promote
venous return
Venous foot
Imitate the physiological pumping
pump
action of weight-bearing on the
venous plexus of the sole of the
foot to simulate the effect of
r reading : https://www.thrombosisadviser.com/en/vte-prevention/other-options-for-vte-prev
normal walking and increase
Pharmacological
prophylaxis
Q1 Who should be offered
prophylaxis?
Thrombolytic therapy
THROMBOLYTI
C THERAPY
Catheter
directed
Systemic
Venous thrombectomy
Insert a catheter sheath
through a small incision in the
femoral vein in the groin or the
popliteal vein below the knee.
Contrast dye is injected
through the sheath and
venography is performed, to
locate the clot site.
A larger incision over the
diseased vein is made and the
clot is removed with a catheter.