DEEP VEIN THROMBOSIS (DVT)

VARICOSE LEG VEINS

 Deep vein thrombosis or deep venous thrombosis (DVT) is the formation of a blood clot (thrombus) within a deep vein, mostly in the legs. Signs may include pain, swelling redness warmness, and engorged superficial veins. Pulmonary embolism, a potentially life-threatening complication, is caused by the detachment (embolization) of a clot that travels to the lungs. Together, DVT and pulmonary embolism constitute a single disease process known as venous thromboembolism. Post-thrombotic syndrome, another complication, significantly contributes to the health-care cost of DVT. Prevention options for at-risk individuals include early and frequent walking, calf exercises, anticoagulants, aspirin, graduated compression stockings.

degrees of varicose veins

 Signs and symptoms

·         pain or tenderness,

·         swelling,

·         warmth,

·         redness or discoloration

·         distention of surface veins. 

In most suspected cases, DVT is ruled out after evaluation and symptoms are more often due to other causes, such as cellulitis musculoskeletal injury, or lymphedema. Other differential diagnoses include hematoma, tumors, venous or arterial aneurysms, and connective tissue disorders.

 It is characterized by an acute and almost total venous occlusion of the entire extremity outflow, including the iliac and femoral veins. The leg is usually painful, cyanosed (blue from lack of oxygen), and edematous (filled with fluid), which may result in venous gangrene.

right leg varicose vein

Causes

Three main factors 

·         Venous stasis

·         Hypercoagulability

·         Changes in the endothelial blood vessel lining, such as physical damage contribute to DVT and are used to explain its formation.

Other risk factors include,

·         Older age, which alters blood composition to favor clotting?

·         Major surgery

·         Trauma,  

·         In orthopedic surgery, venous stasis may be temporarily provoked by a cessation of blood flow as part of the procedure. 

·         Cancer can grow in and around veins, causing venous stasis, and can also stimulate increased levels of tissue factor. 

·         Pregnancy causes blood to favor clotting

·         In postpartum, placental tearing releases substances that favor clotting.

SUMMARY OF RISK FACTORS OF DVT

·         Older age ·         Major surgery and orthopedic surgery ·         Cancers, especially of the bone, ovary, brain, pancreas, and lymphoma] ·         Inactivity and immobilization, as with orthopedic casts, sitting, travel, bed rest, and hospitalization ·         Pregnancy and the postpartum ·         Trauma, minor leg injury, and lower limb amputation ·         Combined oral contraceptives ·         Hormonal replacement therapy ·         Central venous catheters ·         Inflammatory diseases ·         Nephrotic syndrome ·         Obesity ·         Infection ·         HIV

Classification of DVT

 DVT occurs with risk factors, such as surgery, oral contraceptives, trauma, immobility, obesity, or cancer.  Acute DVT is characterized by pain and swelling and is usually occlusive, which means that it obstructs blood flow, whereas non-occlusive DVT is less symptomatic DVT that has no symptoms, but is found only by screening, is labeled asymptomatic or incidental.

An initial episode of DVT is called incident and any subsequent DVT is termed recurrent. Bilateral DVT refers to clots in both legs while unilateral means that only a single leg is affected

 WELLS SCORE RULE FOR MEASURING DEVELOPMENT OF DVT (from 2 - 9)

1.   Active cancer (treatment within last 6 months or palliative): +1 point

2.   Calf swelling ≥ 3 cm compared to asymptomatic calf (measured 10 cm below tibial tuberosity): +1 point

3.   Swollen unilateral superficial veins (non-varicose, in symptomatic leg): +1 point

4.   Unilateral pitting edema (in symptomatic leg): +1 point

5.   Previous documented DVT: +1 point

6.   Swelling of entire leg: +1 point

7.   Localized tenderness along the deep venous system: +1 point

8.   Paralysis, paresis, or recent cast immobilization of lower extremities: +1 point

9.   Recently bedridden ≥ 3 days, or major surgery requiring regional or general anesthetic in the past 12 weeks: +1 point

10. Alternative diagnosis at least as likely: −2 points

Those with Wells scores of two or more have a 28% chance of having DVT, those with a lower score have 6% odds. Alternatively, Wells scores can be categorized as high if greater than two, moderate if one or two, and low if less than one, with likelihoods of 53%, 17%, and 5% respectively.

 

valves of the veins

DIAGNOSIS

·        Evidence of signs and symptoms

·         ultrasound or whole-leg ultrasound. Each technique has drawbacks: a single proximal scan may miss a distal DVT, while whole-leg scanning can lead to distal DVT overtreatment

·         Doppler ultrasound 

·         CT scan venography,

·        MRI venography, or MRI of the thrombus are also possibilities

An ultrasound with a blood clot visible in the left common femoral vein An abdominal CT scan with a clot in the right common iliac vein Venograms of

Prevention.

wear stocking

 Walking and calf exercises reduce venous stasis because leg muscle contractions compress the veins and pump blood up towards the heart. 

In immobile individuals, physical compression methods improve blood flow.

Anticoagulation, which increases the risk of bleeding, might be used in high-risk scenarios.

 Anti-platelet drug aspirin might be used in some people following orthopedic surgery^.

Hospital Management

Hospitalized patients be assessed for their risk of thromboembolism and bleeding before prophylaxis is started.

Heparin or a related drug be used if potential benefits are thought to outweigh potential harms.

Immobilised and confined patients must be turned frequently on bed

 

wear stocking

Post-surgery

Early walking,

Mechanical prophylaxis  compression stockings

Drugs (heparin, warfarin)

Graduated compression stockings are effective after both general and orthopedic surgery.

Pregnancy

Warfarin is only recommended in post delivery women who are at higher risk.

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References

1.     Jump up^ "What are the signs and symptoms of deep vein thrombosis?". National Heart, Lung, and Blood Institute. 28 October 2011. Retrieved 15 April 2012.

^ Jump up to:^a b c d Scarvelis D, Wells P (2006