Successfully reported this slideshow.
Your SlideShare is downloading.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Deep Venous Thrombosis. Diagnosis and
Management.
Dr Rafael Angel Gonzalez Pupo
Resident. Vascular Surgery.
University of ...
Objectives
• Epidemiology
• Pathophysiology
• Risk factors
• Diagnosis
• Current medical, catheter based and surgical
ther...
Epidemiology
• The incidence of recurrent fatal and nonfatal VTE is
estimated to exceed 900,000 cases annually in the
Unit...
The complications of acute venous thromboembolism (VTE) including deep
venous thrombosis (DVT), pulmonary embolism (PE) an...
Pathophysiology
Pathophysiology
Pathophysiology
DVT risk factors
Risk factors
DVT clinical evaluation
DVT clinical evaluation
• Edema
• Pain
• Erythema
• Tenderness
• Prominent superficial veins
• Pain with passive foot dors...
Phlegmasia Alba Dolens
• Painful white edema
• “Milk leg or white leg”
• First described in
pregnant and postpartum
women....
Phlegmasia Cerulea Dolens
• Occlusion of both deep
and superficial venous
system.
• Fluid sequestrations,
significant edem...
Venous gangrene
May-Thurner Syndrome
• Compresion of Left
Iliac Vein by Right
Iliac artery against
the spine.
• Frequent in women
20-40 ye...
DVT diagnostic modalities
Historical
• Impedance
plethysmography.
• Radiolabeled fibrinogen.
• Thermography
• Venography
C...
Nomenclature
Duplex ultrasound
Direct signs Indirect signs
Intramural thrombus Loss of phasicity : Proximal
thrombosis
Incompressibilit...
Duplex ultrasound
CTV
• Sensitivity of 94-98% and specificity of 100%
for thigh and pelvis DVT.
MRV
• It has a sensitivity and specificity of 100% for thigh,
pelvic and pulmonary thrombi.
• It distinguishes a mature fr...
D-dimer
Diagnostic strategies
Algorithm in symptomatic patients with high
probability.
Algorithm for symptomatic patients with low
probability.
Treatment of DVT
Goals of therapy.
• Prevent extension or recurrence of DVT
• Prevent pulmonary embolism
• Minimize early ...
Initial treatment
• Elevation of leg and strict bed rest have been challenged for early
ambulation.
• Anticoagulation. Do ...
Minimize sequelae of DVT
The most important
consideration leading to
guideline recommendations
for thrombus removal in
pat...
Options for thrombus removal
• Systemic thrombolysis
• Catheter directed thrombolysis
• Pharmacomechanical thrombolysis:
-...
Trellis system
• The double balloon catheter is inserted into the thrombosed venous segment
with the proximal balloon posi...
Surgical thrombectomy
Algorithm for thrombus removal
Contraindications to anticoagulation
Absolute contraindications
●Active bleeding
●Severe bleeding diathesis
●Platelet coun...
IVC filter
IVC filter
Antithrombotic Therapy for Venous
Thromboembolic Diseases
-----
Antithrombotic Therapy and Prevention
of Thrombosis: ACCP ...
Anticoagulation in Patients With Isolated Distal DVT
•In patients with acute isolated distal DVT of the leg and without se...
Choice of therapy in proximal leg DVT
•Treatment: Anticoagulants .(IB)
•Suggestion is not to use thrombolytic or thrombect...
Choice of therapy in proximal leg DVT
•Length and intensity of anticoagulant treatment. (1B)
-DVT triggered by surgery: 3 ...
Early thrombus removal strategies for acute deep
venous thrombosis: Clinical Practice Guidelines of
the Society for Vascul...
Anatomical precision
• 1.1. We recommend use of precise anatomic
terminology to characterize the most proximal extent of
v...
Indications for early thrombus removal
• 2.1. We suggest a strategy of early thrombus removal in
selected patients meeting...
Indications for early thrombus removal
• 2.2. We recommend early thrombus removal strategies as the
treatment of choice in...
Indications for early thrombus removal
• 2.3. We recommend that patients with isolated
femoropopliteal deep venous thrombo...
Techniques for early thrombus removal
• 3.1. We suggest percutaneous catheter-based techniques
(pharmacologic or pharmacom...
Periprocedural inferior vena cava filters
• 4.1. We recommend against routine use of inferior vena cava
filters (permanent...
Adjunctive use of venous stents
• 5.1. We recommend the use of self-expanding metallic stents
for treatment of chronic ili...
Early thrombus removal strategies as an
adjuvant to conventional management
• 6.1. We recommend that patients managed with...
Upper extremity DVT
•.
• if DVT that involves the axillary or more proximal veins, anticoagula-
tion therapy with LMWH, IV...
Upper extremity DVT
•.
•In upper extremity DVT not associated with central venous catheter.
Length of anticoagulation: 3 m...
Treatment of Patients With Superficial Vein Thrombosis
•In patients with superficial vein thrombosis of the lower limb of ...
Thromboprophylaxis
Thromboprophylaxis
Caprini Score
Mechanical methods
•Alternative for patients with
contraindications for
anticoagulation.
•Do not use in patients with
peri...
Pharmacologic methods
Postop day 1 open repair AAA
DVT
DVT
DVT
DVT
DVT
DVT
DVT
DVT
DVT
Upcoming SlideShare
Loading in …5
×
  • Be the first to comment

DVT

  1. 1. Deep Venous Thrombosis. Diagnosis and Management. Dr Rafael Angel Gonzalez Pupo Resident. Vascular Surgery. University of Toronto. January 17th, 2016
  2. 2. Objectives • Epidemiology • Pathophysiology • Risk factors • Diagnosis • Current medical, catheter based and surgical therapy • Current DVT guidelines
  3. 3. Epidemiology • The incidence of recurrent fatal and nonfatal VTE is estimated to exceed 900,000 cases annually in the United States alone. • The annual VTE incidence is 122 per 100,000 person- years (DVT, 56 per 100,000; PE, 66 per 100,000).
  4. 4. The complications of acute venous thromboembolism (VTE) including deep venous thrombosis (DVT), pulmonary embolism (PE) and the post-thrombotic syndrome (PTS) are the most common preventable causes of hospital death and a source of substantial long term morbidity.
  5. 5. Pathophysiology
  6. 6. Pathophysiology
  7. 7. Pathophysiology
  8. 8. DVT risk factors
  9. 9. Risk factors
  10. 10. DVT clinical evaluation
  11. 11. DVT clinical evaluation • Edema • Pain • Erythema • Tenderness • Prominent superficial veins • Pain with passive foot dorsiflexion (Homans sign) • Peripheral cyanosis
  12. 12. Phlegmasia Alba Dolens • Painful white edema • “Milk leg or white leg” • First described in pregnant and postpartum women. • Total occlusion of deep iliofemoral venous system. • Open superficial venous system. • Edema, pain, blanching without cyanosis.
  13. 13. Phlegmasia Cerulea Dolens • Occlusion of both deep and superficial venous system. • Fluid sequestrations, significant edema, agonizing pain, cyanosis, bullae. • Compartment syndrome, acute ischemia.
  14. 14. Venous gangrene
  15. 15. May-Thurner Syndrome • Compresion of Left Iliac Vein by Right Iliac artery against the spine. • Frequent in women 20-40 years .
  16. 16. DVT diagnostic modalities Historical • Impedance plethysmography. • Radiolabeled fibrinogen. • Thermography • Venography Current • Duplex ultrasonagraphy • CTV • MRI and MRV • D-dimer
  17. 17. Nomenclature
  18. 18. Duplex ultrasound Direct signs Indirect signs Intramural thrombus Loss of phasicity : Proximal thrombosis Incompressibility + Vein diameter No flow in pulse Doppler Loss of augmentation: Distal thrombosis No flow in color Doppler
  19. 19. Duplex ultrasound
  20. 20. CTV • Sensitivity of 94-98% and specificity of 100% for thigh and pelvis DVT.
  21. 21. MRV • It has a sensitivity and specificity of 100% for thigh, pelvic and pulmonary thrombi. • It distinguishes a mature from an immature clot.
  22. 22. D-dimer
  23. 23. Diagnostic strategies
  24. 24. Algorithm in symptomatic patients with high probability.
  25. 25. Algorithm for symptomatic patients with low probability.
  26. 26. Treatment of DVT Goals of therapy. • Prevent extension or recurrence of DVT • Prevent pulmonary embolism • Minimize early and late sequelae of DVT
  27. 27. Initial treatment • Elevation of leg and strict bed rest have been challenged for early ambulation. • Anticoagulation. Do not wait confirmation from objectives imaging techniques to initiate treatment in patients with high clinical suspicion. • Initiate UFH or LMWH + warfarin and overlap until INR 2.0-3.0 • Fondaparinux • New oral anticoagulants: Rivaroxaban, apixaban and dabigatran. • Extend anticoagulation for 3 months or more depending on risk factors.
  28. 28. Minimize sequelae of DVT The most important consideration leading to guideline recommendations for thrombus removal in patients with extensive DVT is the severe morbidity associated with the PTS and the evidence that early elimination of thrombus prevents or reduces post- thrombotic morbidity.
  29. 29. Options for thrombus removal • Systemic thrombolysis • Catheter directed thrombolysis • Pharmacomechanical thrombolysis: -Endovascular mechanical thrombectomy -Ultrasound accelerated thrombolysis -Isolated segmental pharmacomechanical thrombolysis. • Opertive venous thrombectomy
  30. 30. Trellis system • The double balloon catheter is inserted into the thrombosed venous segment with the proximal balloon positioned at the upper edge of the thrombus. • Balloons are inflated and rTPA is infused into the thrombosed segment isolated by the balloons. • The intervening catheter spins at 1500 rpm for 15-20 minutes. • The liquefied and fragmented thrombus is aspirated
  31. 31. Surgical thrombectomy
  32. 32. Algorithm for thrombus removal
  33. 33. Contraindications to anticoagulation Absolute contraindications ●Active bleeding ●Severe bleeding diathesis ●Platelet count <50,000/microL ●Recent, planned, or emergent surgery/procedure ●Major trauma ●History of intracranial hemorrhage ●History of heparin-induced thrombocytopenia Relative contraindications ●Recurrent bleeding from multiple gastrointestinal telangiectasias ●Intracranial or spinal tumors ●Platelet count <150,000/microL ●Large abdominal aortic aneurysm with concurrent severe hypertension ●Stable aortic dissection
  34. 34. IVC filter
  35. 35. IVC filter
  36. 36. Antithrombotic Therapy for Venous Thromboembolic Diseases ----- Antithrombotic Therapy and Prevention of Thrombosis: ACCP Evidence-Based Clinical Practice Guidelines, 9th ed 801 pages and more than 600 recommendations. Copyright: American College of Chest Physicians 2012©
  37. 37. Anticoagulation in Patients With Isolated Distal DVT •In patients with acute isolated distal DVT of the leg and without severe symptoms or risk factors for extension, we suggest serial imaging of the deep veins for 2 weeks over initial anticoagulation (Grade 2C). •In patients with acute isolated distal DVT of the leg and severe symptoms or risk factors for extension (see text), we suggest initial anticoagulation over serial imaging of the deep veins (Grade 2C). •In patients with acute isolated distal DVT of the leg who are managed with initial anticoagulation, we recommend using the same approach as for patients with acute proximal DVT (Grade 1B). •In patients with acute isolated distal DVT of the leg who are managed with serial imaging, we recommend no anticoagulation if the thrombus does not extend (Grade 1B); we suggest anticoagulation if the thrombus extends but remains confined to the distal veins (Grade 2C); we recommend anticoagulation if the thrombus extends into the proximal veins (Grade 1B).
  38. 38. Choice of therapy in proximal leg DVT •Treatment: Anticoagulants .(IB) •Suggestion is not to use thrombolytic or thrombectomy routinely. (2C) •Treat as outpatient if feasible. (IB). Early ambulation over initial bed rest (2C). •In the acute setting, first few days: Use once daily Dalteparin, Tinzaparin or Fondaparinux or twice daily Enoxaparin. (2C). •Preferred treatment beyond the first few days in the non cancer patient: Warfarin over Rivaroxaban or Dabigatran. (2C). •If DVT and cancer LMWH over VKA and VKA over anti Xa . (2B). •If contraindication to anticoagulation: IVC filter. (IB)
  39. 39. Choice of therapy in proximal leg DVT •Length and intensity of anticoagulant treatment. (1B) -DVT triggered by surgery: 3 months rather than 6 or 12 months. -DVT due to mild risk factor: i.e. non-surgical risk factors such as estrogen therapy, long distance travel, non-surgical hospital stay: 3 months rather than 6 or 12 months or long term. -Unprovoked ( idiopathic) DVT: Long term if risk for bleeding not very high. Re-evaluation after 3 months. -In patients with acute DVT of the leg who undergo thrombosis removal: 3 months. - Target INR if VKA is 2.0-3.0 - In symptomatic patients , use compressive stockings for 2 years.
  40. 40. Early thrombus removal strategies for acute deep venous thrombosis: Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum J Vasc Surg 2012;55:1449-62.)
  41. 41. Anatomical precision • 1.1. We recommend use of precise anatomic terminology to characterize the most proximal extent of venous thrombosis as involving the iliofemoral veins, with or without extension into the inferior vena cava; the femoropopliteal veins; or isolated to the calf veins in preference to simple characterization of a thrombus as proximal or distal (1A).
  42. 42. Indications for early thrombus removal • 2.1. We suggest a strategy of early thrombus removal in selected patients meeting the following criteria: -(a) a first episode of acute iliofemoral deep venous thrombosis - (b) symptoms <14 days in duration - (c) a low risk of bleeding - (d) ambulatory with good functional capacity and an acceptable life expectancy. Grade (2C).
  43. 43. Indications for early thrombus removal • 2.2. We recommend early thrombus removal strategies as the treatment of choice in patients with limbthreatening venous ischemia due to iliofemoral deep venous thrombosis with or without associated femoropopliteal venous thrombosis (phlegmasia cerulea dolens) (Grade 1A).
  44. 44. Indications for early thrombus removal • 2.3. We recommend that patients with isolated femoropopliteal deep venous thrombosis be managed with conventional anticoagulation therapy because there is currently insufficient evidence to support early thrombus removal strategies in this patient population (Grade 1C).
  45. 45. Techniques for early thrombus removal • 3.1. We suggest percutaneous catheter-based techniques (pharmacologic or pharmacomechanical) as first-line therapy for early thrombus removal in patients meeting the criteria in 1.1 (Grade 2C). • 3.2. We suggest a strategy of pharmacomechanical throm- bolysis be considered over catheter-directed pharmacologic thrombolysis alone if expertise and resources are available (Grade 2C). • 3.3. We suggest open surgical venous thrombectomy in selected patients who are candidates for anticoagulation but in whom thrombolytic therapy is contraindicated • (Grade 2C).
  46. 46. Periprocedural inferior vena cava filters • 4.1. We recommend against routine use of inferior vena cava filters (permanent or temporary) in conjunction with catheter-directed pharmacologic thrombolysis of the iliofemoral venous segments (Grade 1C). • 4.2. We suggest that the relative risks vs benefits of periprocedural retrievable inferior vena cava placement be considered in patients undergoing pharmacomechanical thrombolysis and in those with thrombus extending into the inferior vena cava or who have markedly limited cardiopulmonary reserve (Grade 2C).
  47. 47. Adjunctive use of venous stents • 5.1. We recommend the use of self-expanding metallic stents for treatment of chronic iliocaval compressive or obstructive lesions that are uncovered by any of the thrombus removal strategies (Grade 1C). • 5.2. We suggest that stents not be used in the femoral and popliteal veins (Grade 2C).
  48. 48. Early thrombus removal strategies as an adjuvant to conventional management • 6.1. We recommend that patients managed with early thrombus removal be treated with a standard course of conventional anticoagulation after the procedure (Grade 1A). • 6.2. We recommend that all patients be treated with knee- high compression stockings (30 to 40 mmHg) for at least 2 years after the procedure (Grade1C).
  49. 49. Upper extremity DVT •. • if DVT that involves the axillary or more proximal veins, anticoagula- tion therapy with LMWH, IV UFH or SQ UFH is recommended over no treatment. (1B). LMWH or fondaparinux over IV UFH (2C) and over SQ UFH (2B). •If DVT that involves the axillary or more proximal veins, anticoagula- tion therapy alone is suggested rather than thrombolytic therapy. Length of anticoagulation : 3 months. (2B)
  50. 50. Upper extremity DVT •. •In upper extremity DVT not associated with central venous catheter. Length of anticoagulation: 3 months. (2C) •In upper extremity DVT associated with central venous catheter: -Do not removed the catheter if it is functional and there is an ongoing need for the catheter. Anticoagulation should be given as long as the catheter is in place. (1C) •If the catheter is removed, anticoagulation for 3 months. (1B)
  51. 51. Treatment of Patients With Superficial Vein Thrombosis •In patients with superficial vein thrombosis of the lower limb of at least 5 cm in length, we suggest the use of a prophylactic dose of fondaparinux or LMWH for 45 days over no anticoagulation (Grade 2B). •In patients with superficial vein thrombosis who are treated with anticoagulation, we suggest fondaparinux 2.5 mg daily over a prophylactic dose of LMWH (Grade 2C).
  52. 52. Thromboprophylaxis
  53. 53. Thromboprophylaxis
  54. 54. Caprini Score
  55. 55. Mechanical methods •Alternative for patients with contraindications for anticoagulation. •Do not use in patients with peripheral vascular disease, lack of pedal pulses or ABI < 0.85 •Contraindicated in patients with massive edema due to CHF . •Can not use if dermatitis.
  56. 56. Pharmacologic methods
  57. 57. Postop day 1 open repair AAA

    Be the first to comment

    Login to see the comments

  • ThanhNguyen27

    May. 11, 2016
  • RuchiAnam

    May. 28, 2016
  • schumili

    Oct. 10, 2016
  • amomtan

    Jan. 9, 2017
  • DESMinea

    Jan. 11, 2017
  • mostafaakkaoui

    Apr. 10, 2017
  • zinmgmgthan

    Jun. 29, 2017
  • daredevil65

    Jul. 25, 2017
  • AdityaPawar16

    Aug. 20, 2017
  • Ibrahimlaxmidhar

    Sep. 24, 2017
  • KanRoLawrence

    Oct. 22, 2017
  • YiDai9

    Feb. 26, 2018
  • DimpalPatel22

    Jul. 9, 2018
  • daniellephillips503645

    Jul. 17, 2018
  • arztschon

    Mar. 1, 2019
  • rinaerlina96

    Mar. 2, 2019
  • alinemealncon

    Dec. 9, 2019
  • AileenThankachan

    Apr. 1, 2020
  • ChanyaS2

    Oct. 18, 2020
  • OkoteteIrene

    Jan. 25, 2021

Views

Total views

4,340

On Slideshare

0

From embeds

0

Number of embeds

32

Actions

Downloads

0

Shares

0

Comments

0

Likes

23

×