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Deep venous thrombosis dvt Slide 1 Deep venous thrombosis dvt Slide 2 Deep venous thrombosis dvt Slide 3 Deep venous thrombosis dvt Slide 4 Deep venous thrombosis dvt Slide 5 Deep venous thrombosis dvt Slide 6 Deep venous thrombosis dvt Slide 7 Deep venous thrombosis dvt Slide 8 Deep venous thrombosis dvt Slide 9 Deep venous thrombosis dvt Slide 10 Deep venous thrombosis dvt Slide 11 Deep venous thrombosis dvt Slide 12 Deep venous thrombosis dvt Slide 13 Deep venous thrombosis dvt Slide 14 Deep venous thrombosis dvt Slide 15 Deep venous thrombosis dvt Slide 16 Deep venous thrombosis dvt Slide 17 Deep venous thrombosis dvt Slide 18 Deep venous thrombosis dvt Slide 19 Deep venous thrombosis dvt Slide 20 Deep venous thrombosis dvt Slide 21 Deep venous thrombosis dvt Slide 22 Deep venous thrombosis dvt Slide 23 Deep venous thrombosis dvt Slide 24 Deep venous thrombosis dvt Slide 25 Deep venous thrombosis dvt Slide 26 Deep venous thrombosis dvt Slide 27 Deep venous thrombosis dvt Slide 28 Deep venous thrombosis dvt Slide 29 Deep venous thrombosis dvt Slide 30 Deep venous thrombosis dvt Slide 31 Deep venous thrombosis dvt Slide 32 Deep venous thrombosis dvt Slide 33 Deep venous thrombosis dvt Slide 34 Deep venous thrombosis dvt Slide 35 Deep venous thrombosis dvt Slide 36 Deep venous thrombosis dvt Slide 37 Deep venous thrombosis dvt Slide 38 Deep venous thrombosis dvt Slide 39 Deep venous thrombosis dvt Slide 40 Deep venous thrombosis dvt Slide 41 Deep venous thrombosis dvt Slide 42 Deep venous thrombosis dvt Slide 43
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Deep venous thrombosis dvt

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Deep Venous Thrombosis
By Dr Udai Othamn Alghanmi ER head
Meeqat General Hospital ,Madinah

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Deep venous thrombosis dvt

  1. 1. DeepVenousThrombosis Dr.Udai Othman Alghanmi Meeqat General Hospital ER Head
  2. 2. DeepVenousThrombosis • Deep vein thrombosis (DVT) is a condition in which a blood clot (thrombus) forms in one or more of the deep veins in your body, usually in your legs.
  3. 3. Blood Flow • Superficial to deep veins • 100-150ml blood fills in calf (Peripheral Heart) and deep veins • Calf contracts, valves in perforators close and blood goes up the deep veins • Coming up next: Pathophysiology
  4. 4. Pathophysiology • Is a manifestation of Venous Thromboembolism • Virchow’s triad: • Venous Stasis By anything obstructing or slowing flow of venous blood • Activation of Coagulation(hypercoagulable state) Biochemical imbalance between circulating factors • Vein Damage Intrinsic or Extrinsic
  5. 5. Development ofThrombosis • Microscopic thrombus formation and dissolution is continuous process • Increased stasis (more microthrombi not washed away by movement), procoagulant factors, endothelial injury, favors coagulation more than fibrinolysis, thus a thrombus • Coagulation is by Intrinsic or Extrinsic pathway
  6. 6. Virchow’sTriad
  7. 7. Summary of risk factors • A summary of risk factors is as follows: • Age 30 year old x 30= 80 year old • Immobilization longer than 3 days • Pregnancy and the postpartum period • Major surgery in previous 4 weeks • Malignancy (abnormal coagulation, pressure, chemotherapy) • Long plane or car trips (> 4 hours) in previous 4 weeks • Cancer • Previous DVT • Anatomical Variations
  8. 8. Summary of risk factors • Stroke • Acute myocardial infarction (AMI) • Congestive heart failure (CHF) • Sepsis • Nephrotic syndrome • Ulcerative colitis • Multiple trauma • CNS/spinal cord injury • Burns • Lower extremity fractures, injury • Systemic lupus erythematosus (SLE) and the lupus anticoagulant • Behçet syndrome • Homocystinuria • Polycythemia rubra vera
  9. 9. Summary of risk factors • Thrombocytosis • PICC Line> CVC • Inherited disorders of coagulation/fibrinolysis • Antithrombin III deficiency • Protein C deficiency • Protein S deficiency • Prothrombin 20210A mutation • Factor V Leiden • Dysfibrinogenemias and disorders of plasminogen activation • Intravenous (IV) drug abuse • Oral contraceptives • Estrogens • Heparin-induced thrombocytopenia (HIT)
  10. 10. SIGNS AND SX • Pain • Limb Edema • Tenderness • Warmth or Erythema • Can be present or absent, unilateral or bilateral, mild or severe • Presentation can be of Pulmonary Embolism, sudden coughing, haemoptysis, sharp chest pain, rapid breathing or shortness of breath, light headedness.
  11. 11. Physical Examination • Homan’s sign Calf pain on dorsiflexion of foot Positive in less than 33% of DVT patients and more than 50% in patients without DVT Warning: it must be noted that it is of little diagnostic value and is theoretically dangerous because of the possibility of dislodgement of loose clot
  12. 12. Physical Examination • Warmth on area of the clot • Tense leg • Red or discolored skin • The most common abnormal hue is reddish purple from venous engorgement and obstruction. Can be cyanotic or white. • Signs and symptoms depending upon the cause.
  13. 13. Workup • Wells Score
  14. 14. Low pretest probabilty • Go for a D Dimer test • D-dimer levels remain elevated in DVT for about 7 days • Negative value rules out in low pretest probability • Negative result in high pretest probability, has no value, start anti coagulation nonetheless and go for ultrasound.
  15. 15. Intermediate to High Pretest Probability of DVT • Ultrasonography is recommended • Doppler Ultrasound can depict absent or abnormal flow even if clot isn’t visible in normal ultrasound.
  16. 16. Venography • Radiography of a vein after injection of a radiopaque fluid. • Conclusive diagnosis historically required invasive and expensive venography, which is still considered the criterion standard. Since 1990, the diagnosis has been obtained noninvasively by means of sonographic examination.
  17. 17. CBC and Coagulation Profile • Can look for • Polycythemia • Leucocytosis • Thrombocytosis • Low PT, APTT, hypercoaguable state
  18. 18. Further Imaging • CT Scan and MRI if required • Suspecting iliac vein or inferior vena caval thrombosis
  19. 19. Who to manage inpatient • Suspected or proven PE • Significant CV or pulmonary comorbidity • Ileofemoral DVT • Contraindication to anticoagulation • Disorder of Coagulation • Pregnancy • Morbid obesity 150kg+ • Renal Failure • No compliance, far from hospital, resistance to therapy, no close follow up.
  20. 20. Leg Elevation
  21. 21. Treatment • The primary objective for the treatment of DVT are to prevent a PULMONARY EMBOLUS. • The mainstay of treatment is ANTICOAGULATION • Heparin, Vit K antagonists (Warfarin), and Factor Xa inhibitors(Fondaparinux) • Anticoagulation resolves immediate symptoms, intervention is often to reduce 75%long term risk of PTS
  22. 22. Who not to anticoagulate • Intracranial Bleeding • Severe Active Bleeding • Recent brain, spinal cord, eye surgery • Pregnancy • Malignant hypertension • Relative contraindications include Recent Major surgery, recent CVA, severe Thrombocytopenia
  23. 23. Guidelines forAnticoagulation • Admitted patients are treated with LMWH, Unfractionated heparin (UFH), Fondaparinux. • Warfarin 5mg PO is initiated and overlapped for about 5 days until the INR is >2 for 24 hours.
  24. 24. Unfractionated Heparin • Standard of care in admitted patients with DVT before LMWH. • Prevents extension of thrombus and reduce PE risk • Heparin must be overlapped for 4-5 days with warfarin till INR>2 • Because of initial transient hypercoaguable state induced byWarfarin
  25. 25. IV heparin Protocol • Initial bolus of 80U/kg • Constant maintenance of 18u/kg/hr • Half life 60-90 min • 1ml contains 5000u • Check the aPTT or heparin activity level 6 hrs after bolus and adjust infusion rate accordingly • Continue to check the aPTT or heparin every 6 hrs, until 2 successful values therapeutic • Monitor aPTT, hematocrit, Platelets every 24 hrs (HIT) • aPTT is 21-35 sec usually, therapeutic is 1.5 times 50+
  26. 26. LMW H • Clexane (Enoxaparin) • Increased Bioavailability, prolonged Half Life. • Treatment of choice in eligible patients. • 1mg/kg q12 hours leading to therapeutic peak 0.5-1 iu/mL • Antagonist?
  27. 27. Fondaparinux • Inhibits factor Xa interrupts blood coagulation • Generally does not increase PT or PTT • Dose: <50kg: 5 mg SC once daily • 50-100 kg: 7.5 Sc once daily • >100kg 10mg SC once daily • Patients not responding to Heparin • Prophylaxis of DVT in patient of HIT until patient can switch to Warfarin 2.5 mg SC daily • Antagonist?
  28. 28. Warfarin • Warfarin interferes with hepatic synthesis of vitamin K– dependent coagulation factors. • Initiate warfarin on day 1 or 2 of LMWH or unfractionated heparin therapy and overlap until desired INR, THEN discontinue heparin • Start 10 mg PO for 2 days in healthy individuals, 2-5 mg PO/IV qDay for 2 days • Check INR after 2 days and adjust dose according to results • Typical maintenance dose ranges between 2 and 10 mg/day • Maintain an INR of 2.0-3.0
  29. 29. Treatment duration • Maintain an INR of 2.0-3.0 • Surgery-provoked DVT or PE: Treatment duration of 3 months • Transient (reversible) risk factor-induced DVT or PE: Treatment duration of 3 months • First unprovoked proximal DVT or PE with low or moderate bleeding risk: Extended treatment consideration with periodic (ie, annual) risk-benefit analysis • First unprovoked proximal DVT or PE with high bleeding risk: Treatment duration of 3 months
  30. 30. Treatment duration • First unprovoked distal DVT regardless of bleeding risk: Treatment duration of 3 months • Second unprovoked DVT or PE with low or moderate bleeding risk: Extended treatment • Second unprovoked DVT or PE with high bleeding risk: Treatment duration of 3 months • DVT/PE and active cancer: Extended treatment, with periodic risk-benefit analysis (ACCP recommends LMWH over vitamin K antagonist therapy)
  31. 31. Treatment follow up • Regular check up on INR, around a week • Warning signs prompting immediate contact with doctor, stopping warfarin. • Bleeding from any site in body. • it is generally considered dangerous to have an INR above 4.0. An INR above 5.0 may require a medical dose of vitamin K to bring the INR down to a lower level.
  32. 32. Endovascular Intervention • Indications for intervention include the relatively rare phlegmasia or symptomatic inferior vena cava thrombosis that responds poorly to anticoagulation alone, or symptomatic iliofemoral or femoropopliteal DVT in patients with a low risk of bleeding. • The goals of endovascular therapy include reducing the severity and duration of lower-extremity symptoms, preventing pulmonary embolism, diminishing the risk of recurrent venous thrombosis, and preventing postthrombotic syndrome.
  33. 33. Endovascular Intervension Procedures • Percutaneous transcatheter treatment of patients with deep venous thrombosis (DVT) consists of thrombus removal with catheter- directed thrombolysis, mechanical thrombectomy, angioplasty, and/or stenting of venous obstructions.
  34. 34. SurgicalThrombectomy • Surgical thrombus removal has traditionally been used in patients with massive swelling and phlegmasia cerulea dolens
  35. 35. InferiorVenaCava Filters • Inferior vena cava to trap emboli and minimize venous stasis. Inferior vena cava filter is a mechanical barrier to the flow of emboli larger than 4 mm. • Confirmed acute proximal DVT or acute PE in patient with contraindication for anticoagulation (this remains the most common indication for inferior vena cava filter placement) • Recurrent thromboembolism while on anticoagulation • Active bleeding complications requiring termination of anticoagulation therapy
  36. 36. • Early ambulation on day 2 after initiation of outpatient anticoagulant therapy in addition to effective compression is strongly recommended. • The regular use of graduated elastic compression stockings reduced the incidence of PTS by 50%
  37. 37. DVT Prophylaxis
  38. 38. PostThrombotic Syndrome • PTS can affect 23-60% of patients in the two years following DVT of the leg. • Signs and symptoms of PTS in the leg may include: • pain (aching or cramping) • heaviness • itching or tingling • swelling (edema) • varicose veins • brownish or reddish skin discoloration • ulcer
  39. 39. Prevention • prevention of initial and recurrent DVT • early ambulation • use of compression stockings • Electrostimulation devices • anticoagulant medications.
  40. 40. Treatment • proper leg elevation • compression therapy with elastic stockings • wound care for leg ulcers • angioplasty and vascular stents in proximal thrombosed veins by an experienced physician can provide significant relief of swelling and healing of skin ulcers • Compression bandages are useful to treat edemas
  • BalikisOnadipe

    Nov. 11, 2021
  • ArefehGhadiri1

    Nov. 4, 2021

Deep Venous Thrombosis By Dr Udai Othamn Alghanmi ER head Meeqat General Hospital ,Madinah

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