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DEEP Vein Thrombosis
DEEP Vein Thrombosis
• Likely underestimated
- Misdiagnosis
- Occult resolve without complication
- Non-occlusive
- Venous collaterals develop rapidly
DVT: A National Public Health Crisis1
• Up to 2 million people in the United States suffer
from DVT every year2,3
• Complications of DVT, such as PE, kill up to
200,000 people each year, more people than AIDS
and breast cancer combined2-6
High Probability ≥3
Moderate Probability 1 or 2
Low Probabillity 0
Who Should We Study?
• Edema
• Leg pain
• Tenderness
• Superficial thrombophlebitis
- Increased risk of DVT
• Fever
Alternate Diagnosis
Magnetic resonance
venogram showing a
thrombus in the left leg
extending from the
popliteal vein to the
common femoral vein;
the red arrows point to
the position of the
thrombus in the vessel
Ref: Annals of Internal Medicine 2 September 2008
One approach to testing for suspected deep
venous thrombosis
D-dimer
• Fragments
- Degradation of fibrin by plasmin
• Elevated in any condition where clots form
- Trauma, recent surgery, cancer, sepsis
• Low specificity
- r/o DVT
• Elevated for 7 days
Imaging Studies
Study Notes
Contrast Venography - “Gold standard”, 99% sensitive
- Allergic reaction, availability,
IV contrast, costly
- Good for calf, iliac veins, IVC
MRI - Useful in pregnancy
- Can distinguish acute from chronic
- Good for calf, iliac veins
- Cost, accessibility
• External Iliac
• Common Femoral Vein
- Deep femoral vein
- Superficial Femoral Vein
- Popliteal Vein
- Anterior Tibial Vein
- Posterior Tibial Vein
- Peroneal Vein
Some Logistics
• High frequency linear array probe
(7-10MHz)
• Head of bed to 45⁰
• Patient Positioning
What is Duplex Ultrasound?
A
A
V
Compressibility: DVT
A A
V
V
Compressibility
Ultrasound for DVT
• Compression in Hunter’s
canal difficult because
of depth
Femoral Vein
Popliteal
• Positioning
• Vein superficial to artery
• Scan to trifurcation point
Popliteal
Diagnostic Difficulties
-Kearon C, et al.
Limited Ultrasound
• Limited Ultrasound
- Only B-mode compression
- 5 cm inguinal ligament
- 5 cm popliteal fossa
How Good is Limited Ultrasound?
-Lensing, et.al.
How Good is Limited Ultrasound?
- Poppiti et.al.
Are DVT in calf veins ok?
• Smaller
• Propagate
• Treatment?
Do You Study the Asymptomatic Leg?
• Unilateral symptoms
- risk in contralateral leg is <1%
• Lymph node
• Baker’s cyst
• Superficial
thrombophlebitis
• Popliteal artery
aneurysm
Lymph Node
LN
A
Baker Cyst
Popliteal Artery Aneurysm
Upper Extremity DVT
• Massive PE extremely rare
• Lower incidence
- Fewer venous valves
- Higher flow rate
- Less frequent immobility
- Decreased hydrostatic pressure
- Malignancy, catheter induced
DeLaria GA, Hunter JA. Deep venous thrombosis. Implications after open heart surgery. Chest. 1991 Feb;99(2):284-8
Management
Are there any new treatments under study
for iliofemoral DVT?
Combined mechanical and chemical
thrombolysis
Mechanical Compression
• No convincing evidence of mortality value over placebo.
Plantar vs. Calf
• DVT in 21.0% plantar vs. 6.5% calf (p = 0.009).
Knee-length vs. Thigh-length
• Equivalent effect w improved compliance in KL group.
Mechanical vs. Chemical
• OR 0.46 (CI 0.16-1.29) for all heparin vs. mechanical
Aspirin
• Not recommended for DVT prophylaxis
• Aspirin vs. LMWH
• 63% RRR among 205 ortho pts LMWH vs. ASA.
• Among hip trauma pts, 44% vs. 28% ASA vs. LMWH
UFH and LMWH
• UFH decreases incidence of DVT by 20% over placebo
• LMWH decreases incidence of DVT by 30% over UFH.
Mechanism of Heparins
Unfractionated heparin
inactivates both Factor IIa
and Xa
Fondiparinux is only a
pentasaccharide sequence
10– 0.1–
Moderate risk 20 2–4 1–2 0.4
Minor surgery in patients with risk
factors LDUH (q12h), LMWH ( 3,400 U daily), GCS, or IPC
20– 0.4–
High risk 40 4–8 2–4 1.0
Surgery in patients > 60 yr LDUH (q8h), LMWH (> 3,400 U daily), or IPC
40–
Highest risk 80 10–20 4–10 0.2–5
Surgery in patients with multiple LMWH (> 3,400 U daily), fondaparinux, oral VKAs
risk factors, Trauma, Ortho (INR, 2–3), or IPC/GCS + LDUH/LMWH