Deep Vein Thrombosis:

the danger and how to prevent

 What Is Deep Vein Thrombosis (DVT)?

• DVT is a blood clot that forms

in a vein deep in the body
• Most often occurs in the deep
veins of the legs, either
above the knee or below it
• The blood clot or part of it can
break free (called embolism)
and become lodged in the blood
vessels of the lung, causing
pulmonary embolism (PE)
Deep veins of the legs.
Incidence

• 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

Some Causes of Death in the US Annual No. of Deaths

PE Up to 200,000
AIDS 16,371
Breast cancer 40,580

1. American Public Health Association. Available at: http://www.apha.org/news/press/2003/DVT_whitepaper.pdf.

2. Gerotziafas GT. Curr Opin Pulm Med. 2004;10:356-365. 3. Anderson FA Jr. Arch Intern Med. 1991;151:933-938.
4. Centers for Disease Control. Available at: http://www.cdc.gov. 5. American Cancer Society. Available at:
http://www.cancer.org. 6. Bick RL. Clin Appl Thromb Hemost. 1999;5:2-9.
Risk Factors
• Trauma
• General - CNS / spinal cord injury
- Age - Burns
- Immobilization > 3d - Lower extremity fractures
- Pregnancy / post-
partum • Hematologic
- Major surgery < 4 - Thrombocytosis
weeks - Anti-thrombin III
- Trip (>4h) in past 4 deficiency
weeks - Protein C deficiency
• Medical - Protein S deficiency
- Factor V Leiden
- Cancer
- Previous DVT • Drugs
- CHF - OCP
- Sepsis - Estrogens
- Nephrotic syndrome
Ref: BMJ 2011;343:d5916 doi: 10.1136/bmj.d5916
Wells Clinical Score for DVT
Clinical Parameter Score
Active cancer +1
Paralysis or recent immobilization of extremities +1
Recently bedridden for > 3 days or major surgery <4 weeks +1
Tenderness along distribution of deep venous system +1
Entire leg swollen +1
Calf swelling > 3cm circumference difference from unaffected leg +1
Pitting edema +1
Previous DVT +1
Collateral superficial veins +1
Alternative diagnosis as likely or more likely than DVT -2

High Probability ≥3
Moderate Probability 1 or 2
Low Probabillity 0
Who Should We Study?

Ref: Annals of Internal Medicine 2 September 2008

The Life of a Clot…

• Valve cusps of deep calf veins

- Dissolve
- Adherence and Organization
- 5-10 days
- Propagate
- Embolize
- Chronic Venous Insufficiency
History and Physical

• Edema
• Leg pain
• Tenderness
• Superficial thrombophlebitis
- Increased risk of DVT
• Fever
 Alternate Diagnosis

• Achilles tendinitis • Lymphedema

• Arterial insufficiency • Muscle / soft tissue
• Arthritis injury
• Cellulitis / lymphangitis • Neurogenic pain
• Extrinsic vein • Postphlebitic syndrome
compression • Ruptured Baker cyst
• Hematoma • Fracture / bony lesions
• Superficial
thrombophlebitis
 Phlegmasia cerulea dolens: the entire left leg is swollen and
inflamed, with a blue-red aspect. The leg is very painful. It occurs
when the whole venous return of the leg is blocked by a deep vein
thrombosis. It can ultimately lead to gangrene of the leg
Magnetic resonance venogram

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

CT - Can do PE study at same time

- Good for calf, iliac veins
Duplex Ultrasonography - No radiation, bedside, cost
- Non-occlusive thrombi
- Cannot distinguish acute from chronic
- Poor visualization of calf, iliac veins
Lower Extremity Venous Anatomy

• 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?

B-mode Imaging + Doppler Ultrasound

Doppler Ultrasound: Color
Doppler Ultrasound: Spectral
Ultrasound for DVT

• Major criterion - Failure to compress vascular lumen

- Not visualization of lumen
- Acute thrombus can be anechoic
- Slow flowing blood can have internal echoes

• Minor criterion - Absence of normal doppler signals

- Absence of flow
- Absence of respiratory variation in flow
- Decreased augmentation with distal compression
- Distension of vessel
Major Criteria: Compressibility

• Collapse of lumen of vein

- Complete apposition of anterior and posterior wall

• Compress with transducer in transverse

- Longitudinal compression slides off vessel wall
leading to false negative
- Use to follow course of vein

• May visualize thrombus; not necessary for diagnosis

Compressibility: Normal Findings

A
A
V
Compressibility: DVT

A A
V
V
Compressibility
Ultrasound for DVT

• Major criterion - Failure to compress vascular lumen

- Not visualization of lumen
- Acute thrombus can be anechoic
- Slow flowing blood can have internal echoes

• Minor criterion - Absence of normal doppler signals

- Absence of flow
- Absence of respiratory variation in flow
- Decreased augmentation with distal compression
- Distension of vessel
Minor Criteria: Flow
Minor Criteria: Respiratory Variation
Minor Criteria: Respiratory Variation
Minor Criteria: Augmentation
Femoral Vein

• Begin at inguinal ligament

• Distally bifurcates into superficial and deep

femoral veins

• Compression in Hunter’s
canal difficult because
of depth
Femoral Vein
Popliteal
• Positioning
• Vein superficial to artery
• Scan to trifurcation point
Popliteal
 Diagnostic Difficulties

• False negatives • False positives

- Adductor canal - Chronic vs. acute
- Complete occlusion - Proximal obstruction
- Ilio-femoral DVT limits compressibility
- Duplicated vessels - Superficial vein filled with
- Technical difficulties thrombus
- obese patients
- significant lower • Operator Dependence
extremity edema
How Good is it?

• Noninvasive Diagnosis of Deep Venous Thrombosis

- Large review of US for DVT

- Proximal DVT: sensitivity 95%, specificity 96%
- Calf vein DVT: great variation
- Overall: sensitivity 89%, specificity 94%

-Kearon C, et al.
Limited Ultrasound

• Image entire venous system

- Technically difficult
- Time

• Limited Ultrasound
- Only B-mode compression
- 5 cm inguinal ligament
- 5 cm popliteal fossa
How Good is Limited Ultrasound?

• Detection of Deep Vein Thrombosis by B-mode

Ultrasonography

- Sole criterion was compressibility of common

femoral
or popliteal vein
- 100% sensitive for proximal DVT
- 91% sensitive overall

-Lensing, et.al.
How Good is Limited Ultrasound?

• Limited B-mode venous Imaging Versus

Complete Color-flow Duplex Venous
Scanning for Detection of Proximal Deep
Venous Thrombosis

- time reduction 37 minutes vs. 5.5

minutes

- 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%

• Assist in difficult anatomic interpretations

• Does it matter if anti-coagulating anyway?

Other Ultrasound Diagnosis

• 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

• Clavicle prohibits adequate compression

- Evaluate using color or spectral Doppler
What Happens to the Clot?

• Clot retracts and becomes echogenic

• Vein wall becomes thickened, echogenic and

resistant to compression

• In 12-24 months, 50% have complete resolution of

thrombus and normal compressibility

• Difficult to evaluate acute vs. chronic

- Post-treatment baseline study for comparison
High Incidence of Venous
Thrombosis following Cardiac
Surgery

Girish R. Mood, MD, Heather L. Gornik, MD, MHS, Vidyasagar

Kalahasti, MD, Donald Hammer, MD, W. H. Wilson Tang, MD, FAHA.
 Background:
Absolute risk of DVT in hospitalized patients

General Surgery 15-40%

Major gynecologic surgery 15-40%
Major urologic surgery 15-40%
Neurosurgery 15-40%
Hip or Knee surgery 40-60%
Spinal cord surgery 60-80%
Critical care patients 10-80%
Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: the
Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S
Deep venous thrombosis after open heart surgery:
10,638 patients
(1975-1988)

7,979 (75%) had CABG

2,659 had valve ± CABG

Patients with LE edema,

pain, ↑ temp underwent
Imaging studies

77 (0.7%) had DVT

36 patients had DVT

41 patients had PE
without PE

16 patients had DVT being

25 patients without DVT
treated with heparin

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

(A and B) The EKOS Endowave Peripheral

Lysis System consists of a multi-lumen
infusion catheter with removable, coaxial
ultrasound core and a control unit that
simultaneously delivers high frequency
(2.2 MHz), low energy (0.45 W)
ultrasound energy and thrombolytic drug
into the thrombus.

(C) The Trellis-8 catheter directed

thrombolysis device combines balloon
containment of a thrombus with chemical
and mechanical thrombolysis. The
thrombus is isolated after placing the
catheter by inflating the proximal and
distal balloons.

(D) The Angiojet Power Pulse system uses

a complex mixture of rapid fluid streaming
and hydrodynamic forces to fracture the
thrombus, allowing extraction at the
catheter tip as a result of negative
pressure.
Mechanical Prophylaxis
 Overview

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

Gregory et al. J Trauma 1999; 47:1

 Compression

Roderick et al. HTA, 2005; 9

 Compression

Roderick et al. HTA, 2005; 9

Chemical Prophylaxis
 Overview

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

LMWH has increased affinity

for Factor Xa

Fondiparinux is only a
pentasaccharide sequence

Weitz. NEJM, 1997; 337:688

 Pharmokinetics

Tran and Lee. Ann Pharm 2003; 37: 1632.

 DVT Recommendations
DVT, % PE, %

Level of Risk Successful Prevention Strategies

Calf Proximal Clinical Fatal

Low risk 2 0.4 0.2 <0.01

Minor surgery in patients < 40 yr No specific prophylaxis; early and "aggressive"
with no additional risk factors mobilization

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

Geerts et al. Chest, 2004; 126:338S

 DVT prophylaxis

• Bariatric surgery: recommend higher dosages of

lmwh or lduh than for non- obese patients (2c)

• Extended prophylaxis for major abdominal/pelvic

cancer surgery for up to 4 weeks.

• Hip/knee 10-35 days

• Stroke, SCI & major trauma prefer lmwh & consider

continuing during rehab

• Renal Failure and UFH vs LMWH

Thank You