Index
It is a manifestation of venous thromboembolism (VTE).
Background: Although most cases of DVT are hidden and resolve spontaneously without complications, death due to massive pulmonary embolism associated with DVT causes up to 300,000 deaths per year in the United States.
DVT is a condition that occurs when a blood clot forms in a deep vein within a part of the body.
It mainly affects the large veins in the leg and thigh, but it can occur in other deep veins, such as the arms and pelvis.
Signs and symptoms
The symptoms of deep vein thrombosis (DVT) may include the following:
Edema.
- Leg pain – occurs in 50% of patients but is not specific.
- Tenderness – occurs in 75% of patients.
- Heat or erythema of the skin over the area of thrombosis.
The clinical symptoms of pulmonary embolism (PE) as a primary manifestation:
Up to 46% of patients with classic symptoms have negative venograms, and up to 50% of those with venous thrombosis documented by images lack specific symptoms.
No physical findings or combination of symptoms and signs are sufficiently accurate to establish the diagnosis of DVT, but the material results in DVT may include the following:
- Calf pain in the dorsiflexion of the foot.
- A palpable subcutaneous venous segment, indurated, resembling a cord.
- Uneven discoloration of the lower extremity.
- Appearance bleached from the leg by edema (relatively rare).
Possible complications of DVT include the following:
- Up to 40% of patients have silent PE when diagnosed with symptomatic DVT.
- Paradoxical embolism (rare).
- Recurrent TVP.
- The post-thrombotic syndrome.
Diagnosis
The recommendations of the American Academy of Family Physicians / American College of Physicians for the study of patients with possible DVT are the following:
Validated clinical prediction rules (e.g., Wells) should be used to estimate the pretest probability of venous thromboembolism and interpret the test results.
It is reasonable to obtain a high sensitivity D-dimer in appropriately selected patients with a low DVT or PE test probability.
Ultrasonography is recommended in patients with a probability of intermediate to high pretest of lower extremity DVT.
In patients with an intermediate or high pretest probability of PD, diagnostic imaging studies are required (e.g., ventilation-perfusion scan, multidetector helical CT, and pulmonary angiography).
The primary laboratory studies to consider are the following:
- D-dimer test.
- Coagulation studies (for example, prothrombin time and activated partial thromboplastin time) evaluate a hypercoagulable state.
Management and treatment of DVT
Treatment options for DVT include the following:
- Anticoagulation (pillar of therapy) – Heparins, warfarin, factor Xa inhibitors, and several emerging anticoagulants.
- Pharmacological thrombolysis.
- Endovascular and surgical interventions.
- Physical measurements (for example, elastic compression stockings).
- The heparin products used in the treatment of DVT include the following:
- Low molecular weight heparin (for example, enoxaparin).
- Unfractionated heparin.
The factor Xa inhibitors used in the treatment of DVT include the following:
Fondaparinux: This agent appears to be comparable to enoxaparin concerning efficacy and safety.
Rivaroxaban: This agent seems to prevent the recurrence of VTE as effectively as enoxaparin followed by a vitamin K antagonist and may be associated with minor bleeding. In addition, it appears to be usable in high-risk groups.
Endovascular therapy reduces the severity and duration of lower extremity symptoms, prevents PE, decreases the risk of recurrent VTE, and prevents PTS.
Percutaneous transcatheter treatment of DVT includes the following:
Thrombus removal with catheter-directed thrombolysis: The American College of Chest Physicians recommends thrombolytic therapy only for patients with massive iliofemoral venous thrombosis associated with limb ischemia or vascular compromise.
- Mechanical thrombectomy
- Angioplasty.
- Stenting of venous obstructions.
The American Heart Association (AHA) recommendations for lower vena cava filters include the following:
- Confirmed acute proximal DVT or acute PE in patients contraindicated for anticoagulation.
- Recurrent thromboembolism during anticoagulation.
- Active hemorrhagic complications that require termination of anticoagulation therapy.
Deep vein thrombosis (DVT) and pulmonary embolism (PE) are manifestations of a single disease entity, namely venous thromboembolism (VTE).
The earliest known reference to peripheral venous disease is found in Eber’s papyrus, which dates from 1550 BC and documents the potentially fatal bleeding resulting from surgery on varicose veins.
In 1644, Schenk first observed venous thrombosis when describing an occlusion in the inferior vena cava. In 1846, Virchow recognized the association between venous thrombosis in the legs and PE.
DVT is the presence of coagulated blood, a thrombus, in one of the deep venous ducts that return blood to the heart. The clinical puzzle is that the symptoms (pain and swelling) are often nonspecific or absent.
However, if left untreated, the thrombus may become fragmented or dislodged and migrate to obstruct the arterial supply to the lung, causing potentially fatal PE.
Forecast
Death from DVT is attributed to massive pulmonary embolism (MPE), which causes up to 300,000 deaths annually in the United States. PE is the leading cause of preventable hospital mortality.
The Longitudinal Investigation of the Etiology of Thromboembolism (LITE, for its acronym in English), which combined data from two prospective cohort studies, the risk of atherosclerosis in the communities and the cardiovascular health study determined the incidence of symptomatic DVT and pulmonary embolism in 21,680 participants aged 45 years or older who were followed for 7.6 years.
Recurrent thromboembolism appears to be a severe complication of inflammatory bowel disease.
