VENOUS THROMBOEMBOLISM

Objectives

Aetiological factors Risk factors Pathophysiology Clinical presentation Investigations Prophylaxis Treatment options

DEFINITION
Formation of a semi-solid coagulum within flowing blood in the venous system

DVT EPIDEMIOLOGY
Annual incidence 1/1000 Accounts for over one half of VTE Up to 80% of patients with VTE have one or more risk factors Majority of lower extremity DVT arise from calf veins but ~20% begin in proximal veins About 20% of calf-limited DVTs will propagate proximally

AETIOLOGY
Virchows triad
Endothelial damage Stasis Coagulability

RISK FACTORS
Malignancy Surgery Trauma Pregnancy

 Oral contraceptives or hormonal therapy Immobilization Inherited thrombophillia Previous DVT

CLINICAL PRESENTATION
CLASSICAL SIGNS
calf pain Tenderness Swelling redness Homans sign

 Overall sensitivity/specificity = 3-91% Unreliable for diagnostic decisions Up to 50% have none of these Wells developed and tested a clinical prediction model for DVT

CASE
37 years old moderately obese female on OCP presents to you with a two day history of painless R leg swelling. Shes been elevating her leg several days after a severe ankle sprain during playing with her daughter

 No prior medical history, recent surgery or weight loss. Exam is notable for R ankle splint and pitting edema in R calf, which is 1.5 cm larger than the L.

WHAT ARE THE RISK FACTORS IN OUR PATIENT?

DVT Case
Our patient has 2-3 risk factors
OCP, +/- immobilization and trauma

Her Wells score gives her a moderate pretest probability for DVT A d-dimer test is performed

INVESTIGATIONS

D-Dimer
Fibrin degradation product elevated in active thrombosis Negative test can help exclude VTE Less helpful in malignancy and recent surgery

D-Dimer
In 283 patients with suspected DVT, lowmoderate Wells DVT score and negative ddimer only 1 (NPV 99.6%) had DVT over next 3 months

Sensitive d-dimer testing can rule out DVT in lowmoderate risk patients

DVT Case
D-dimer performed is postitive in our patient Unfortunately a positive ddimer is not helpful diagnostically An imaging study is done

IMAGING
Compression US :
first line test, high sens/spec

Venography
gold standard

MRI
Lower quality evidence only at present

DVT Case
Compression US negative Options include:
Venography or MRI Serial compression US single US done at 5-7 days reliably excludes calf-limited DVT Follow clinically for resolution of symptoms riskier, no data supporting safety of this option

VENOGRAM SHOWING DVT

Thrombophilia screening Factor V leiden, Prot C/S deficiency, Antithrombin III deficiency
Idiopathic DVT < 50 years Family history of DVT Thrombosis in an unusual site Recurrent DVT

CASE
The patient in Case 1 elected to be followed clinically. She returned to clinic 3 days later with persistent swelling, but no new symptoms She was to return the following week, but instead you are called to the ER 10 days later after she presents with acute onset of dyspnea and pleuritic chest pain

PE Epidemiology and Etiology

100-200,000 deaths per year due to PE Most PE arise from lower extremity DVT In patients with DVT, 40-60% will have a PE on V/Q scanning

Pulmonary embolus is not a disease. It is a complication of DVT. Ken Moser MD

PE Clinical Presentation
Dyspnea, pleuritic pain and cough most common symptoms Tachypnea, rales and tachycardia most common signs ABG, EKG and CXR
May be abnormal Lack specificity to aid diagnosis

PIOPED Study. JAMA. 1990;263(20):2753-59. Stein PD, Goldhaber SZ, Henry JW. Chest 1995;107:139-43

PE Case 2
Findings in the ER
Alert white female, mildly anxious T 101, HR 105, RR 18 R LE edema and redness Lungs clear to auscultation ABG mild respiratory alkalosis; aA gradient = 17 CXR showing mild atelectasis

D-dimer positive as before, troponin normal

PE Assign Pretest Probability

Single most important step in the diagnosis of pulmonary embolism May be done based on clinical judgment or aided by a clinical scoring system Modified Wells Criteria is the most widely used and studied Reliably stratifies patients by likelihood of PE to allow selection of safe (<2% VTE risk if no anticoagulation) management strategy

PE Case 2
High risk for PE by Modified Wells Criteria (Wells score = 9) Positive D-dimer, but negative test would not have safely excluded PE Options include:
CT angiogram V/Q scan Lower extremity compression US

PE Imaging Studies
V/Q scans in diagnosing PE
Drawbacks: more difficult test and 73% patients had indeterminate scans

LE compression US
Finding of a DVT completes workup Negative study insufficient to exclude VTE

PIOPED Study. JAMA. 1990;263(20):2753-59

PE Case 2
MDCT segmental embolus Therapy
Enoxaparin 1mg/kg sq every 12 hours for 5 days Warfarin started day 1 at 5 mg a day CBC on day 3-5 and INR every day if inpatient May stop enoxaparin after 5 days if INR > 2.0 Warfarin continued to keep INR at 2.5 (2.0-3.0 range) for 3 months

MANAGEMENT

VTE Other Therapy Issues

Anticoagulation same for DVT & PE Compression stockings prevent post-phlebitic syndrome Thrombolysis in iliac vein thrombosis Venous thrombectomy Vena cava filters - limited evidence and modest benefit

 Enoxaparin 1mg/kg sc every 12 hours for 5 days Warfarin started day 1 at 5 mg a day CBC on day 3-5 and INR every day if inpatient May stop enoxaparin after 5 days if INR > 2.0 Warfarin continued to keep INR at 2.5 (2.0-3.0 range) for 3 months

VTE Prophylaxis in Medical Patients Indications

In all patients undergoing surgery in moderate and high risk groups. CHF or severe respiratory disease Bed rest with additional risk factor
Cancer Prior VTE

Most ICU patients

OPTIONS
Low dose unfractionated heparin or LMWH Sequential compression devices Graduated compression stockings

TAKE HOME POINTS

DVT and PE are the same disease Assigning pretest probability for VTE is an essential step in diagnosis A noninvasive testing strategy can result in safe management for most patients suspected of having VTE VTE can be safely treated with LMWH for at least 5 days and simultaneous warfarin initiation without a loading dose Always consider VTE prophylaxis in inpatients