DEEP VEIN THROMBOSIS

(DVT)
Instrumental Diagnosis Epidemiology Symptoms & Signs Diagnosis & Therapy Laborat
ory Prophylaxis
Dr. Roberto Nobile
Specialist in General Surgery
DEEP VEIN THROMBOSIS
What is DVT?
DEEP VEIN THROMBOSIS
Vein thrombosis identifies the occlusion of a venous vessel into any district of
the body. Deep vein thrombosis is the occlusion of a venous vessel of the deep
circulation and can affect any district. Venous thromboembolism is the third mos
t common cardiovascular disease after myocardial ischemia and stroke brain. The
sites most frequently involved are the veins of the legs.
DEEP VEIN THROMBOSIS
The venous system of lower limbs is composed of a superficial and deep system.
DEEP VEIN THROMBOSIS
Deep vein thrombosis with thrombo-embolic complications that may arise (eg pulmo
nary embolism), constitutes a serious and potentially fatal disease that often c
omplicates the clinical course of patients with other diseases, but also affects
individuals in terms of apparent good health.
DEEP VEIN THROMBOSIS
'S pulmonary embolus is a blood clot that over 95% of cases a blood clot detache
s from red smooth surface of a deep vein thrombosis (DVT) of the veins above the
knee (popliteal, femoral, iliac) or by a thrombus more distal untreated extende
d proximally.
DEEP VEIN THROMBOSIS
EPIDEMIOLOGY

The exact incidence of deep vein thrombosis is not known because of the difficul
t diagnosis, the relative unreliability and its lack of specificity. Pulmonary e
mbolism, usually secondary to DVT, is certainly one of the most common causes of
hospital death. The post-thrombotic Syndrome is a chronic complication of DVT,
the estimated 1 - 1.5% of the population with a high number of ulcers phlebostat
ic.
DEEP VEIN THROMBOSIS
EPIDEMIOLOGY
There are an estimated 100,000 to 160,000 cases per year in the general populati
on west. In Italy in particular are seen about 50,000 cases a year.
DEEP VEIN THROMBOSIS
EPIDEMIOLOGY
FREQUENCY (%) of DVT (Medicine)
Stroke, stroke paretic limb, not paretic limb Preoperative Radiotherapy Myocardi
al Infarction Hospitalization Internal Medicine Infectious Diseases Chronic
60 to 70% 10% 40% 50-20% 50-20% 10-15% 5%
Studies based on tests or fibrinogen phlebography
Deep vein thrombosis

FREQUENCY (%) of DVT (Surgery) Trauma Spinal 75-80% limb amputation from 60 to 7
0% Surgery 60% hip fractures of the lower 40 to 50% more knee surgery open prost
atectomy 40% 40% General Surgery abdominal 30% renal transplantation 20 to 30% T
horacic Surgery (noncardiac) 30% 25% meniscectomy Neurosurgery open 20 to 25%
DEEP VEIN THROMBOSIS
EPIDEMIOLOGY
And 'considered a true "social evil" for the high work disability and social cos
t, is characterized by pain until true venous claudication, edema, trophic skin
disorders by up to liposclerosi and ulceration. The 25 to 40% of ulcers phlebost
atic is of post-thrombotic.
DEEP VEIN THROMBOSIS
EPIDEMIOLOGY
Many people in hospital are at risk. Not all hospitalized patients are at risk.
DEEP VEIN THROMBOSIS
EPIDEMIOLOGY people are at risk when it is determined the process characterized
by the triad of Virchow:

Activation of blood clotting with thrombin production. Alteration of the fibrino

lytic system. Alteration of the vein wall (endothelium) venous stasis associ
ated with:
DEEP VEIN THROMBOSIS
EPIDEMIOLOGY GENERAL RISKS
SPECIAL RISKS

SPECIFIC RISKS
DEEP VEIN THROMBOSIS
GENERAL RISKS
AGE 'OVER 40 YEARS past Venous Thromboembolism chronic venous insufficienc
y PRESENCE OF OBESITY' EXTENDED PROPERTIES 'SEPS hormone replacement thera
py (menopause) Hormone therapy (contraceptives) TRAVEL

DEEP VEIN THROMBOSIS

GENERAL RISKS past Venous Thromboembolism
An episode of lower limb DVT is the most important risk factor for a subsequent
episode of DVT. To establish with certainty a previous episode of DVT is necessa
ry that the symptoms and signs have been associated with at least a screening ob
jective: phlebography, Echocolordoppler, plethysmography.
DEEP VEIN THROMBOSIS
GENERAL RISKS chronic venous insufficiency
Chronic venous insufficiency (CVI) is the result of a failure of the operation o
f peripheral veins. One can distinguish between a failure of the superficial ven
ous system, the deep venous system, or both;€such situations lead to venous hype
rtension in the legs and venous stasis localized or widespread, affecting trophi
c structures perivenous and especially on the microcirculation, edema is its cha
racteristic manifestation.
DEEP VEIN THROMBOSIS
From the general risks of DVT AA.II. May lead to either IVC
IVC may result from a DVT
DEEP VEIN THROMBOSIS
GENERAL RISK OBESITY '
Obesity can be a significant independent risk factor in DVT. This must be evalua
ted on body mass index calculated as: weight in kg: the square of height in mete
rs. The risk rises when BMI (Body Mass Index) is> 27.
DEEP VEIN THROMBOSIS
GENERAL RISKS Hormone Replacement Therapy Hormone therapy CONTRACEPTIVES
There are currently no known increased incidence of DVT in these groups of women
.
DEEP VEIN THROMBOSIS
GENERAL TRAVEL RISKS
And 'demonstrated that long journeys, which entail the sitting for long periods,
may predispose to venous thromboembolism, there is often no symptoms until seve
ral hours after the end of them.
DEEP VEIN THROMBOSIS
SPECIAL RISKS

TOPOGRAPHY

Chronobiology

Thrombophilia
DEEP VEIN THROMBOSIS
SPECIAL RISKS TOPOGRAPHY

Calf vein CAVA ILIAC VEINS PROXIMAL Femoral popliteal Crosses SAPHENOUS axillary
vein - subclavian
Maximum Risk!

DEEP VEIN THROMBOSIS

SPECIAL RISKS Chronobiology
And 'now sufficient evidence of the circadian rhythm pattern for different event
s with acute thrombosis of the cardiovascular load that are determined early in
the morning, in relation to the possible imbalance that occurs in that period be
tween the factors of coagulation and fibrinolysis . This consideration raises a
useful chronological indication on heparin prophylaxis (Cronoprotezione).
DEEP VEIN THROMBOSIS
SPECIAL RISKS Thrombophilia HEREDITARY are characterized by the onset of thrombo
tic episodes largely (but not exclusively) veins, the more 'common in young age
(under 40-45 years) often recurrent and associated with the presence of a family
history of thrombosis.
DEEP VEIN THROMBOSIS
SPECIAL RISKS Thrombophilia deficiency Antithrombin III deficiency Protein C d
eficiency Protein S Resistance to Activated Protein C (APC-R) dysfibrinogenemi
a Disorders Plasminogen hyperhomocysteinemia

DEEP VEIN THROMBOSIS

The heritable thrombophilia can be grouped:

Deficiency of coagulation inhibitors - are represented by protein deficiency or

impairment of Antithrombin III, Protein C, Protein S Mutation of factor V Leiden
(resistance to activated protein C). Prothrombin gene mutation G20210A. The pre
valence of these thrombophilic conditions, low in the general population, increa
ses when we consider those with previous thromboembolic selected, for example th
e appearance of the first event under the age of 45 aa., Or recurring events, or
family history of thrombosis.
DEEP VEIN THROMBOSIS

Acquired thrombophilia: anti-phospholipid antibody syndrome (APA) / LAC lupus an

ticoagulant type):
The APA are ab of IgG and IgM directed against phospholipid protein complexes, s
ome may act in vitro as anticoagulants (lupus type - old definition of lupus ant
icoagulant) stretching phospholipid dependent coagulation tests (aPTT and to a l
esser extent, PT) in vivo act as thrombogenic factors in association with clinic
al manifestations of arterial thrombosis and / or venous. They appear in the cou
rse of autoimmune disease, myelo / lymphoproliferative disorders, cancer, viral
infections, in chronic active, with certain drugs or in isolation, without any o
ther morbid condition.
DEEP VEIN THROMBOSIS
SPECIAL RISKS Thrombophilia
Situations where it is shown to perform screening for thrombophilia: Age Youth (
<45 aa). Idiopathic VTE or after minor stimuli. VTE applicant. family histor
y of VTE.
DEEP VEIN THROMBOSIS
SPECIAL RISKS Thrombophilia
Recommended tests for thrombophilia screening aPTT PT-Fibrinogen ATIII pro
tein C and S Factor V Leiden Mutation Research Prothrombin Gene Mutation L
AC anticardiolipin ab.

DEEP VEIN THROMBOSIS

SPECIFIC RISKS

MEDICAL PATIENTS

ORTHOPAEDIC SURGICAL PATIENTS PATIENTS

PATIENTS Gynaecology and Obstetrics

GERIATRIC
DEEP VEIN THROMBOSIS
SPECIFIC HEALTH RISK PATIENTS
Less known and less studied in the surgical population, the group of medical con
ditions in which evidence of a DVT, usually discovered at a distance from the ev
ent, but high growth.
DEEP VEIN THROMBOSIS
SPECIFIC HEALTH RISK PATIENTS
DVT risk medical conditions:
Lures exceeding 3 days. Recent Myocardial Infarction Recent Stroke Cancer
Heart Failure IVC nephrotic syndrome Venous Catheters stay in inflammato
ry bowel disease Pneumonia

DEEP VEIN THROMBOSIS

SPECIFIC HEALTH RISK PATIENTS
NEOPLASMS & VENOUS THROMBOSIS The coagulation disorders in the course of cancer
can cause DVT in patients with metastatic spread or terminal and anticancer ther
apies can be an aggravating factor in the paraneoplastic thrombophilia. The corr
elation, however, has represented by DVT "Idiopathic" or EP seemingly primitive
sign of onset of cancer.
DEEP VEIN THROMBOSIS
SPECIFIC SURGICAL RISK PATIENTS
Patients undergoing surgery are known to be at risk of venous thromboembolism, p
articularly the abdominal and pelvic surgery and interventions lasting> 1 hour.
DEEP VEIN THROMBOSIS
RISKS SPECIFIC GENERAL SURGERY
The degree of risk is increased by various surgical situations:
Intervention (election / urgency - laparotomy / laparochirurgia Anesthesia (ep
idural / general) mobilization (pre and post-operative) Hydration transf
usions Sepsis
Risk can 'CONTINUE after discharge
DEEP VEIN THROMBOSIS
SPECIFIC RISKS & laparoscopic surgery DVT
You can create dangerous situations when:

Minimally invasive intervention, but prolonged abdominal gas insufflation and

the Trendelenburg position reversed Rapid discharge and poor monitoring of the p
atient in this respect
DEEP VEIN THROMBOSIS
SPECIFIC RISKS orthopedic patients
Patients undergoing elective major orthopedic surgery and Traumatized are at hig
h risk of VTE, when he neglects prevention. Pulmonary embolism is the real facto
r of severity of the hip, because without prophylaxis, the 2 / 3 postoperative d
eaths are a result. Major surgery is the equally thrombogenic of the knee, altho
ugh unilateral and pulmonary embolism occurs late in the 4th week post-operative
ly. It thus emphasizes the importance of extended prophylaxis after discharge.
DEEP VEIN THROMBOSIS
SPECIFIC RISKS orthopedic patients
In traumatology percentages of frequency of DVT are such as to justify the wides
pread use of venography and of 'Echocolordoppler pre-operatively. And 'demonstra
ted that 50% of DVT occur within the 5th day after trauma and increased risk of
PE occurs between the 5th and the 14th postoperative day, and persists up to 3 m
onths.
DEEP VEIN THROMBOSIS
SPECIFIC RISK PATIENTS Gynaecological and obstetrical
40% of deaths after gynecologic surgery is caused by PE and high-risk patients w
ith Ca or Uterine Cervical the EP is the 1st cause of death. The EP is also one
of the most common causes of death in pregnancy and in cases of legal abortion i
s the 2nd cause of death. Other variables that influence the thromboembolic risk
are:
Previous DVT or PE Cancer Radiation Obesity varices (IVC) Prolonged be
d rest antithrombin III deficiency, protein C or S

DEEP VEIN THROMBOSIS

SPECIFIC RISKS gynecological surgery
The DVT is less common after surgery compared to Gynaecological Surgery, even fo
r the minority of patients, but data are relevant (14 - 29%) and acute in patien
ts operated for carcinoma (35%). Moreover, peculiar complication of gynecology,
the DVT as well as rise and extend proximally to the calf, may be PELVIC or ovar
ian cancer.
DEEP VEIN THROMBOSIS
SPECIFIC RISKS IN PREGNANCY
Pregnancy has a substantial effect on the triad of VIRCOW (hypercoagulability, v
enous stasis, abnormal venous wall), so the pregnant woman has a five times high
er risk of DVT compared with a control group of same age. The identification of
clinical DVT is difficult and the most appropriate diagnostic test and ultrasoun
d B-mode COMPRESSED being discouraged phlebography. The thrombotic risk remains
in the puerperium.
DEEP VEIN THROMBOSIS
SPECIFIC RISKS IN GERIATRIC
The risk factor ETA '(> 60 years) is in itself a cause of DVT with an incidence
estimated at 9%.
DEEP VEIN THROMBOSIS
METHODS OF INVESTIGATION The diagnosis of DVT and PE is not easy!
Should be related:

Clinical symptoms and signs

INSTRUMENTAL DIAGNOSTIC TESTS

TESTS ESTABLISHMENTS
DEEP VEIN THROMBOSIS
Clinical symptoms and signs of DVT
Given that the clinical diagnosis is unreliable because 50% of patients had sign
ificant symptoms and signs in the affected.
Heat pain Edema Abnormal skin color subcutaneous venous distension (veins
sentinels Pratt) Sore caused the calf (sign Bauer) painful dorsiflexion of t
he foot (Homans sign) fever

DEEP VEIN THROMBOSIS

DIFFERENTIAL DIAGNOSIS
Superficial thrombosis (thrombophlebitis) Inflammation of the subcutaneous tis
sue or muscle tendon rupture muscle tear injury of the knee intra-articula
r synovial cyst (Baker) cutaneous vasculitis Lymphedema extrinsic compress
ion (cysts or tumors)

DIAGNOSIS, SYMPTOMS AND SIGNS OF EP

Diagnosis can be made only by angiography
(CT, spiral CT, can be very useful AngioRNM) Dyspnoea> 90% Tachypnea> 90% pleu
ritic chest pain> 70% 60% Anxiety Cough> 50% fever> 40% 30% Hemoptysis
sweating> 25 % edema AA.II. > 20% Syncope> 10%

DEEP VEIN THROMBOSIS

DIAGNOSTIC TESTS instrumental clinical point of view it is important to define a
n individual patient's risk profile before the instrumental tests. There is a sc
oring system that identifies the risk categories of clinical probability by comb
ining data obtained from patient medical history.
DEEP VEIN THROMBOSIS
GENERAL FACTORS 1
<40 Years 40-60 Years> 60 Years Absence of immobility from 1 to 3 days. > 3 days
. Travel <5 hours Travel> 5 hours Obesity (BMI) Absence <20 Overweight 21 to 27
Obesity> 27 0 1 2 0 1 2 0 1 0 1 2
DEEP VEIN THROMBOSIS
GENERAL FACTORS 2
Previous DVT - No - I suspect - Tested - Multiple IVC - None - Varices / edema p
hlebostatic Thrombophilia - No suspect - I suspect - Tried and treated - Tried a
nd untreated 0 1 2 3 0 1 0 1 2 3
DEEP VEIN THROMBOSIS
GENERAL FACTORS 3
Contraceptive pill - <0.05 mg. ethinyl estradiol -> 0.05 mg. We recommend the su
spension of ethinyl estradiol contraceptive 4 weeks before surgery at risk Sepsi
s - None - Presence of hormone replacement therapy in menopause - None - Presenc
e
0 1
0 1 0 1
DEEP VEIN THROMBOSIS
SURGERY
Type and duration of surgical anesthesia Local Minor surgery - time <45 minutes
Minor surgery - duration> 45 minutes Major surgery (> 3 hours) or pelvic operati
ons 0 2 4 6
Additional factors to consider are: The type of anesthesia, hydration, blood tra
nsfusions, sepsis.
DEEP VEIN THROMBOSIS
OBSTETRICS & GYNECOLOGY
- None - Pregnancy - Minor Surgery Gynecology 0 2 2
- Cesareo uncomplicated - Cancer
4 6
DEEP VEIN THROMBOSIS
ORTHOPAEDICS & TRAUMATOLOGY
- None - Reduced tissue damage (bruises, contusions, sprains) - Fracture of Tibi
a and / or fibula - hip fracture - hip fracture or pelvis - Orthopaedic Surgery
(hip, knee prosthesis) 0 2 4 6 8 8
DEEP VEIN THROMBOSIS
MEDICINE
Myocardial infarction - no heart failure - no stroke - no pneumonia - no nephrot
ic syndrome - absence or amputation of leg paresis inflammatory bowel disease la
ck Venous Catheters indwelling transvenous pacemaker system - no tumors - no 0 0
0 0 0 0 0 0 Presence Presence Presence 0 0 Presence Presence Presence Presence
Presence Presence Located Dissemination local or metastatic adenocarcinoma 2 2 2
2 2 6 2 2 2 2 4 6
DEEP VEIN THROMBOSIS
DIAGNOSTIC LABORATORY TESTS
The routine blood tests are usually normal in the course of DVT although always
check Platelets, fibrinogen and other coagulation factors. The fibrinopeptide A
CIRCULATING fibrin and products of fibrin degradation can provide guidance but a
re not diagnostic. The values of antithrombin III, protein C and clotting time a
re important for therapy, but not diagnostic of DVT.
DEEP VEIN THROMBOSIS

DIAGNOSTIC LABORATORY TESTS Determination of D-dimers - (degradation products

fibrin. D-dimer levels measured in the circulation are the result of balance bet
ween their training and their clearance, in normal subjects their half-lives of
about 48 h. Elevated plasma levels of d-dimers, as well as the presence of venou
s thrombi and arterial can frequently be caused by many other conditions where t
here is fibrin formation in the vascular spaces or resorption of degradation pro
ducts from extravascular spaces - subcutaneous hematoma , surgical wounds, etc..
- Determination of d-dimer has proven highly sensitive but poorly specific for
the presence of thrombi.€In conclusion, the high NPV of testing means that it is
useful to exclude DVT in case of normality, rather than confirm if found to be
faulty.
DEEP VEIN THROMBOSIS
THERAPY
The goals of treatment of DVT, both proximal and distal, are to prevent local ex
tension of thrombi and emboli, and then the departure of the real risk of EP, to
promote or accelerate the fibrinolysis, and finally in preventing long-term com
plications post-thrombotic syndrome. The anticoagulant drugs (heparin and oral a
nticoagulants), the fibrinolytic, are currently used therapeutic repertoire.
DEEP VEIN THROMBOSIS
THERAPY PREVENTION OF DVT
General Surgery Fraxiparina 2850 IU daily sc x 7 days. Enoxaparin 40mg daily sc
Dalteparin 2500-5000U daily sc Enoxaparin 30mg twice daily sc Enoxaparin 30mg tw
ice daily sc UFH 5000 IU twice daily enoxaparin 30 mg twice daily sc UFH 5000 IU
three times a day 2-3 times a UHF 5000 IU dalteparin 5000 IU / day 2-3 times a
UHF 5000 IU dalteparin 5000 IU daily sc Enoxaparin 40 mg sc daily
Knee arthroplasty prostheses Neurosurgery Thoracic Surgery Trauma Medical Condit
ions with hospital ICU admission Pregnancy (history of DVT or PE)
DEEP VEIN THROMBOSIS
CONTRAINDICATIONS / PRECAUTIONS for heparin therapy
Hypersensitivity heparin Severe thrombocytopenia bleeding dissecting aneur
ysms Hemophilia Presence of epidural catheter bacterial endocarditis u
ncontrolled hypertension
DEEP VEIN THROMBOSIS
STEP to oral anticoagulants
Heparin therapy
suspension after 24 h 4-5 days
Warfarin INR 2.0 50 to 10 mg.
Haemostasis 1998
DEEP VEIN THROMBOSIS
At the start of oral anticoagulant therapy are not recommended high doses cargo
(20-40 mg of warfarin) may cause skin necrosis, particularly in patients with de
ficiency of protein C and S It usually starts with 5 mg. (Better) or 10 mg in 2
doses of warfarin 4 mg. of acenocoumarol
DEEP VEIN THROMBOSIS
Indications of thrombolysis (embolectomy medical) diagnosis Patients with ma
ssive PE and hemodynamic impairment (persistent systemic arterial hypotension, c
irculatory shock) Patients with extensive DVT of 'iliac-femoral venous axis.
DEEP VEIN THROMBOSIS
Contraindications to thrombolysis
ABSOLUTE
ongoing internal bleeding History of intracranial hemorrhage, brain tumor
haemorrhagic diathesis
CONCERNING
surgery <10 days major trauma <15 days Severe uncontrolled hypertension (>
180/110) Platelets <100,000 diabetic retinopathy Pregnancy Bacterial en
docarditis
DEEP VEIN THROMBOSIS
In case of absolute contraindications to thrombolysis surgical embolectomy m
echanical embolectomy
DEEP VEIN THROMBOSIS
In case of risk of pulmonary embolism Interruption of the inferior vena cava By
this we mean those instrumental procedures that allow the placement of vena cava
filters percutaneously whether permanent or temporary.
DEEP VEIN THROMBOSIS
INDICATIONS contraindications to the use of anticoagulants failure of anticoagul
ation prophylaxis in patients at high risk of DVT with clinical documentation in
place floating thrombus in patients undergoing surgery not be postponed CONTRAI
NDICATIONS severe coagulopathy with bleeding predisposition thrombus obstructing
the path of integration available refusal by the patient
DEEP VEIN THROMBOSIS
CONCLUSIONS
The objectives of clinical piu'importanti a timely and correct diagnosis and tre
atment are to:

Reduce morbidity and mortality associated with acute manifestations

Reduce the recurrence rate of new acute events

Combat the incidence of sequelae distance represented by the post-thrombotic syn

drome (post-phlebitis) often highly debilitating and high social costs.
Thanks