MANAGEMENT OF DEEP VEIN THROMBOSIS

FOCUSED ON MATISSE STUDY

What Is Deep Vein Thrombosis (DVT)?
Deep vein thrombosis (DVT) is a blood clot that forms in a vein
deep in the body.
Blood clots occur when blood thickens and clumps together.
Most deep vein blood clots occur in the lower leg or thigh.
A blood clot in a deep vein can break off and travel through
the bloodstream.
Blood clots in the thigh are more likely to break off and cause
PE than blood clots in the lower leg.
Blood clots also can form in veins closer to the skins surface.
However, these clots wont break off and cause PE.
 DVT (deep vein thrombosis) and PE (pulmonary
embolism) are collectively referred to as venous
thromboembolism (VTE)
DVT and PE are a single clinical entity
Risk of early death in DVT + PE is 18 X higher than in DVT alone
of PE cases present with sudden death
Other predictors of poor survival in DVT are :
o older age,
o male gender,
o confinement to hospital,
o CHF,
o chronic lung disease,
o neurological disease,
o active malignancy.
5. Fragmentation of the thrombus
(computer graphics superimposed on in-body
photograph)
As the size of the thrombotic mass increases, it
becomes more of a threat. Especially if the heart rate is
normalised, fragments of the thrombus may break away
to be swept into the circulation.
 Pathogenesis of DVT

Virchows triad :

Damage to the vessel wall : prevents the endothelium

from inhibiting coagulation and initiating local fibrinolysis.
venous stasis : due to immobilization or venous
obstruction inhibits the clearance and dilution of activated
coagulant factors.
hypercoagulability : congenital or acquired
thrombophilia promotes coagulation
Signs and Symptoms of a DVT
Swelling, usually in one leg (or arm)
Leg pain or tenderness often described as a cramp
Reddish or bluish skin discoloration
Leg (or arm) warm to touch

Signs and Symptoms of a PE

Sudden shortness of breath

Chest pain-sharp, stabbing; may get worse with deep breath
Rapid heart rate
Unexplained cough, sometimes with bloody mucus
 PE

Sudden shortness of breath

Chest pain that worsens when you take a deep breath or when you cough
Feeling lightheaded or dizzy, or fainting
Rapid pulse
Coughing up blood
DIAGNOSIS: The diagnosis of DVT is based on
1) Pretest probability (clinical suspicion)
The Wells Score is the most widely used.
2) Venous Compression Ultrasound (CUS)
3) D-dimer

DIAGNOSTIC STRATEGY:
TWOLEVEL WELLS SCORE FOR DVT DIAGNOSIS

CLINICAL FINDINGS POINTS

Paralysis, paresis or recent orthopedic casting of lower extremity 1
Bedridden >3 days recently or major surgery within past 12 weeks 1
Localized tenderness of the deep veins 1
Swelling of entire leg 1
Calf swelling 3 cm greater than other leg (measured 10 cm below
the tibial tuberosity) 1
Pitting edema greater in the symptomatic leg 1
Nonvaricose collateral superficial veins 1
Active cancer or cancer treated within 6 months 1
Previously documented DVT 1
Alternative diagnosis at least as likely as DVT (Baker's cyst, cellulitis,
muscle damage, superficial vein thrombosis, postthrombotic syndrome,
inguinal lymphadenopathy, extrinsic venous compression) 2

WELLS SCORE PROBABILITY OF DVT STRATA

<2 6% Unlikely
2 28% Likely
Risk factors
Inheriting a blood-clotting disorder..
Prolonged bed rest, such as during a long hospital stay, or paralysis.
Injury or surgery.
Pregnancy.
Birth control pills (oral contraceptives) or hormone replacement therapy.
Being overweight or obese.
Smoking.
Cancer.
Heart failure.
Inflammatory bowel disease.
A personal or family history of DVT or PE.
Age.
Sitting for long periods of time, such as when driving or flying.
 Complications of DVT

Risk factors for PTS

Inadequate initial anticoagulation
Recurrent DVT
Higher BMI
Distal vein thrombosis
Recently, persistently elevated D- dimers
Not impact for long term anticoagulation
Postphlebitic syndrome (PTS)
Develops in 20- 30% of DVT
A common complication that can occur after deep vein
thrombosis is known as postphlebitic syndrome, also called
postthrombotic syndrome.
Damage to your veins from the blood clot reduces blood
flow in the affected areas, which can cause:
Persistent swelling of your legs (edema)
Leg pain
Skin discoloration
Skin sores
Differential diagnosis of DVT

Hematoma
Bakers cyst
Pulled muscle or tendons
PTS
Lymphedema
Compartment syndrome
Cardial, renal , hypoproteinemic edema
Lymphangitis
Erysipelas
Superficial thrombophlebitis
Lumbar and ischiatic pain
 Treatment of DVT
Initial Anticoagulation for Patients With
Acute DVT of the Leg

In patients with acute DVT of the leg treated with VKA therapy,
we recommend :
Initial treatment with parenteral anticoagulation
(LMWH, fondaparinux, IV UFH, or SC UFH) over
no such initial treatment (Grade 1B).
Treatment of DVT .

1. Blood thinners : Anticoagulants.

Heparin is typically given intravenously
Enoxaparin (Lovenox), dalteparin (Fragmin) or fondaparinux
(Arixtra), are injected under the skin.
You might receive an injectable blood thinner for a few days,
after which pills such as warfarin (Coumadin, Jantoven) or
dabigatran (Pradaxa) are started. Once warfarin has thinned your
blood, the injectable blood thinners are stopped. If you take
warfarin, you'll need periodic blood tests to check how long it
takes your blood to clot.
Other blood thinners can be given in pill form without the need
for an injectable blood thinner. These include rivaroxaban
(Xarelto), apixaban (Eliquis) or edoxaban (Savaysa).
2. Clot busters.
If you have a more serious type of deep vein thrombosis
or pulmonary embolism, or if other medications aren't
working, your doctor might prescribe drugs that break up
clots quickly, called clot busters or thrombolytics.

3. Filters.
A vena cava filter prevents clots that break loose
from lodging in your lungs.

4. Compression stockings.
To help prevent swelling associated with
deep vein thrombosis, these are worn on your legs from
your feet to about the level of your knees.
In general :
patients should be treated with anticoagulant therapy for a
minimum of 3 months.
Patients with a reversible risk factor have a low risk of
recurrence after 3 months of anticoagulant therapy.
In contrast, patients with idiopathic or unprovoked DVT who
are treated for only 3 months have a 10% to 27% risk of
recurrence in the year after anticoagulants are discontinued.
Continuing warfarin after this period protects the patient
against future recurrence but also exposes the patient to the
risk of anticoagulant-related bleeding.
 MATISSE-DVT
Mondial Assessment of Thromboembolism
treatment Initiated by Synthetic pentasaccharide
with Symptomatic Endpoints Deep Vein Thrombosis
(2004)

Condition :
Initial treatment of symptomatic DVT

Objective :
To evaluate the efficacy and safety of fondaparinux
compared with enoxaparin in the initial treatment of
symptomatic DVT
Trial design :
Randomized, double-blind placebo-controlled study

Active treatment:
Fondaparinux 7.5 mg (5.0 mg in patients weighing <50 kg and
10.0 mg in patients weighing >100 kg) s.c. once daily for at least
5 days and until the use of vitamin K antagonists resulted in an
INR >2.0; enoxaparin placebo (n=1098)

Control treatment:
Enoxaparin 1 mg/kg s.c. twice daily for at least 5 days and until
vitamin K antagonists induced an INR >2.0; fondaparinux
placebo (n=1107)
Endpoints
Primary efficacy endpoint:
3-month incidence of symptomatic recurrent VTE
complications (DVT and PE)

Primary safety endpoints:

Major bleeding during the initial treatment period and 3-
months mortality

Trial participants :
2205 patients (mean age 61 years) with acute symptomatic
DVT and who required antithrombotic therapy
Results :
Efficacy outcome:
The composite primary endpoint of recurrent
thromboembolic events at 3 months occurred in 43 of the
1098 patients receiving fondaparinux (3.9%) and in 45 of the
1107 patients assigned to enoxaparin (4.1%)

Safety outcome:
The incidence of major bleeding during initial treatment was
1.1% in the fondaparinux group and in 1.2% in the
enoxaparin group. At 3 months, 3.8% of the patients given
fondaparinux and 3.0% of the patients given enoxaparin had
died
Summary

Efficacy:

Once-daily administration of fondaparinux was not

inferior to twice daily administration of enoxaparin for
initially treating symptomatic DVT

Safety:

The incidence of major bleeding was similar with

fondaparinux and enoxaparin
Benefit of Arixtra

Always dosed once-daily

Synthetic, nonheparin compound
Specific Factor Xa inhibition
Rapid onset of action
Does not inactivate thrombin
1st FDA-approved in unique class
Contra indication of Fondaparinux

Severe renal impairment (creatinine clearance <30

mL/min) in prophylaxis or treatment of venous
thromboembolism.
Body weight <50 kg (venous thromboembolism
prophylaxis only).
Bleeding risk is increased in renal impairment and in
patients with low body weight.
Tara Lipinski has spent almost every day of
her life ice-skating. At the age of 15, she
became the youngest person ever to win a
Gold Medal during a Winter Olympics. This
was due, in part, to her signature movea
stunning but physically demanding triple
loop/jump combination. However, by age 18,
Lipinski was facing hip surgery, an event that
would lead her to an awareness of deep vein
thrombosis (DVT), a dangerous potential side
effect of surgery. Ten years later, she is still on
a mission to educate people about the
realities of this conditionespecially young
people.
Deep vein thrombosis (DVT) can be a killer.
Thats why you have to understand and
prevent DVTat any age.
THANK YOU