View source for Deep venous thrombosis

==Background==
{{Venous thromboembolism types}}

===Anatomy===
{{Venous system anatomy leg}}

==Clinical Features==
===Physical Exam===
*Leg swelling with circumference >3cm more than unaffected side
*Tenderness over calf muscle
*Homan's sign - pain during dorsiflexion of foot (SN 60-96% and SP 20-72%)<ref>Anand SS, et al. Does this patient have deep vein thrombosis? JAMA. 1998; 279(14):1094-9.</ref>

==Differential Diagnosis==
*Arterial thrombosis
*[[Cellulitis]]
*[[Septic Joint]]
*[[Osteomyelitis]]
*[[Compartment Syndrome]]
*[[Nec fasc]]
*[[Gout]]
*Neuropathy
*Nerve entrapment
*Sciatica
*[[Fracture]]
*Reflex Sympathetic Dystrophy
*Lymphangitis
*Buerger's disease
*Arthritis
*Tendonitis
*Myositis
*Arteritis
*[[Paget-Schroetter Syndrome]]

{{Calf pain DDX}}

==Diagnosis==
===Modified Wells Score===
*Active cancer (<6 mo) - 1pt
*Paralysis, paresis, or immob of extremity - 1pt
*Bedridden >3 d b/c of symptoms (w/in 4 wk) - 1pt
*TTP along deep venous system - 1pt
*Entire leg swollen - 1pt
*Unilateral calf swelling >3cm below tibial tuberosity - 1pt
*Unilateral pitting edema - 1pt
*Collateral superficial veins (not varicose) - 1pt
*Previously documented DVT - 1pt
*Alternative dx as likely or more likely than DVT - (-)2pts

[[File:Deep vein thrombosis of the right leg.jpg|thumbnail|DVT of right leg]]
[[File:DVT.jpeg|thumbnail|Large DVT of left leg]]

====Probability====
*0-1 = Low probability
*≥2 = High probability

=====Low Probability=====
*Send d-dimer
**If positive, obtain [[Ultrasound: DVT|ultrasound]]

=====High Probability=====
*Send d-dimer AND obtain [[Ultrasound: DVT|ultrasound]]
**If both negative = no DVT
**If [[Ultrasound: DVT|ultrasound]] positive = DVT
**If positive d-dimer, but neg [[Ultrasound: DVT|ultrasound]]:
***Repeat [[Ultrasound: DVT|ultrasound]] in 1 week

====ACEP Clinical Algorithm<ref>Del Rios M et al. Focus on: Emergency Ultrasound For Deep Vein Thrombosis. ACEP News. March 2009. https://www.acep.org/clinical---practice-management/focus-on--emergency-ultrasound-for-deep-vein-thrombosis/.</ref>====
[[File:DVT-clinical-algorithm.jpg|thumbnail|DVT clinical algorithm]]

==Management==
===Therapy Indications===
''treatment centers around anticoagulation although if signs of ischemia, thrombectomy is also an option''
'''Proximal DVT''' 
*If NO phlegmasia cerulea dolens:
**Anticoagulate with [[heparin]]/[[coumadin]] x 3 months
*If phlegmasia cerulea dolens:
**Consider thrombolytics +/- thrombectomy 
**Anticoagulate with [[heparin]]/[[coumadin]] x 3 months
*If anticoagulation contraindicated:
**[[IVC filter]]

'''Distal DVT''' 
*Symptomatic 
**Anticoagulate with [[heparin]]/[[coumadin]] x 3 months
*Asymptomatic with extension of thrombus toward proximal veins
**Anticoagulate with [[heparin]]/[[coumadin]] x 3 months
*Asymptomatic without extension
**Discharge with compressive U/S q2 weeks

==Anticoagulation Options==
===[[Coumadin]] Regimen===
*Standard anticoagulation regimen
**[[Enoxaparin]] 1 mg/kg q12h 4-5 days
**[[Coumadin]]
***typical starting dose 5 mg/day
***give 7d supply with first dose in ED
*GFR <30 and/or potentially requiring reversal
**[[Unfractionated Heparin]] 80 units/kg bolus then 18 units/kg/hour 
***Check PTT after 6hr; adjust infusion to maintain PTT at 1.5-2.5x control
**[[Coumadin]] as above

===[[Rivaroxaban]] (Xarelto) Regimen===
*Standard
**Start 15mg PO BID x 21 days, then 20mg PO daily (duration depending on risk factors)
**No need for initial enoxaparin
*Renal dosing
**Check creatinine on all patients prior to initiation
**CrCl <30 avoid use

===Contraindications to anticoagulation===
*Active hemorrhage
*Platelets <50
*History of [[intracerebral hemorrhage]]

==Disposition==
'''Inpatient therapy for patients with ANY of the following:'''
*Iliofemoral DVT
*Phlegmasia cerulea dolens
*High risk of bleeding on anticoagulation
*Significant comorbidities
*Symptoms of concurrent [[PE]]
*Recent (within 2 weeks) stroke or transient ischemic attack
*Severe renal dysfunction (GFR < 30)
*History of heparin sensitivity or [[Heparin-Induced Thrombocytopenia]]
*Weight > 150kg
'''Outpatient therapy for patients with ALL of the following:'''
*Ambulatory
*Hemodynamically stable
*Low risk of bleeding in patient
*Absence of renal failure
*Able to administer (or have administered) [[LMWH]] +/- [[coumadin]] with appropriate monitoring 
Arrange for 2-3 day follow-up in anticoagulation clinic

==See Also==
*[[DVT ultrasound]]
*[[Paget-Schroetter Syndrome]]

==External Links==
*[http://www.mdcalc.com/wells-criteria-for-dvt/ MDCalc - Wells' Criteria for DVT]

==References==
<references/>

[[Category:Cardiology]]
[[Category:Orthopedics]]
[[Category:Vascular]]