Deep venous thrombosis: Difference between revisions

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==Diagnosis==
==Background==
==Modified Wells Score==
{{Venous thromboembolism types}}
#Active cancer (<6 mo) - 1pt
#Paralysis, paresis, or immob of extremity - 1pt
#Bedridden >3 d b/c of sx (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
===Probability===
*0-1 = Low probability
*≥2 = High probability


====Low Probability====
{{Venous system anatomy leg}}
*Send d-dimer
**If pos obtain utz


====High Probability====
==Clinical Features==
*Send d-dimer AND obtain utz
[[File:Deep vein thrombosis of the right leg.jpg|thumbnail|DVT of right leg]]
**If both negative done
[[File:DVT.jpeg|thumbnail|Large [[DVT]] of left leg]]
**If utz positive done
*Leg swelling with circumference >3cm more than unaffected side
**If pos d-dimer but neg UTZ:
*Tenderness over calf muscle
***Repeat utz in 1wk
*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>


==DDx==
==Differential Diagnosis==
#Arterial embolism
*[[Acute arterial ischemia|Arterial thrombosis]]
#[[Septic Joint]]
*Arteritis
#[[Osteomyelitis]]
*[[Arthritis]]
#[[Compartment Syndrome]]
*[[Buerger disease]]
#[[Nec fasc]]
*[[Cellulitis]]
#[[Gout]]
*[[Compartment syndrome]]
#Neuropathy
*[[Complex regional pain syndrome]]
#Nerve entrapment
*[[Fractures (main)|Fracture]]
#Sciatica
*[[Gout and Pseudogout|Gout]]
#Fracture
*[[Lymphangitis]]
#Reflex sympathetic dystrophy
*Myositis
#Lymphangitis
*[[Necrotizing fasciitis]]
#Buerger's disease
*Nerve entrapment
#Arthritis
*[[Neuropathy]]
#Tendonitis
*[[Osteomyelitis]]
#Myositis
*[[Paget-Schroetter syndrome]]
#Arteritis
*Sciatica
*[[Septic Arthritis (General)|Septic Joint]]
*Tendonitis
 
{{Calf pain DDX}}
{{Unilateral leg swelling DDX}}
 
==Evaluation==
[[File:DVT-clinical-algorithm.jpg|thumbnail|ACEP DVT Evaluation Algorithm]]
*Clinical exam
*Risk stratification for further testing indicated using, e.g. Modified Wells Score
 
===[[Modified Wells Score]]===
{{Modified Wells Score}}
 
===Upper extremity DVT===
''Requires ultrasound for diagnosis.  Cannot be ruled out with d-dimer.<ref>Kucher N. Clinical practice Deep-vein thrombosis of the upper extremities. N Engl J Med. 2011;364:861–869.</ref>''
 
 
*Generally involves axillary or subclavian veins
*Primary upper extremity DVT typically presents in young healthy individuals
*Secondary upper extremity DVT often due to indwelling catheters
*Obtain a chest x-ray to rule out bony abnormalities that may be causing venous obstruction
 
==Management==
''The distinction between distal and proximal relates to veins below and above the knee respectively.<ref>Gualtiero P. How I treat isolated distal deep vein thrombosis (IDDVT). Blood 2014 123:1802-1809; doi: https://doi.org/10.1182/blood-2013-10-512616</ref> Patients with '''superficial venous thromboses such as the long saphenous and short saphenous are at risk of developing a DV'''T, especially in patients who have a history of prior [[DVT]] although management with anticoagulation is controversial.<ref>Litzendorf ME. Satiani B. Superficial Venous thrombosis:disease progression and evolving treatment approaches. Vasc Health Risk Manag. 2011(7). 569-575</ref>''
===Proximal DVT===
''Proximal veins are the '''external iliac''', '''common femoral''', '''greater saphenous''', '''profound femoral''', '''(superficial) femoral vein''', '''popliteal vein'''''
*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===
''Distal veins are the '''anterior tibial''', '''posterior tibial''', '''peroneal''', '''gastrocnemius, soleus.'''''
*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
 
===VTE in Pregnancy<ref>DʼAlton ME et al. National Partnership for Maternal Safety: Consensus bundle on venous thromboembolism. Obstet Gynecol 2016 Oct; 128:688.</ref>===
*Therapeutic [[Enoxaparin|LMWH]] or [[Unfractionated_heparin|unfractionated heparin]] anticoagulation dose in:
**Antepartum outpatient with multiple prior VTEs or any VTE with high-risk thrombophilia until ''6 weeks postpartum''
**Postpartum inpatient with prior unprovoked, estrogen-provoked VTE, or low-risk thrombophilia ''for duration of admission''
*Lower prophylactic anticoagulation dose in:
**Antepartum outpatient with prior unprovoked, estrogen-provoked VTE, or low-risk thrombophilia until''6 weeks postpartum''
**Patients admitted > 72 hrs, not at high risk for bleeding or imminent delivery
**Resume 12 hours after C-section and removal of epidural / spinal needle in indicated patients
*Halt anticoagulation if imminent delivery, C-section, epidural / spinal needle
 
===Recurrent DVT on Therapeutic Anticoagulation===
*Admit patients for vascular surgery and hematologist consult
*Consider Greenfield IVC filter placement
*Typically start heparin for additional anticoagulation
 
===Upper extremity DVT===
*If secondary to catheter, do not necessarily have to remove <ref> Kovacs MJ et al. A pilot study of central venous catheter survival in cancer patients using low-molecular-weight heparin (dalteparin) and warfarin without catheter removal for the treatment of upper extremity deep vein thrombosis (the catheter study) JTH. 2007;5:1650–1653. </ref>
*Anticoagulation as per lower extremity DVTs.
*Patient should be admitted
 
==Anticoagulation Options==
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Medication'''
| align="center" style="background:#f0f0f0;"|'''[[Warfarin]] (Coumadin)'''
| align="center" style="background:#f0f0f0;"|'''[[Rivaroxaban]] (Xarelto)'''
| align="center" style="background:#f0f0f0;"|'''[[Apixaban]] (Eliquis)'''
|-
| Standard Dosing||
*[[Enoxaparin]] 1mg/kg q12h x 4-5 days
*[[Warfarin]]
**Starting dose of 5mg/day
**Give 7d supply with first dose in ED
||
*15mg PO BID x 21 days
**Then 20mg PO daily (duration depending on risk factors)
||
*10mg PO BID x 7 days
**Then 5mg PO BID daily (duration depending on risk factors)
|-
| Renal Dosing||
*[[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
*[[Warfarin]] as above
||
*Check creatinine on all patients prior to initiation
*CrCl <30 avoid use
||
*No dosage adjustments necessary for renal impairment
**However, CrCl <25 mL/minute were excluded from clinical trials
|}
 
===Contraindications to anticoagulation===
*Active hemorrhage
*Platelets <50
*History of [[intracerebral hemorrhage]]


==Disposition==
==Disposition==
Consider admission for:
===Discharge===
#Presence of massive DVT (phlegmasia cerulea dolens)
Consider if all of the following are present:
#Presence of concurrent symptoms of PE
*Ambulatory
#High-risk of anticoagulation-related bleeding
*Hemodynamically stable
#Recent (within 2 weeks) stroke or transient ischemic attack
*Low risk of bleeding in patient
#Severe renal dysfunction (GFR < 30)
*Absence of renal failure
#History of heparin sensitivity or heparin-induced thrombocytopenia
*Able to administer anticoagulation with appropriate monitoring
#Weight > 150kg
*Able to arrange for 2-3 day follow-up


==Treatment==
===Admit===
*Outpatient
For any of the following:
**Enoxaparin 0.5 mg/kg subcutaneously X1 in ED by RN
*Ileofemoral DVT that is a candidate for thrombectomy (should have the following):<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646749/</ref>
**Enoxaparin 0.5 mg/kg subcutaneously X1 in ED by pt
**Acute iliofemoral DVT (symptom duration <21 days)
**Coumadin 5 mg po x 1 in ED
**Low risk of bleeding
**Enoxaparin 1mg/kg sc q12hr x 5 days
**Good functional status and reasonable life expectancy
**Warfarin 5mg PO daily (give 7 days worth only)
*[[Phlegmasia cerulea dolens]]
**Arrange for 2-3 day follow-up in anticoagulation clinic
*High risk of bleeding on anticoagulation
*Inpatient
*Significant comorbidities
**Warfarin AND
*Symptoms of concurrent [[PE]]
**Enoxaparin: 1 mg/kg SC q12hr OR 1.5mg/kg SC qday OR
*Recent (within 2 weeks) stroke or transient ischemic attack
**Unfrationated heparin: 80 units/kg bolus; then 18 units/kg/hr
*Severe renal dysfunction (GFR < 30)
***Check PTT after 6hr; adjust infusion to maintain PTT at 1.5-2.5x control
*History of heparin sensitivity or [[Heparin-Induced Thrombocytopenia]]
*Weight > 150kg
*Upper extremity DVT


==See Also==
==See Also==
[[Ultrasound: DVT]]
*[[DVT ultrasound]]
*[[Paget-Schroetter syndrome]]


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


UpToDate
==References==
<references/>


[[Category:Cards]]
[[Category:Cardiology]]
[[Category:Ortho]]
[[Category:Vascular]]

Revision as of 23:03, 12 December 2019

Background

Clinical Spectrum of Venous thromboembolism

Only 40% of ambulatory ED patients with PE have concomitant DVT[1][2]

Leg Vein Anatomy

Blausen 0609 LegVeins.png

Significant risk of PE:

  • Common femoral vein
  • (Superficial) femoral vein
    • (Superficial) femoral vein is part of the deep system, not the superficial system as the name suggests!
  • Popliteal veins

Clinical Features

DVT of right leg
Large DVT of left leg
  • 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%)[3]

Differential Diagnosis

Calf pain

Unilateral leg swelling

Differential Diagnosis of Pedal Edema

Evaluation

ACEP DVT Evaluation Algorithm
  • Clinical exam
  • Risk stratification for further testing indicated using, e.g. Modified Wells Score

Modified Wells Score

Modified Wells Score

Can be applied for patients whose clinical presentation is concerning for a DVT in order to risk stratify.

  • Active cancer (<6 mo) (1pt)
  • Paralysis, paresis, or immobility of extremity (1pt)
  • Bedridden >3 days because of symptoms within 4 weeks (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 diagnosis as likely or more likely than DVT (-2pts)

Scoring:

  • A score of 0 or lower → minimal risk - DVT prevalence of 5%. D-dimer testing is safe in this group - negative d-dimer decreases the probability of disease to <1% allowing an ultrasound to be deferred.
  • A score of 1-2 → moderate risk - DVT prevalence of 17%. D-dimer testing still effective and a negative test decreases post-test probability disease to <1%
  • A score of 3 or higher → high risk - DVT prevalence of 17-53% → patients should receive an ultrasound[4]

Upper extremity DVT

Requires ultrasound for diagnosis. Cannot be ruled out with d-dimer.[5]


  • Generally involves axillary or subclavian veins
  • Primary upper extremity DVT typically presents in young healthy individuals
  • Secondary upper extremity DVT often due to indwelling catheters
  • Obtain a chest x-ray to rule out bony abnormalities that may be causing venous obstruction

Management

The distinction between distal and proximal relates to veins below and above the knee respectively.[6] Patients with superficial venous thromboses such as the long saphenous and short saphenous are at risk of developing a DVT, especially in patients who have a history of prior DVT although management with anticoagulation is controversial.[7]

Proximal DVT

Proximal veins are the external iliac, common femoral, greater saphenous, profound femoral, (superficial) femoral vein, popliteal vein

  • If NO phlegmasia cerulea dolens:
  • If phlegmasia cerulea dolens:
    • Consider thrombolytics +/- thrombectomy
    • Anticoagulate with heparin/coumadin x 3 months
  • If anticoagulation contraindicated:

Distal DVT

Distal veins are the anterior tibial, posterior tibial, peroneal, gastrocnemius, soleus.

  • Symptomatic
  • Asymptomatic with extension of thrombus toward proximal veins
  • Asymptomatic without extension
    • Discharge with compressive U/S q2 weeks

VTE in Pregnancy[8]

  • Therapeutic LMWH or unfractionated heparin anticoagulation dose in:
    • Antepartum outpatient with multiple prior VTEs or any VTE with high-risk thrombophilia until 6 weeks postpartum
    • Postpartum inpatient with prior unprovoked, estrogen-provoked VTE, or low-risk thrombophilia for duration of admission
  • Lower prophylactic anticoagulation dose in:
    • Antepartum outpatient with prior unprovoked, estrogen-provoked VTE, or low-risk thrombophilia until6 weeks postpartum
    • Patients admitted > 72 hrs, not at high risk for bleeding or imminent delivery
    • Resume 12 hours after C-section and removal of epidural / spinal needle in indicated patients
  • Halt anticoagulation if imminent delivery, C-section, epidural / spinal needle

Recurrent DVT on Therapeutic Anticoagulation

  • Admit patients for vascular surgery and hematologist consult
  • Consider Greenfield IVC filter placement
  • Typically start heparin for additional anticoagulation

Upper extremity DVT

  • If secondary to catheter, do not necessarily have to remove [9]
  • Anticoagulation as per lower extremity DVTs.
  • Patient should be admitted

Anticoagulation Options

Medication Warfarin (Coumadin) Rivaroxaban (Xarelto) Apixaban (Eliquis)
Standard Dosing
  • Enoxaparin 1mg/kg q12h x 4-5 days
  • Warfarin
    • Starting dose of 5mg/day
    • Give 7d supply with first dose in ED
  • 15mg PO BID x 21 days
    • Then 20mg PO daily (duration depending on risk factors)
  • 10mg PO BID x 7 days
    • Then 5mg PO BID daily (duration depending on risk factors)
Renal Dosing
  • 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
  • Warfarin as above
  • Check creatinine on all patients prior to initiation
  • CrCl <30 avoid use
  • No dosage adjustments necessary for renal impairment
    • However, CrCl <25 mL/minute were excluded from clinical trials

Contraindications to anticoagulation

Disposition

Discharge

Consider if all of the following are present:

  • Ambulatory
  • Hemodynamically stable
  • Low risk of bleeding in patient
  • Absence of renal failure
  • Able to administer anticoagulation with appropriate monitoring
  • Able to arrange for 2-3 day follow-up

Admit

For any of the following:

  • Ileofemoral DVT that is a candidate for thrombectomy (should have the following):[10]
    • Acute iliofemoral DVT (symptom duration <21 days)
    • Low risk of bleeding
    • Good functional status and reasonable life expectancy
  • 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
  • Upper extremity DVT

See Also

External Links

References

  1. Righini M, Le GG, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008; 371(9621):1343-1352.
  2. Daniel KR, Jackson RE, Kline JA. Utility of the lower extremity venous ultrasound in the diagnosis and exclusion of pulmonary embolism in outpatients. Ann Emerg Med. 2000; 35(6):547-554.
  3. Anand SS, et al. Does this patient have deep vein thrombosis? JAMA. 1998; 279(14):1094-9.
  4. 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/
  5. Kucher N. Clinical practice Deep-vein thrombosis of the upper extremities. N Engl J Med. 2011;364:861–869.
  6. Gualtiero P. How I treat isolated distal deep vein thrombosis (IDDVT). Blood 2014 123:1802-1809; doi: https://doi.org/10.1182/blood-2013-10-512616
  7. Litzendorf ME. Satiani B. Superficial Venous thrombosis:disease progression and evolving treatment approaches. Vasc Health Risk Manag. 2011(7). 569-575
  8. DʼAlton ME et al. National Partnership for Maternal Safety: Consensus bundle on venous thromboembolism. Obstet Gynecol 2016 Oct; 128:688.
  9. Kovacs MJ et al. A pilot study of central venous catheter survival in cancer patients using low-molecular-weight heparin (dalteparin) and warfarin without catheter removal for the treatment of upper extremity deep vein thrombosis (the catheter study) JTH. 2007;5:1650–1653.
  10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646749/