Deep venous thrombosis: Difference between revisions

 
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==Background==
==Background==
Patients with superficial venous thromboses such as the long saphenous, short saphenous and dorsal venous arch increases the risk of developing a DVT, especially in patients who have a history of prior [[DVT]].<ref>Litzendorf ME. Satiani B. Superficial Venous thrombosis:disease progression and evolving treatment approaches. Vasc Health Risk Manag. 2011(7). 569-575</ref>
[[File:Deep vein thrombosis of the right leg.jpg|thumbnail|DVT of right leg]]
[[File:DVT.jpeg|thumbnail|Large DVT of left leg]]
{{Venous thromboembolism types}}
{{Venous thromboembolism types}}


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


==Clinical Features==
==Clinical Features==
===Physical Exam===
[[File:Deep vein thrombosis of the right leg.jpg|thumbnail|DVT of right leg]]
[[File:DVT.jpeg|thumbnail|Large [[DVT]] of left leg]]
*Leg swelling with circumference >3cm more than unaffected side
*Leg swelling with circumference >3cm more than unaffected side
*Tenderness over calf muscle
*Tenderness over calf muscle
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==Differential Diagnosis==
==Differential Diagnosis==
*Arterial thrombosis
*[[Acute arterial ischemia|Arterial thrombosis]]
*Arteritis
*[[Arthritis]]
*[[Buerger disease]]
*[[Cellulitis]]
*[[Cellulitis]]
*[[Septic Joint]]
*[[Compartment syndrome]]
*[[Complex regional pain syndrome]]
*[[Fractures (main)|Fracture]]
*[[Gout and Pseudogout|Gout]]
*[[Lymphangitis]]
*Myositis
*[[Necrotizing fasciitis]]
*Nerve entrapment
*[[Neuropathy]]
*[[Osteomyelitis]]
*[[Osteomyelitis]]
*[[Compartment Syndrome]]
*[[Paget-Schroetter syndrome]]
*[[Nec fasc]]
*[[Gout]]
*Neuropathy
*Nerve entrapment
*Sciatica
*Sciatica
*[[Fracture]]
*[[Septic Arthritis (General)|Septic Joint]]
*Reflex Sympathetic Dystrophy
*Lymphangitis
*Buerger's disease
*Arthritis
*Tendonitis
*Tendonitis
*Myositis
*Arteritis
*[[Paget-Schroetter Syndrome]]


{{Calf pain DDX}}
{{Calf pain DDX}}
{{Unilateral leg swelling DDX}}


==Evaluation==
==Evaluation==
Evaluation can take place with a the Modified Wells Score or by simply using clinical judgment.
[[File:DVT-clinical-algorithm.jpg|thumbnail|ACEP DVT Evaluation Algorithm]]
===[[Modified Wells Score]]===
*Clinical exam
*Risk stratification for further testing indicated using, e.g. Modified Wells Score  
 
{{Modified Wells Score}}
{{Modified Wells Score}}
[[File:DVT-clinical-algorithm.jpg|thumbnail|ACEP DVT Clinical Algorithm]]
 
===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==
==Management==
''The distinction between distal and proximal relates to veins below and above the knee respectively.
''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 DVT===
''Proximal veins are the external iliac, common femoral, greater saphenous, profound femoral, (superficial) femoral vein, popliteal vein''
''Proximal veins are the '''external iliac''', '''common femoral''', '''greater saphenous''', '''profound femoral''', '''(superficial) femoral vein''', '''popliteal vein'''''
*If NO phlegmasia cerulea dolens:
*If NO phlegmasia cerulea dolens:
**Anticoagulate with [[heparin]]/[[coumadin]] x 3 months
**Anticoagulate with [[apixaban]], [[rivaroxaban]], or [[heparin]]/[[coumadin]] x 3 months
*If phlegmasia cerulea dolens:
*If phlegmasia cerulea dolens:
**Consider thrombolytics +/- thrombectomy  
**Consider thrombolytics +/- thrombectomy  
**Anticoagulate with [[heparin]]/[[coumadin]] x 3 months
**Anticoagulate with [[apixaban]], [[rivaroxaban]], or [[heparin]]/[[coumadin]] x 3 months
*If anticoagulation contraindicated:
*If anticoagulation contraindicated:
**[[IVC filter]]
**[[IVC filter]]


===Distal DVT===
===Distal DVT===
''Distal veins are the anterior tibial , posterior tibial , peroneal , gastrocnemius, soleus.''
''Distal veins are the '''anterior tibial''', '''posterior tibial''', '''peroneal''', '''gastrocnemius, soleus.'''''
*Symptomatic  
*Symptomatic  
**Anticoagulate with [[heparin]]/[[coumadin]] x 3 months
**Anticoagulate with [[apixaban]], [[rivaroxaban]], or [[heparin]]/[[coumadin]] x 3 months
*Asymptomatic with extension of thrombus toward proximal veins
*Asymptomatic with extension of thrombus toward proximal veins
**Anticoagulate with [[heparin]]/[[coumadin]] x 3 months
**Anticoagulate with [[apixaban]], [[rivaroxaban]], or [[heparin]]/[[coumadin]] x 3 months
*Asymptomatic without extension
*Asymptomatic without extension
**Discharge with compressive U/S q2 weeks
**Discharge with compressive U/S q2 weeks
*2020 review from JAMA<ref>Diagnosis and Treatment of Lower Extremity Venous Thromboembolism: A Review.  JAMA. 2020 Nov 3;324(17):1765-1776. doi: https://doi.org/10.1001/jama.2020.17272</ref> recommend treat calf DVT if "severe symptoms or risk factors for pulmonary embolism or extension to proximal veins (such as hospitalization, history of VTE, and cancer)."


'''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>
===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 LMWH or unfractionated heparin anticoagulation dose in:
*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''
**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''
**Postpartum inpatient with prior unprovoked, estrogen-provoked VTE, or low-risk thrombophilia ''for duration of admission''
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**Resume 12 hours after C-section and removal of epidural / spinal needle in indicated patients
**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
*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==
==Anticoagulation Options==
===[[Coumadin]] Regimen===
{| {{table}}
*Standard anticoagulation regimen
| align="center" style="background:#f0f0f0;"|'''Medication'''
**[[Enoxaparin]] 1mg/kg q12h 4-5 days
| align="center" style="background:#f0f0f0;"|'''[[Warfarin]] (Coumadin)'''
**[[Coumadin]]
| align="center" style="background:#f0f0f0;"|'''[[Rivaroxaban]] (Xarelto)'''
***typical starting dose 5mg/day
| align="center" style="background:#f0f0f0;"|'''[[Apixaban]] (Eliquis)'''
***give 7d supply with first dose in ED
| align="center" style="background:#f0f0f0;"|'''[[Dabigatran]] (Pradaxa)'''
*GFR <30 and/or potentially requiring reversal
|-
**[[Unfractionated Heparin]] 80 units/kg bolus then 18 units/kg/hour  
| Standard Dosing||
***Check PTT after 6hr; adjust infusion to maintain PTT at 1.5-2.5x control
*[[Enoxaparin]] 1mg/kg q12h x 4-5 days  
**[[Coumadin]] as above
*[[Warfarin]]  
 
**Starting dose of 5mg/day  
===[[Rivaroxaban]] (Xarelto) Regimen===
**Give 7d supply with first dose in ED
*Standard
||
**Start 15mg PO BID x 21 days, then 20mg PO daily (duration depending on risk factors)
*15mg PO BID x 21 days
**No need for initial enoxaparin
**Then 20mg PO daily (duration depending on risk factors)
*Renal dosing
||
**Check creatinine on all patients prior to initiation
*10mg PO BID x 7 days
**CrCl <30 avoid use
**Then 5mg PO BID daily (duration depending on risk factors)
||
*[[Enoxaparin]] 1mg/kg q12h x 4-5 days
*Pradaxa 150mg BID <ref> https://pubmed.ncbi.nlm.nih.gov/19966341/ </ref>
|-
| 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
||
*CrCl<50 avoid use
|}


===Contraindications to anticoagulation===
===Contraindications to anticoagulation===
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==Disposition==
==Disposition==
'''Inpatient therapy for patients with ANY of the following:'''
===Discharge===
*Iliofemoral DVT
Consider if all of the following are present:
*Phlegmasia cerulea dolens
*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):<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646749/</ref>
**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
*High risk of bleeding on anticoagulation
*Significant comorbidities
*Significant comorbidities
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*History of heparin sensitivity or [[Heparin-Induced Thrombocytopenia]]
*History of heparin sensitivity or [[Heparin-Induced Thrombocytopenia]]
*Weight > 150kg
*Weight > 150kg
'''Outpatient therapy for patients with ALL of the following:'''
*Upper extremity DVT
*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==
==See Also==
*[[Anticoagulants]]
*[[Pulmonary embolism]]
*[[DVT ultrasound]]
*[[DVT ultrasound]]
*[[Paget-Schroetter Syndrome]]
*[[Paget-Schroetter syndrome]]


==External Links==
==External Links==
*[http://www.mdcalc.com/wells-criteria-for-dvt/ MDCalc - Wells' Criteria for DVT]
*[http://www.mdcalc.com/wells-criteria-for-dvt/ MDCalc - Wells' Criteria for DVT]
*[https://rebelem.com/tag/deep-vein-thrombosis/ REBEL EM - Should I Stay or Should I Go: Outpatient Treatment of Venous Thromboembolism]
*[https://coreem.net/core/deep-venous-thrombosis-dvt/ CORE EM - Deep Venous Thrombosis (DVT)]


==References==
==References==
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[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Orthopedics]]
[[Category:Vascular]]
[[Category:Vascular]]

Latest revision as of 08:53, 23 May 2023

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

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

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
  • 2020 review from JAMA[8] recommend treat calf DVT if "severe symptoms or risk factors for pulmonary embolism or extension to proximal veins (such as hospitalization, history of VTE, and cancer)."

VTE in Pregnancy[9]

  • 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 [10]
  • Anticoagulation as per lower extremity DVTs.
  • Patient should be admitted

Anticoagulation Options

Medication Warfarin (Coumadin) Rivaroxaban (Xarelto) Apixaban (Eliquis) Dabigatran (Pradaxa)
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
  • CrCl<50 avoid use

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):[12]
    • 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. Diagnosis and Treatment of Lower Extremity Venous Thromboembolism: A Review. JAMA. 2020 Nov 3;324(17):1765-1776. doi: https://doi.org/10.1001/jama.2020.17272
  9. DʼAlton ME et al. National Partnership for Maternal Safety: Consensus bundle on venous thromboembolism. Obstet Gynecol 2016 Oct; 128:688.
  10. 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.
  11. https://pubmed.ncbi.nlm.nih.gov/19966341/
  12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646749/