Deep vein thrombosis - Wikipedia, the free encyclopediahttp://en.wikipedia.org/wiki/Deep_vein_thrombosis From Wikipedia, the free encyclopedia In medicine, deep vein thrombosis (also known as deep venous thrombosis and usually abbreviated as DVT) is the formation of a blood clot ("thrombus") in a deep vein. It is a form of thrombophlebitis (inflammation of a vein with clot formation). Deep vein thrombosis commonly affects the leg veins (such as the femoral vein or the popliteal vein) or the deep veins of the pelvis. Occasionally the veins of the arm are affected (if spontaneous, this is known as Paget-Schrötter disease). A DVT can occur without symptoms, but in many cases the affected extremity will be painful, swollen, red, warm and the superficial veins may be engorged. The most serious complication of a DVT is that the clot could dislodge and travel to the lungs, which is called a pulmonary embolism (PE). DVT is a medical emergency, so, all limb swellings, however trivial, should be regarded as a DVT until proven otherwise. Untreated lower extremity DVT has a 3% PE-related mortality rate. Deaths associated with upper extremity DVT are extremely rare.[1] A late complication of DVT is the post-thrombotic syndrome, which can manifest itself as edema, pain or discomfort and skin problems. According to Virchow's triad, venous thrombosis occurs via three mechanisms: decreased flow rate of the blood, damage to the blood vessel wall and an increased tendency of the blood to clot (hypercoagulability). Several medical conditions can lead to DVT, such as compression of the veins, physical trauma, cancer, infections, certain inflammatory diseases and specific conditions such as stroke, heart failure or nephrotic syndrome. There are several factors which can increase a person's risk for DVT, including surgery, hospitalization, immobilization (such as when orthopedic casts are used, or during long-haul flights, leading to traveller's thrombosis), smoking, obesity, age, certain drugs (such as estrogen, or erythropoietin) and inborn tendencies to form clots known as thrombophilia (for example, in carriers of factor V Leiden). Women have an increased risk during pregnancy, if they are on the Pill, and in the postnatal period, due to increased estrogen levels. The most commonly used tests for the diagnosis of DVT are a blood test called D-dimers and doppler ultrasound of the affected veins. Sometimes, further testing is required to find the cause of the DVT. In specific cases, an attempt can be made to break down the clot (using thrombolytic agents). To prevent further accrual and formation of new clots with a risk of pulmonary embolism, anticoagulation (blood thinners) is advised (if not possible, an inferior vena cava filter may be used). Prevention of DVT is advised in many medical and surgical inpatients using anticoagulants, graduated compression stockings (also known as thromboembolic deterrent stockings) or intermittent pneumatic compression (IPC) devices. 1 of 13 Deep vein thrombosis Classification and external resources A deep vein thrombosis of the right leg. Note the swelling and redness. ICD-10 I80.2 (http://apps.who.int /classifications/apps/icd/icd10online /?gi80.htm+i802) ICD-9 453.40 (http://www.icd9data.com /getICD9Code.ashx?icd9=453.40) DiseasesDB 3498 24-May-11 6:34 AM Deep vein thrombosis .nih.gov /cgi/mesh/2011/MB_cgi?field=uid& term=D020246) MeSH There may be no symptoms referable to the location of the DVT.htm) eMedicine med/2785 (http://www.gov /medlineplus/ency/article /000156.com /med/topic2785.nih.htm) 1 Signs and symptoms 2 Cause 3 Diagnosis 3.3 Thrombectomy 5. 2 of 13 24-May-11 6:34 AM .1 General medical inpatients 4.emedicine.2 Thrombolysis 5. there may be some form of DVT. which often remains clinically inapparent (unless pulmonary embolism develops).nlm.diseasesdatabase.Wikipedia.4 Travellers 5 Management 5.3 Pregnancy 4.org/wiki/Deep_vein_thrombosis (http://www.4 Compression stockings 5.3 Blood tests 3.wikipedia.htm) D020246 (http://www.4 Imaging 4 Prevention 4.1 Physical examination 3. In up to 25% of all hospitalized patients.6 Hospitalization 6 Prognosis 7 Epidemiology 8 See also 9 References 10 External links MedlinePlus 000156 (http://www.nlm. the free encyclopedia http://en.2 Surgery patients 4.2 Probability scoring 3.5 Inferior vena cava filter 5.com /ddb3498.1 Anticoagulation 5. swelling and redness of the leg and dilation of the surface veins. but the classical symptoms of DVT include pain. a combination of immobility and relative dehydration). infection. protein S. DVTs are distinguished as being above or below the popliteal vein. such as measuring the circumference of the affected and the contralateral limb at a fixed point (to objectivate edema). immobilization.Wikipedia. Virchow noted that more deep venous thrombosis occurred in the left leg than in the right and proposed compression of the left common iliac vein by the overlying right common iliac artery as the underlying cause (see May-Thurner syndrome). The risk of pulmonary embolism is higher in the presence of more extensive clots.[2] A family history can reveal a hereditary factor in the development of DVT. and qualities of the vessel wall.[4] The most common risk factors are recent surgery or hospitalization. which is often tender. tobacco usage and air travel ("economy class syndrome". recent long-haul flying. Other risk factors include advanced age. "growing" in the direction of flow of the vein.[6][7] Thrombophilia (tendency to develop thrombosis) often expresses itself with recurrent thromboses. recent studies have shown that risk of DVT is higher in travellers who smoke.Deep vein thrombosis . obesity. It usually results from acute occlusion of the iliac and femoral veins because of DVT. and palpating the venous tract. The leg is usually painful. Venous gangrene may supervene. including the use of estrogen-containing methods of hormonal contraception. or mutations in the factor V and prothrombin genes. the free encyclopedia http://en. including deficiencies in the anticoagulation factors protein C.[5][6] 40% of these patients did not receive heparin prophylaxis. antithrombin. intravenous drug use and a history of miscarriage (which is a feature of several disorders that can also cause thrombosis). use of combined (estrogen-containing) forms of hormonal contraception. are obese. In phlegmasia cerulea dolens. It is recognized that thrombi usually develop first in the calf veins.wikipedia. as this may warrant further investigation (see pulmonary embolism). Very extensive DVTs can extend into the iliac veins or the inferior vena cava. or are currently taking contraceptive pills.org/wiki/Deep_vein_thrombosis There are several techniques during physical examination to increase the detection of DVT.[3] Main article: Thrombosis Virchow's triad is a group of three factors known to affect clot formation: rate of flow. Physical examination is unreliable for excluding the diagnosis of deep vein thrombosis. In phlegmasia alba dolens. including the iliac and femoral veins. A careful history has to be taken considering risk factors (see below). Approximately 35 percent of DVT patients have at least one hereditary thrombophilia. It is vital that the possibility of pulmonary embolism be included in the history. cyanosed (blue from lack of oxygen) and edematous (filled with fluid). the consistency (thickness) of the blood. there is an acute and nearly total venous occlusion of the entire extremity outflow. In the case of long-haul flying. 3 of 13 24-May-11 6:34 AM . the leg is pale and cool with a diminished arterial pulse caused by spasm. 10.org/wiki/Deep_vein_thrombosis The gold standard is intravenous venography. Scarvelis and Wells overviewed a set of clinical prediction rules for DVT.deep vein thrombosis is likely.[10][11] Wells score or criteria: (Possible score -2 to 9) 1. Pratt's sign: Squeezing of posterior calf elicits pain. The arrow indicates the filling defect in the vein visualised using radiocontrast. or major surgery requiring regional or general anesthetic in past 4 weeks +1 point Alternative diagnosis at least as likely -2 points Interpretation: Score of 2 or higher . However.[8] Probability scoring In 2006. this test is rarely performed. Score of less than 2 . Consider imaging the leg veins. Active cancer (treatment within last 6 months or palliative) +1 point Calf swelling >3 cm compared to other calf (measured 10 cm below tibial tuberosity) +1 point Collateral superficial veins (non-varicose) +1 point Pitting edema (confined to symptomatic leg) +1 point Previous documented DVT +1 point. 8.deep vein thrombosis is unlikely.Deep vein thrombosis . 7. 9. 4.[9] on the heels of a widely adopted set of clinical criteria for pulmonary embolism. 3. Swelling of entire leg +1 point Localized pain along distribution of deep venous system +1 point Paralysis. which involves injecting a peripheral vein of the affected limb with a contrast agent and taking X-rays. 2. Physical examination Homans sign: Dorsiflexion of foot elicits pain in posterior calf.Wikipedia. Abdominal computed tomographic scan showing a common iliac vein thrombosis. Consider blood test such as d-dimer test to further rule out deep vein thrombosis. Blood tests 4 of 13 24-May-11 6:34 AM . to reveal whether the venous supply has been obstructed. 6. the free encyclopedia http://en. these medical signs do not perform well and are not included in clinical prediction rules that combine best findings in order to diagnose DVT. Because of its invasiveness. paresis.wikipedia. 5. or recent cast immobilization of lower extremities +1 point Recently bedridden > 3 days. A low D-dimer level should prompt other possible diagnoses (such as a ruptured Baker's cyst. This test involves both a B mode image and Doppler flow analysis. It is most sensitive and specific for detecting proximal thrombi (in the popliteal and femoral veins). or who are confined to bed An ultrasound image demonstrating a blood clot in the left common femoral vein. if the patient is at sufficiently low clinical probability of DVT).e. compression ultrasound scanning of the leg veins.wikipedia. and that the blood clot is being dissolved by plasmin. Duplex Ultrasonography. 5 of 13 24-May-11 6:34 AM .[15] General medical inpatients Regarding general medical inpatients the guidelines state. This cross-linked fibrin degradation product is an indication that thrombosis is occurring. can reveal a blood clot and its extent (i. Doppler ultrasonography.Deep vein thrombosis . the free encyclopedia http://en. APTT. whether it is below or above the knee). current practice is to commence investigations by testing for D-dimer levels. but substantially less so for distal thrombi (in the calf veins). "In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease.[14] Clinical practice guidelines by the American College of Chest Physicians (ACCP) provide recommendations on DVT prophylaxis in hospitalized patients. combined with duplex measurements (to determine blood flow).org/wiki/Deep_vein_thrombosis D-dimer Main article: d-dimer In a low-probability situation. due to its high sensitivity.[12][13] Other blood tests Other blood tests usually performed at this point are[citation needed]: complete blood count Primary coagulation studies: PT.Wikipedia. has replaced venography as the most widely used test in the evaluation of the disease. Fibrinogen liver enzymes renal function and electrolytes Imaging Impedance plethysmography. specificity and reproducibility. IPC machines use air bladders that are wrapped around the thigh and/or calf. If UFH is used. IPC devices have proven protective in bed.wikipedia. Walking activates the body's muscle pumps. The bladders alternately inflate and deflate. Regarding patients at lesser risk of DVT." With regards to which patients are at risk. 5000 U 3 times daily may be more effective.[17] Since publication of the ACCP guidelines.[21] It is not clear why these two trials conflict. LMWH can only currently be administered subcutaneously by injection.[16] LMWH may be more effective than unfractionated heparin (UFH). Early and regular ambulation (walking) is a treatment that predates anticoagulants and is still recognized and used today. The meta-analysis concluded " Anticoagulant prophylaxis is effective in preventing symptomatic venous thromboembolism during anticoagulant prophylaxis in at-risk hospitalized medical patients. we recommend prophylaxis with low-dose unfractionated heparin-LDUH (Grade 1A) or LMWH (Grade 1A). an additional randomized controlled trial[18] and meta-analysis[19] including the trial have been published.Deep vein thrombosis . Since the ACCP guidelines.[21][22] In stroke patients. most studies in the meta-analysis were of patients with New York Heart Association Functional Classification (NYHA) III-IV heart failure.[23] Chronic renal dialysis patients may be at increased risk of thromboembolism. squeezing the muscles and increasing blood velocity by as much as 500%.org/wiki/Deep_vein_thrombosis and have one or more additional risk factors. compression stockings have been studied for preventing clots in stroke patients. IPC machines have been proven effective on knee and hip surgery patients (a population with a risk as high as 80% with no prophylactic treatment) of developing DVT and PE. Surgery patients In patients who have undergone surgery. Pregnancy Main article: Hypercoagulability in pregnancy The risk of deep vein thrombosis is increased in pregnancy because of a physiologically adaptive mechanism of increased hypercoagulability to 6 of 13 24-May-11 6:34 AM . Prophylaxis for pregnant women who have a history of thrombosis may be limited to LMWH injections or may not be necessary if their risk factors are mainly temporary. thigh-length stockings are more effective than knee stockings in the nonblinded CLOTS 2 randomized controlled trial[22] while thigh-length stockings were not better than no stockings in the CLOTS 1 nonblinded randomized controlled trial. the trial above[18] and an earlier trial[20] are relevant yet inconclusive.or chair-ridden patients at very high risk or with contraindications to heparins. the free encyclopedia http://en.Wikipedia. low molecular weight heparins (LMWH) are routinely administered to prevent thrombosis. including active cancer. increasing venous velocity and preventing stasis. acute neurologic disease. or inflammatory bowel disease. Additional research is needed to determine the risk for venous thromboembolism in these patients after prophylaxis has been stopped. previous VTE.[24] but randomized controlled trials have not addressed the risk benefit of prophylaxis.[15]" Enoxaparin or unfractionated heparin may be used. sepsis. the free encyclopedia http://en. In general. Thus.Deep vein thrombosis .[31] An abnormal D-dimer level at the end of treatment might signal the need for continued treatment among patients with a first unprovoked proximal 7 of 13 24-May-11 6:34 AM . The results showed that asymptomatic DVT occurred in 10% of the passengers who did not wear compression tights.org/wiki/Deep_vein_thrombosis prevent postpartum hemorrhage.[26][27] Travellers Main article: Traveller's thrombosis There is clinical evidence to suggest that wearing compression socks or compression tights while travelling also reduces the incidence of thrombosis in people on long haul flights. anticoagulation is generally "life-long.wikipedia. In a 2008 Cochrane review. patients are initiated on a brief course (i. However.e. the most commonly used anticoagulant in chronic administration. changes in the anticoagulation regimen during pregnancy can be performed to minimize the risks to the developing fetus while maintaining therapeutic levels of anticoagulation in the mother. less than a week) of heparin treatment while they start on a 3. the risk of thrombosis or embolism may become substantial. the legs) may cease coagulation. pulmonary embolism is still as possible. A randomised study in 2001 compared two sets of long haul airline passengers.[30] Once the thrombosis is treated with RBC-thinning agents. The passengers were all scanned and blood tested to check for the incidence of DVT.g. The authors concluded that wearing elastic compression hosiery reduces the incidence of DVT in long haul airline passengers.Wikipedia. Low molecular weight heparin (LMWH) is preferred. it was found that anticoagulation used in combination with leg compression is a more effective therapy than anticoagulation alone.[25] However.e.. In patients who have had recurrent DVTs (two or more). The group wearing compression hosiery had no DVTs. renal failure or imminent need for invasive procedure).. is known to have teratogenic effects on the fetus if administered in early pregnancy.[29] though unfractionated heparin is given in patients who have a contraindication to LMWH (e.[25] While the general consensus among physicians is that the safety of the mother supersedes the safety of the developing fetus. while the area affected with deep venous thrombosis (i. thinning agents do not lessen the chance of embolism to the pulmonary or coronary arteries. The main issue with anticoagulation in pregnancy is that warfarin. when combined with an additional underlying hypercoagulable states. one set wore travel compression hosiery the others did not.[28] Anticoagulation Main article: Anticoagulation Anticoagulation is the usual treatment for DVT. the affected area has a fair chance of returning to its normal proportions." The Cochrane Collaboration has meta-analyzed the risk and benefits of prolonged anti-coagulation.to 6-month course of warfarin (or related vitamin K inhibitors). TheNewGuidelines. for the prevention of the post-thrombotic syndrome.[36] They reduce the risk of postthrombotic syndrome.[35] there may be an increase in serious bleeding complications. for patients with a first episode of idiopathic DVT. A meta-analysis of randomized controlled trials by the Cochrane Collaboration showed reduced incidence of post-thrombotic syndrome. Thrombolysis Main article: Thrombolysis Thrombolysis is generally reserved for extensive clot. long-term treatment with a VKA for 3 months.wikipedia. the recommendations include the following: for patients with a first episode of DVT secondary to a transient (reversible) risk factor.[33] Current recommendations for initial treatment of acute DVT include initiation of a vitamin K antagonist (VKA) together with LMWH or UFH on the first treatment day. Combination therapy that uses mechanical thrombectomy to deliver localized thrombolytics has recently received considerable attention as a treatment for DVT. For the duration and intensity of treatment for acute DVT of the leg. the free encyclopedia http://en. the American College of Chest Physicians (ACCP) published new evidence-based clinical guidelines for the treatment of venous thromboembolic (VTE) disease which for the first time suggested the use of pharmacomechanical thrombolysis in the treatment of certain cases of acute DVT. The dose of VKA is adjusted to maintain INR in the range of 2.0.org/wiki/Deep_vein_thrombosis deep-vein thrombosis.Deep vein thrombosis .[38] The number needed to treat is relatively high.g. at 4 to 5 patients needing to have been treated to prevent one case of post-thrombotic 8 of 13 24-May-11 6:34 AM . Compression stockings Elastic compression stockings should be routinely applied "beginning within 1 month of diagnosis of proximal DVT and continuing for a minimum of 1 year after diagnosis".0 to 3. e.[32] Despite the fact that no one disputes this. Although a meta-analysis of randomized controlled trials by the Cochrane Collaboration shows improved outcomes with thrombolysis.0.org) Thrombectomy Thrombus can be removed with a mechanical thrombectomy device. based on a meta analysis done by the Cochrane Collaboration where they found only one randomized trial of anti coagulation vs placebo in the treatment of VTE in which there was no significant difference between the two.org (http://www. an iliofemoral thrombosis. treatment with a VKA for at least 6 to 12 months. Complete 2008 ACCP VTE guidelines can be downloaded at no charge at: TheNewGuidelines.[37] The stockings in almost all trials were stronger than routine anti-embolism stockings and created either 20–30 mm Hg or 30–40 mm Hg. In July 2008.[34] Heparin may be discontinued when the international normalized ratio (INR) is stable and greater than 2. the use of an elastic compression stocking is recommended. Most trials used knee-high stockings.[29] Starting within one week may be more effective.Wikipedia. 000 people under the age of 18 experiences deep vein thrombosis. malignancy). the free encyclopedia http://en. However these filters are themselves potential of thrombosis.[41] IVC filters are viewed as a temporizing measure for preventing life-threatening pulmonary embolism.wikipedia. It presents with leg edema.000 to 600.[39] Inferior vena cava filter Main article: Inferior vena cava filter Inferior vena cava filter reduces pulmonary embolism[40] and is an option for patients with an absolute contraindiciation to anticoagulant treatment (e. DVTs occur in about 1 per 1000 persons per year.g.Wikipedia. dermatitis and ulceration (usually on the medial aspect of the lower leg). relatively active lifestyle when compared with adults..[43] Hospitalization should be considered in patients with more than two of the following risk factors as these patients may have more risk of complications during treatment[44]: bilateral DVT renal insufficiency low body weight (<70 kg/154 lbs) recent immobility chronic heart failure cancer Post-thrombotic syndrome occurs in 15% of patients with deep vein thrombosis (DVT). venous claudication. possibly due to a child's high rate of heartbeats per minute.Deep vein thrombosis . About 1 in 100.000 Americans each year suffer from DVT and pulmonary embolism and at least 100. nocturnal cramping. 9 of 13 24-May-11 6:34 AM .g. skin pigmentation.org/wiki/Deep_vein_thrombosis syndrome. cerebral hemorrhage) or those rare patients who have objectively documented recurrent PEs while on anticoagulation. and fewer comorbidities (e. an inferior vena cava filter (also referred to as a Greenfield filter) may prevent pulmonary embolisation of the leg clot.000 deaths may be directly or indirectly related to these diseases. It is estimated that approximately 350.[45] DVT is much less common in the pediatric population.[42] Hospitalization Treatment at home is an option according to a meta-analysis by the Cochrane Collaboration. pain. Rosamond W.wikipedia. PMID 16403932 (http://www. ^ Virchow R. "Does this patient have deep vein thrombosis?". MD (last modified March 2008).nih. Lessard D.Wikipedia.167.pubmedcentral.doi.ncbi.nlm. Fergusson D.ncbi. and behavior.1503/cmaj. Arch. 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