Vascular: Deep Venous Thrombosis (DVT)

Deep Vein Thrombosis (DVT)

Definitions

  • Venous Thromboembolism (VTE) – Blood Clot within the Venous System
  • Deep Vein Thrombosis (DVT) – Blood Clot within the Deep Venous System
    • Provoked DVT – DVT Caused by a Known Event (Surgery, etc.)
    • Unprovoked – DVT with No Known Provoking Event
    • Proximal DVT – Iliac, Femoral or Popliteal Vessels
    • Distal DVT – Below the Knee with No Proximal Component
  • Pulmonary Embolism (PE) – Blood Clot Occlusion of the Pulmonary Arteries, Most Often Due to a DVT

Risk Factors

Location

  • Most Common Site: Calf
  • Left Side 2x More Common Than Right
  • May-Thurner Syndrome: Left Iliac Vein Thrombosis Due to Compression by Right Iliac Artery

Presentation

  • Symptoms:
    • Swelling
    • Pain
    • Warmth
    • Erythema
  • Homans Sign: Pain with Foot Dorsiflexion
    • No Diagnostic Value – Poor Sensitivity & Specificity
  • Phlegmasia Alba Dolens
    • Early DVT Impairment of Arterial Supply
    • Sx: White, Painful & Swollen
  • Phlegmasia Cerulea Dolens
    • Late DVT Impairment of Arterial Supply
    • Sx: Blue, Painful & Swollen Mn
    • Indicates Impending Gangrene
    • Half Have Malignancy

Leg Swelling Due to DVT 1

Phlegmasia Alba Dolens 2

Phlegmasia Cerulea Dolens 3

Diagnosis

  • Dx: Ultrasound
  • US Findings:
    • General DVT Findings:
      • Intramural Thrombus
      • Noncompressible Veins
      • Venous Dilation
      • No Flow
    • Acute US Findings:
      • Echolucent/Hypoechoic
      • Homogenous
      • Poorly Attached
      • Smooth Borders
      • Nonrigid
      • Venous Dilation
      • Small Collaterals
    • Chronic US Findings:
      • Brightly Echogenic
      • Heterogenous
      • Well Attached
      • Irregular Borders
      • Rigid
      • Small/Contracted Veins
      • Large Collaterals
  • D-Dimer is Not Specific & Generally Not Useful in the Surgical Setting

Femoral DVT on US 2

Deep Vein Thrombosis (DVT) – Treatment

Prophylaxis

Treatment – First Episode

  • Proximal DVT
    • Provoked: 3-6 Months Anticoagulation
    • Unprovoked: Long-Term (> 12 Months) Anticoagulation
    • Consider Lifelong Anticoagulation if Hypercoagulable Disorder Present
  • Distal DVT
    • Symptomatic: Anticoagulation
    • Asymptomatic: Serial US x2 Weeks
  • Phlegmasia Cerulea Dolens
    • Non-Threatened Extremity: Catheter-Directed Thrombolytics
    • Threatened Extremity: Thrombectomy
  • Choice of Agent:
    • General Options:
      • Unfractionated Heparin
      • Low Molecular Weight Heparin (Lovenox)
      • Fondaparinux
      • Rivaroxaban
      • Apixaban
      • Warfarin/Coumadin – Cannot Be Sole Initial Treatment
    • Malignancy: Low Molecular Weight Heparin (Lovenox)
    • Pregnancy: Heparin or Low Molecular Weight Heparin (Lovenox)
      • Warfarin is Teratogenic
  • *May-Thurner Syndrome Managed with Venography, Thrombolysis/Thrombectomy & Left Iliac Stent

Treatment – Subsequent Episodes

  • Second Episode: Long-Term (> 12 Months) Anticoagulation
  • Third Episode: Life-Long Anticoagulation

IVC Filter

  • Goal: PE Prophylaxis
  • Indications:
    • Acute Proximal DVT or PE with Anticoagulation Absolute Contraindication
      • Includes:
        • Active Bleeding
        • Acute Intracranial Hemorrhage
        • Major Trauma
        • High Bleeding-Risk Surgery
    • Recurrent VTE Despite Therapeutic Anticoagulation
  • Placement:
    • Access Through Right IJ – Most Direct Access
    • Position:
      • Infrarenal IVC (Generally Preferred)
        • Minimize Risk of Filter Obstruction Occluding the Renal Veins
      • Suprarenal IVC
        • Used for a Renal Vein Thrombosis
        • Used in Pregnancy – To Avoid Contact with a Gravid Uterus
  • Removal:
    • Filters Should Be Removed as Long as Protection is No Longer Needed
    • Overall Retrieval Rate: 25-34%
    • Best Predictor of Removal: Thrombosis Clinic Follow Up Appointment
    • Highest Risk of Difficult Removal: Placement > 7 Months
  • Complications:
    • Increases DVT Risk
    • IVC Thrombosis
    • Filter Migration
    • Filter Erosion

IVC Filter Placement 4

Mnemonics

DVT Color Changes by Severity

  • USA!: Red, White & Blue
    • Red – Swollen Red DVT
    • White – Phlegmasia Alba Dolens
    • Blue – Phlegmasia Cerulea Dolens
  • Cerulea is “Cruel” & Worst

References

  1. Babu MR, Ramesh C, Thirumurugan K, Prasad GA. Deep vein thrombosis: A rare complication in oral and maxillofacial surgery: A review of two cases. Contemp Clin Dent. 2013 Apr;4(2):236-8. (License: CC BY-NC-SA-3.0)
  2. Suciadi L P, Aristo A N (March 24, 2021) Phlegmasia Alba Dolens Complicating Rhabdomyolysis. Cureus 13(3): e14080. (License: CC BY-4.0)
  3. Yang SS, Yun WS. Surgical Thrombectomy for Phlegmasia Cerulea Dolens. Vasc Specialist Int. 2016 Dec;32(4):201-204. (License: CC BY-NC-4.0)
  4. Kishima H, Fukunaga M, Nishian K, Saita T, Horimatsu T, Sugahara M, Mine T, Masuyama T. Aspiration thrombectomy in a patient with suprarenal inferior vena cava thrombosis. Case Rep Cardiol. 2015;2015:495065. (License: CC BY-3.0)