Deep venous thrombosis: Difference between revisions

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==Background==
==Background==
[[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}}


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==Clinical Features==
==Clinical Features==
===Physical Exam===
*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}}


==Diagnosis==
==Evaluation==
===Modified Wells Score===
[[File:DVT-clinical-algorithm.jpg|thumbnail|ACEP [[DVT]]Clinical Algorithm]]
*Active cancer (<6 mo) - 1pt
*Clinical exam
*Paralysis, paresis, or immob of extremity - 1pt
*Risk stratification for further testing indicated using, e.g. Modified Wells Score
*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


[[File:Deep vein thrombosis of the right leg.jpg|thumbnail|DVT of right leg]]
===[[Modified Wells Score]]===
[[File:DVT.jpeg|thumbnail|Large DVT of left leg]]
{{Modified Wells Score}}
 
====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


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


'''Distal DVT'''  
===Distal DVT===
''Distal veins are the '''anterior tibial''', '''posterior tibial''', '''peroneal''', '''gastrocnemius, soleus.'''''
*Symptomatic  
*Symptomatic  
**Anticoagulate with [[heparin]]/[[coumadin]] x 3 months
**Anticoagulate with [[heparin]]/[[coumadin]] x 3 months
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*Asymptomatic without extension
*Asymptomatic without extension
**Discharge with compressive U/S q2 weeks
**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


==Anticoagulation Options==
==Anticoagulation Options==
===[[Coumadin]] Regimen===
===[[Coumadin]] Regimen===
*Standard anticoagulation regimen
*Standard anticoagulation regimen
**[[Enoxaparin]] 1 mg/kg q12h 4-5 days
**[[Enoxaparin]] 1mg/kg q12h 4-5 days
**[[Coumadin]]
**[[Coumadin]]
***typical starting dose 5 mg/day
***typical starting dose 5mg/day
***give 7d supply with first dose in ED
***give 7d supply with first dose in ED
*GFR <30 and/or potentially requiring reversal
*GFR <30 and/or potentially requiring reversal
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**Check creatinine on all patients prior to initiation
**Check creatinine on all patients prior to initiation
**CrCl <30 avoid use
**CrCl <30 avoid use
===[[Apixaban]] (Eliquis) Regimen===
*Standard
**Start 10mg PO BID x 7 days, then 5mg PO BID daily (duration depending on risk factors)
**No need for initial enoxaparin
*Renal dosing
**No dosage adjustments necessary for renal impairment, but CrCl <25 mL/minute were excluded from clinical trials


===Contraindications to anticoagulation===
===Contraindications to anticoagulation===
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==Disposition==
==Disposition==
'''Inpatient therapy for patients with ANY of the following:'''
===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:
*Iliofemoral DVT
*Iliofemoral DVT
*Phlegmasia cerulea dolens
*Phlegmasia cerulea dolens
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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:'''
*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==
*[[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]


==References ==
==References==
<references/>
<references/>


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

Revision as of 12:23, 25 September 2017

Background

DVT of right leg
Large DVTof left leg

Clinical Spectrum of Venous thromboembolism

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

Anatomy

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

  • 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

Evaluation

ACEP DVTClinical 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]

Management

The distinction between distal and proximal relates to veins below and above the knee respectively.[5] 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.[6]

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[7]

  • 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

Anticoagulation Options

Coumadin Regimen

  • Standard anticoagulation regimen
    • Enoxaparin 1mg/kg q12h 4-5 days
    • Coumadin
      • typical starting dose 5mg/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

Apixaban (Eliquis) Regimen

  • Standard
    • Start 10mg PO BID x 7 days, then 5mg PO BID daily (duration depending on risk factors)
    • No need for initial enoxaparin
  • Renal dosing
    • No dosage adjustments necessary for renal impairment, but 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:

  • 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

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. ↑ 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
  6. ↑ Litzendorf ME. Satiani B. Superficial Venous thrombosis:disease progression and evolving treatment approaches. Vasc Health Risk Manag. 2011(7). 569-575
  7. ↑ DʼAlton ME et al. National Partnership for Maternal Safety: Consensus bundle on venous thromboembolism. Obstet Gynecol 2016 Oct; 128:688.
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