Deep venous thrombosis: Difference between revisions
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==Diagnosis==
==Background==
==Modified Wells Score==
[[File:Deep vein thrombosis of the right leg.jpg|thumbnail|DVT of right leg]]
#Active cancer (<6 mo) - 1pt
[[File:DVT.jpeg|thumbnail|Large [[DVT]]of left leg]]
#Paralysis, paresis, or immob of extremity - 1pt
{{Venous thromboembolism types}}
#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
*Leg swelling with circumference >3cm more than unaffected side
**If both negative done
*Tenderness over calf muscle
**If utz positive done
*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>
**If pos d-dimer but neg UTZ:
***Repeat utz in 1wk


==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}}
 
==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
 
==Anticoagulation Options==
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Medication'''
| align="center" style="background:#f0f0f0;"|'''[[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
*[[Coumadin]]
**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
*[[Coumadin]] 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


==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 05:22, 30 November 2018

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]

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

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]

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

Medication Coumadin Rivaroxaban (Xarelto) Apixaban (Eliquis)
Standard Dosing
  • Enoxaparin 1mg/kg q12h x 4-5 days
  • Coumadin
    • 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
  • Coumadin 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):[8]
    • 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

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.
  8. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646749/
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