DVT topic discussion

1. DVT TOPIC DISCUSSION Presenter : Dr. AZZAM SATTI Prepared by Dr . AHMED SAYED

2. Definition : • Deep-vein thrombosis (also known as deep­venous thrombosis or DVT) is the formation of a blood clot ("thrombus") in a deep vein. • Pulmonary embolism (PE) is a condition that occurs when an artery in your lung becomes blocked.

3. Thrombosis :

4. Virchow's Triad

5. Signs & Symptoms : - Pain in the leg . - Tenderness in the calf (one of the most important signs) . - Leg tenderness. - Swelling of the leg. - Increased warmth of the leg . - Redness in the leg . - Bluish skin discoloration .

6. DIAGNOSIS OF DVT : • Clinical examination • Investigations

7. CLINICAL EXAMINATION : Phlegmasia alba dolens (white leg) Phlegmasia cerulea dolens (blue leg)

8. Investigations :

9. Duplex Ultra sonography - Projected sound waves bounce off structures in the leg and create images that reveal abnormalities. The addition of color Doppler imaging improves accuracy. Venography- An x-ray of leg and pelvis will show the calf and thigh veins and reveal any blockages.

10. Cuff-impedance plethysmography ­uses blood pressure checks at different places in the leg to identify possible blockages. MRI - particularly effective in diagnosing DVT in the pelvis, and as effective as venography in diagnosing DVT in the thigh.

11. Potential Complications : • Pulmonary emboli- most serious complication of DVT . • Chronic venous insufficiency - Long-term DVT can degenerate the venous valves. • Post- phlebotic syndrome - long-term complication of DVT which occurs due to damage and scarring to the veins and is characterized by swelling, discomfort and skin pigmentation in the affected area.

12. DVT Risk Factors RISK FACTORS = 3 POINTS RISK FACTORS = 5 POINTS Age > 75 years Elective major lower extremity arthroplasty Major surgery(>3 hours) Hip, pelvis, or leg fracture(<l month) Hx of DVT/PE or clotting disorder Stroke(< 1 month) Acute spinal cord injury (paralysis<l month) Family hx of Thrombosis Heparin-induced thrombocytopenia Thrombophilia

13. MANAGEMENTS FOR DVT : • ANTI-COAGLANT AGENT “ HEPARIN , WARFARIN, ANTI-FACTOR Xa . • ENDOVASCULAR THEARPY .

14. Indications for Percutaneous Transcatheter Treatment • Phlegmasia cerulea dolens treatment • Inferior vena cava thrombosis treatment • Subacute and chronic Iliofemoral DVT treatment • Acute iliofemoral or femoropopliteal DVT treatment • Asymptomatic DVT

15. Phlegmasia cerulea dolens treatment : • Phlegmasia cerulea dolens is an indication for emergency catheter-directed thrombolysis in patients with moderate or low bleeding risks.

16. Inferior vena cava thrombosis treatment • Acute or subacute inferior vena cava thrombosis that causes at least moderate pelvic congestion, limb symptoms, or compromised visceral venous drainage warrants catheter-directed thrombolysis. Involvement of the suprarenal cava, renal veins, and/or hepatic veins may precipitate acute renal or hepatic failure. Thrombus that involves the upper inferior vena cava may make it impossible to place an inferior vena cava filter for pulmonary embolism (PE) prophylaxis.

18. Subacute and chronic Iliofemoral DVT treatment • Subacute and chronic iliofemoral DVT is accompanied by moderate to severe pelvic or limb symptoms with a low bleeding risk. Because recanalization of the iliac vein is unlikely, iliofemoral DVT often produces valvular reflux. • This combination of outflow obstruction and reflux is associated with the most symptomatic forms of PTS.

19. Acute iliofemoral or femoropopliteal DVT treatment •  Few DVT cases resolve after heparin therapy, but systemic thrombolysis improves the rate to 30%, and catheter-directed thrombolysis removes 80% of thrombi.

20. Asymptomatic DVT •  However, while the incidence of PTS may not warrant endovascular treatment, some reports suggest that treatment of asymptomatic DVT may be necessary to prevent most cases of PE that are diagnosed at autopsy. Patients with asymptomatic proximal DVT had a 13.7% risk of mortality risk versus a 2% mortality risk in patients without DVT at all.

21. Percutaneous transcatheter treatment of patients with deep venous thrombosis (DVT) consists : • thrombus removal with catheter-directed thrombolysis . • mechanical thrombectomy. • Angioplasty . • stenting of venous .

22. The goals of endovascular therapy : • reducing the severity and duration of lower-extremity symptoms . • preventing PE . • diminishing the risk of recurrent venous thrombosis. • preventing post-thrombotic syndrome (PTS).

23. Catheter-Directed Thrombolysis Versus Systemic Intravenous Thrombolytic Therapy: • Direct intra-thrombus injection of the thrombolytic agent protects the medication from deactivation by circulating inhibitors and achieves higher drug concentration at the site of thrombosis with a lower total dose than would be used for systemic intravenous thrombolytic therapy. • The lower circulating drug levels are the suggested mechanism for the lower incidence of systemic and, in particular, intracranial hemorrhagic complications reported with catheter-directed thrombolysis.

24. Post-thrombotic syndrome “PTS” : • the cause of PTS is not entirely clear. • Inflammationas well as damage to the venous valves from the thrombus itself. •  valvular incompetence combined with persistent venous obstruction from thrombus increases the pressure in veins and capillaries , Venous hypertension induces a rupture of small superficial veins, subcutaneous hemorrhage[7] and an increase of tissue permeability. That is manifested by pain, swelling, discoloration, and even ulceration.

25. THANK YOU . . .