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Incidence - PowerPoint PPT Presentation

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Deep Vein Thrombosis & Malignancy Department of Radiation Oncology Presented by Dr. Muhammad Zubaer Hussain. Incidence. About 600,000 hospitalizations per year occur for DVT in the United States. 100,000 to 300,000 VTE-related deaths occur annually in the United States.

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Deep VeinThrombosis&MalignancyDepartment of Radiation OncologyPresented byDr. Muhammad Zubaer Hussain

  • About 600,000 hospitalizations per year occur for DVT in the United States.
  • 100,000 to 300,000 VTE-related deaths occur annually in the United States.
  • Approximately 1 person in 20 develops a DVT in the course of his or her lifetime.
in hospital vte
In-hospital VTE

In hospitalized patients, the incidence of venous thrombosis is considerably higher and varies from 20-70%.

The in-hospital case- fatality rate for VTE is 12% rising to 21% in elderly persons.

Venous thrombosis is second leading cause of death in cancer patients.

lower limb dvt
Lower Limb DVT
  • Although most DVT is occult and resolves spontaneously without complication,
  • It is the underlying source of 90% of acute PEs
  • PE occurs in approximately 10% of patients with acute DVT and can cause up to 10% of in hospital deaths.
  • Cause 25,000 deaths per year in the United States.
upper limb dvt
Upper Limb DVT
  • Asymmetry in the supraclavicularfossa or in the circumference of the upper arms.
  • A prominent superficial venous pattern may be evident on the anterior chest wall.
lower limb dvt1
Lower Limb DVT

Upper Limb DVT

risk factors
Risk Factors
  • Age(In elderly persons, the incidence is increased 4-fold)
  • Immobilization longer than 3 days
  • Pregnancy and the postpartum period
  • Major surgery in previous 4 weeks
  • Plane/car trips (> 4 hours) in previous 4 wks
  • Cancer (30%)
  • Previous DVT
risk factors contd
Risk Factors…Contd
  • Stroke (DVT is found in 53% of paralyzed limbs, compared with only 7% on the nonaffected side.)
  • Acute myocardial infarction (AMI)
  • Congestive heart failure (CHF)
  • Sepsis
  • Nephrotic syndrome
  • Ulcerative colitis
  • Multiple trauma
  • CNS/spinal cord injury
  • Burns
risk factors1
Risk Factors
  • Homocystinuria
  • Polycythemiarubravera
  • Thrombocytosis
  • Inherited disorders of coagulation
  • Drug abuse
  • Oral contraceptives
malignancy dvt
Malignancy & DVT
  • Malignancy is noted in as many as 30% of patients with venous thrombosis.
  • 90% of cancer patients having some abnormal coagulation factors.
  • Chemotherapy may increase the risk of venous thrombosis by affecting the vascular endothelium, coagulation cascades, and tumor cell lysis.
  • The incidence has been shown to increase in those patients undergoing longer courses of therapy.
aetiology of dvt in cancer patients
  • Hypercoagulable State
    • Increased plasma levels of Clotting factors
    • Cancer procoagulant
    • Tissue factor
    • Cytokines
    • Inrceasedplasminogen activator
  • Surgical Intervertion
  • Chemotherapy
  • Prolonged Immobilization
type of cancers with dvt
  • Pancreas
  • Lung
  • Breast
  • GI tumor
  • Prostate
  • Multiple Myeloma
  • Lymphoma
  • Leaukaemia
postoperative venous thrombosis
Postoperative venous thrombosis
  • Varies depending on a multitude of patient factors, including the type of surgery undertaken.
  • Without prophylaxis, general surgery operations typically have an incidence of DVT around 20% in benign disease, whereas 36% in cancer patients.
symptoms and signs
Symptoms and Signs

Lower limb DVT characteristically starts with

  • Pain (50%)
  • Swelling
  • An increase in temperature and
  • Dilatation of the superficial veins.
  • Often, however, there are only minimal S/S
  • Typically unilateral but may be bilateral

(when clot extends proximally into the inferior vena cava. )

( Bilateral DVT is more commonly seen in patients with underlying malignancy )

symptoms and signs1
Symptoms and Signs
  • Most specific symptom Leg pain - Occurs in 50% of patients but is nonspecific
  • Tenderness - Occurs in 75% of patients
  • Warmth or Erythema of the skin over the area of thrombosis
symptoms and signs contd
Symptoms and Signs …contd
  • Clinical symptoms of pulmonary embolism (PE) as the primary manifestation
  • Calf pain on dorsiflexion of the foot (Homans sign)
  • Variable discoloration of the lower extremity
symptoms and signs contd1
Symptoms and Signs …contd
  • Baker's cysts usually occur in patients with rheumatoid arthritis.
  • Cellulitis is usually distinguished by
    • Marked skin erythema and temperature which is localisedwithin a well-demarcated area of the leg and may be associated with an obvious source of entry of infection
    • Fever and chills
  • Postphlebitic syndrome.
    • Leg is diffusely edematous
    • skin ulceration, especially in the medial malleolus of the leg


  • Compression USG (sensitivity is ~99.5%)
  • Venogram
d dimer
  • D-dimer is a useful "rule out" test.
  • Sensitivity >80% for DVT and >95% for PE.
  • Levels increase in patients with
    • MI
    • Pneumonia
    • Sepsis

VTE can cause

  • death from PE

or, among survivors

  • Ch. thromboembolic Pulmonary HTN
  • Postphlebitic/Post thrombotic/Chronic venous insufficiency± Ulceration

Prophylactic management:

Non Pharmacological:

  • Early mobilization of all patients
  • Intermittent pneumatic compression
  • Mechanical foot pumps
  • Graduated compression stockings.

Prophylactic management (Contd)

Pharmacological: (Moderate to High risk of DVT)

  • Low molecular weight heparins (eg. Enoxaparin)
  • Unfractionated heparin
  • Fondaparinux
  • Apixaban
  • Dabigatran
  • Rivaroxaban
  • Warfarin
  • Aspirin

Prophylactic management (Contd)


  • Enoxaparin 40mg sc once daily
  • Fondaparinux 2.5 mg sc once daily
  • Apixaban PO ( Showing promising result in clinical trial)
  • Warfarin10 mg on the first and second days, with 5 mg on

the third day; subsequent doses are titrated against the INR.


Moderate risk of DVT:

  • Major surgery


  • Major medical illness, e.g.
    • Heart failure
    • Myocardial infarction with complications
    • Sepsis
    • Active malignancy
    • Stroke and other conditions leading to lower limb paralysis

High risk of DVT:

  • Major abdominal or pelvic surgery

for malignancy


with history of DVT


known thrombophilia

  • Major hip or knee surgery
  • Neurosurgery
management of established dvt
Management of Established DVT
  • General management:
  • Elevation of limb
  • Analgesia
  • Anticoagulant: (mainstay of treatment)
  • Inferior Vena Caval (IVC) Filters
    • CI to anticoagulation and
    • Recurrent venous thrombosis despite intensive anticoagulation.
management of established dvt1
Management of Established DVT
  • Anticoagulant:

Low molecular weight heparin(LMWH):

1mg/kg sc 12 hrly


Unfractionated heparin

5000 U iv loading  continuous inf20U/kg/hr

Parenteral anticoagulation should be continued for a minimum of 5 days

Warfarin: 10 mg on the first and second days, with 5 mg on the third day; subsequent doses are titrated against the INR.