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Deep vein thrombosis

Updated : July 9, 2024





Background

DVT stands for deep vein thrombosis, blood clot formation in the deep veins, mainly in the limbs but also in the arms, mesentery, and brain. It is a common and critical health issue and has been classified as a VTE disease.

It is ranked as the third most significant contributor to cardiovascular-related fatalities, attributed to heart attacks and strokes. While pulmonary embolisms are not always observed in the patients, repletion of clot formations and the occurrence of the “post-thrombotic syndrome” dramatically impact the health conditions and quality of life.

Epidemiology

The occurrence of DVT and the rate at which this condition presents can be influenced by region, distribution of the people, and access to health care services. DVT has higher prevalence rates in Western civilization. It is an ailment that equally cuts across the sexes, with a higher prevalence in women during pregnancy and soon after childbirth. It is possible for anyone of any age, but its prevalence is higher among the old age group. The condition is prevalent among older people.

It was indicated that women might have a slightly higher prevalence of DVT than men, especially during pregnancy, because of hormonal changes and the degree of venous stasis. The gender difference is insignificant, although the results lean more toward the females. There are several reasons patients admitted to hospitals are at a higher risk, Including mobility issues, surgery, and existing conditions. In acute care hospitals measures such as use of blood thinners or compression tights are used to minimize occurrences of hospital acquired DVT.

Anatomy

Pathophysiology

Thrombosis can be considered as an adaptive process that has the function of stopping bleeding and sealing the injured blood vessels. Fibrinolysis is seen as an opposing force to check thrombosis or to prevent the condition from getting worse. Venous thrombosis is generally initiated by factors and Virchow’s triad present in varying capacities involving the patient.

However, the above-named factors combined lead to an early contact of thrombus with the endothelium which leads to the local release of cytokines and adhesion of WBCs to the endothelium layer.

New developments of thrombosis directly depend on the interplay between the coagulation and thrombolytic systems. Lower limb deep vein DVT below the knee is most seen, which typically begins from the areas of low blood flow, particularly from the soleal sinuses located behind the blood venous pockets.

Etiology

Obesity: Obesity is known to cause venous stasis, and it exposes one to DVT.

Cancer: Patients diagnosed with cancer are more susceptive to the formation of DVT because of substances that liberate clotting factors.

Genetic Factors: There are those who have inherited genes that can cause formation of DVT, and these genes may be inherited from parents to children.

Inflammatory Conditions: Several diseases such as inflammatory bowel disease and vasculitis are among the diseases that predispose a patient to develop DVT.

Varicose Veins: Patients with varicose veins are likely to have an increased risk of developing DVT because of changes in blood circulation patterns in the affected veins.

Genetics

Prognostic Factors

The overall outcome in patients with deep vein thrombosis is usually better if the condition is detected early, and the right treatment is started as soon as possible. This may help prevent the growth of the clot or the risk of further problems that may be life threatening.

Clinical History

Complete understanding of the patient’s medical and family history and occurrences, events, or circumstances that may contribute to the predisposition to developing deep vein thrombosis. Common risk factors include surgery, trauma, cancer, prolonged immobility, smoking, obesity, hormonal contraceptives, or if he has a family history of this condition or DVT. Joint replacement and primary abdominal operations are some of the operations to put a patient at a higher risk of deep vein thrombosis.

Physical Examination

D-dimer Test

Ultrasound

Venography

MRI or CT Venography

Age group

Associated comorbidity

Cancer

Heart Disease

Respiratory Disease

Obesity

Inherited Blood Clotting Disorders

Previous DVT or Pulmonary Embolism (PE)

Associated activity

Acuity of presentation

Acute Presentation:

Signs are manifested acutely, and the severity of the imaginal stage’s symptoms can be high.

Common acute symptoms include:

Local edema of one leg or one arm.

Soreness is accompanied by pain, commonly in the calf muscles.

Umbilical hernia or bruise-like discoloration of the skin on the leg.

A sensation of warmth is felt in the concerned leg.

Differential Diagnoses

Cellulitis

Ruptured Baker cyst

Superficial thrombophlebitis

Vasculitis

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

The main strategies in the management of deep vein thrombosis are the prevention of the clot, minimization of the occurrence of complications, and prevention of the reappearance of a clot. It usually involves the brief use of anticoagulation medication heparin and is followed by oral anticoagulation Warfarin or direct oral anticoagulant (DOACs). In extreme situations, thrombolytic agents will be administered to dissolve the clot.

Using compression bandages, raising the legs, and pain treatment will help ease the symptoms and decrease the size of the affected limbs. Meticulous non-pharmacological interventions like early mobilization may be recommended; nevertheless, patients with recurrent DVT may need to be put on lifelong anticoagulation. In the case of DVT, preventive measures involve patient education, regular observation, and appropriately designed treatment regimens that would help prevent the occurrence of other complications.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Non-pharmacological approach in treating Deep vein thrombosis

Mobility and Exercise

Encourage Regular Movement: Make sure that people, particularly desk-bound employees or travellers, stand up and walk around at least every hour.

Exercise Programs: Indicate walking activities and other forms of exercises to be done on the legs such calf movements, leg exercising and massages.

Workplace Adjustments

Ergonomic Workstations: Ensure standing desks or ergonomically convertible desks so that the employees stand during their working time.

Break Reminders: Similarly, the employees may be reminded to take a break and stand up from their seats using apps or Alarms to circulate.

Travel Recommendations

Frequent Stops: For people, who travel long distances by plane, by car, etc., suggest getting up and stretch from time to time.

Compression Stockings: It is recommended to wear compression stockings to enhance blood circulation in the legs.

Hydration

Promote Hydration: Ensure that water is easily accessible to the patient and that they drink enough, because lack of proper hydration raises the threat of formation of blood clots.

Role of anticoagulants in treating deep vein thrombosis

 

Heparins

Unfractionated Heparin (UFH): Given by intravenous or subcutaneous route, UFH increases the action of antithrombin that helps neutralize thrombin and other substances causing clot formation.

Low Molecular Weight Heparin (LMWH): Some are enoxaparin that is sold under the brand name Lovenox and dalteparin sold under fragmin brand. LMWH is administered subcutaneously and has a better predictable effect on anticoagulation than UFH.

Use of Vitamin K Antagonists in treating deep vein thrombosis

Warfarin (Coumadin): It’s an oral anticoagulant that helps in reducing the synthesis of vitamin K dependent clotting factors. Moreover, Warfarin causes adverse effects and needs daily monitoring of the patient’s blood levels commonly known as the International Normalized Ratio (INR).

Effectiveness of Direct Oral Anticoagulants (DOACs) in treating deep vein thrombosis

Factor Xa Inhibitors: These include rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa). These drugs block the enzyme activity of Factor Xa, which is essential for forming a blood clot.

Direct Thrombin Inhibitors: Dabigatran (Pradaxa) is an example of such factors or variables influencing prescription. This one directly interferes with thrombin activity; it will not allow the transformation of fibrinogen to fibrin.

Role of intervention with procedure in treating deep vein thrombosis

Thrombectomy: This is a process of surgery where the clot is cleared from the vein deliberately. It is generally performed when there are complications of DVT, and your doctor believes that your limb is at serious risk of being affected or the vein affected is very large.

Catheter-directed Thrombolysis: During this process a catheter is fed through the vein, and it is directed to where the blood clot is located. Administration of a dissolution drug (thrombolytic agent) takes place directly on the site of the clot through the catheter. This approach is frequently applied in the process of extensive DVT.

Venous Stenting: Stents are occasionally inserted into veins to maintain their open condition if they are constricted or obstructed, usually after thrombolysis, to stop DVT from recurring.

Role of management in treating deep vein thrombosis

Initial Management:

Diagnosis: To ascertain the diagnosis, one must obtain an imaging study like a Doppler ultrasound or venography.

Anticoagulation Therapy: Initiate anticoagulation therapy with LMWH, heparin or any other agents which will help in preventing the formation of more clots.

Pain and Symptom Management: They will require wearing compression stockings and may take pain relievers as necessary.

Acute Phase Treatment:

Oral Anticoagulants: Switch to the parenteral agents, often oral anticoagulants like Warfarin or direct oral anticoagulants, and monitor INR where Warfarin is used.

Monitoring: Screening tests to assess the need for anticoagulation therapy and the risks to the patient in long-term use.

Maintenance and Long-term Management:

Continued Anticoagulation: To sustain a therapeutic level of anticoagulation (Perceived as 3-6 months depending on risk factors).

Lifestyle Modifications: Explain to the patients the importance of not staying still for long hours and ask patients to do something about obesity and smoking.

Prevention of Recurrence:

Extended Anticoagulation: Patients who have a high risk of recurrence should think about receiving prolonged anticoagulation.

Follow-up: Follow-up appointments as needed for the subsequent check-ups in order rule out complication or re-emergence of the complaints.

Management of Complications:

Post-Thrombotic Syndrome: Try to treat pain and inflammatory processes using only such measures as compression therapy and physical therapy.

Pulmonary Embolism: It is advisable to stay alert for signs that may exhibit pulmonary embolism and treat it if it develops.

Medication

 

edoxaban 

After 5-10 days of initial treatment:

≤60kg:30mg orally every day >60kg:60mg orally every day



Dose Adjustments

Renal impairment (PE/DVT)
15-50ml/min-30mg orally every day
>50ml/min-No dosage adjustment needed
Renal impairment (Atrial fibrillation)
CrCl<15ml/min: No data available
CrCl 15-50ml/min:30mg orally every
day
CrCl>50-95ml/min: Dosage adjustment not necessary
CrCl>95ml/min: Not recommended

dalteparin 


indicated for Deep vein thrombosis after Hip replacement surgery:


Beginning of the preoperative period (the evening before surgery; allow approximately 24 hours between doses)
5000 IU subcutaneously every 10-14 hours before surgery
5000 IU subcutaneous every 4-8 hours after surgery
5000 IU subcutaneous during the postoperative period administer once a day

• Day of surgery-preoperative start
Subcutaneous administration of 2500 international units within two hours of surgery
2500 international units subcutaneously 4 to 8 hours after surgery or later if hemostasis has not been achieved
Allow a minimum of 6 hours between this dose and the dose to be given on postoperative day 1, and adjust the timing of the dose on postoperative day one accordingly. Five thousand international units subcutaneously once a day during the postoperative period

• Postoperative period
2500 international units subcutaneously 4 to 8 hours after surgery or later if hemostasis has not been established; allow a minimum of 6 hours between this dosage and the dose to be administered on postoperative day 1 and alter the scheduling of the dose on postoperative day 1 appropriately 5000 international units subcutaneously once daily during the postoperative period
Therapy duration:5 to 10days after surgery



dalteparin 


Deep vein thrombosis after abdominal surgery:


• Moderate thromboembolic risk:
2500 international units subcutaneously once a day, beginning 1 to 2 hours before surgery and continued once a day postoperatively.

• High thromboembolic risk:
may be administered as a subcutaneous injection the evening before surgery and once a day postoperatively at a dose of 5000 IU per injection or as two injections of 2500 IU, each given 1 to 2 hours apart before surgery, followed by a daily injection of 5000 IU postoperatively

Therapy duration:5-10days



heparin 

Prophylaxis
7500 units subcutaneous every 12 hours, OR
5000 units subcutaneous every 8-12hours
Treatment
Intravenous bolus of 80 units/kg, following continuous infusion of about 18 units/kg in hour, OR
subcutaneous injection 250 units/kg, following 250 units/kg for every 12 hours
5000 units Intravenous bolus, following continuous infusion of 1300 units/hr, OR
Dosing considerations
There are a number of concentrations available; caution is necessary to prevent the medication errors



dabigatran 


Indicated for Deep Vein Thrombosis – Prophylaxis
150 mg orally two times a day
Note: If required, anticoagulant activity can be evaluated using aPTT or ECT instead of INR, although typically the measurement of anticoagulant activity is unnecessary with this medication
Prevention of Thromboembolism in Atrial Fibrillation
150 mg orally two times a day
Note: If required, anticoagulant activity can be evaluated using aPTT or ECT instead of INR, although typically the measurement of anticoagulant activity is unnecessary with this medication
Deep Vein Thrombosis or Pulmonary Embolism as Prophylaxis Following Hip Replacement Surgery
The recommended dosing regimen for this medication is to administer 110 mg orally 1-4 hours following surgery and after hemostasis has been achieved. Subsequently, the patient should take 220 mg orally one time a day for a duration of 28-35 days
Note: In the event that this medication is not administered on the day of surgery, treatment should begin with 220 mg orally one time a day after hemostasis has been established



desirudin 

Indicated for prophylactic treatment of deep vein thrombosis in patients who will undergo elective hip replacement surgery
Initially, 15 mg subcutaneously 5-15 minutes before surgery (only after regional anesthesia)
Maintain the dose at 15 mg subcutaneously every 12 hours
Carry out the evaluation risk of the bleeding disorder before drug administration
The product is discontinued in the United States



nadroparin 

For Patients with standard bleeding risk:
Administer dose of 171 anti-Xa units/kg subcutaneously one time a day
Fixed dosing:
40 to 49 kg: dose of 7600 anti-Xa units subcutaneously one time daily
≥90 kg: dose of 17100 anti-Xa units subcutaneously one time daily
For Patients with increased risk for bleeding:
Administer dose of 86 anti-Xa units/kg subcutaneously each 12 hours
Fixed dosing:
40 to 49 kg: dose of 3800 anti-Xa units subcutaneously each 12 hours
≥90 kg: dose of 8550 anti-Xa units subcutaneously each 12 hours



anisindione 

Take initial dose of 300 mg, 200 mg and 100 mg orally on first, second and third day respectively



certoparin 


Indicated for Deep Vein Thrombosis
One time a day subcutaneously
The maximum dose is 3000 IU



urokinase 

4400 units/kg dissolved into 15 ml of 0.9% sodium chloride were infused intravenously (IV) over 10 minutes initially, followed by 4400 units/kg/hr for 12–24 hours



reviparin 

0.25 ml is administered subcutaneously daily at least 2 hours before the surgery




100

IU/kg

Solution

Subcutaneous (SC)

once a day

1

week



 
 

dalteparin 


Indicated for Deep vein thrombosis after abdominal surgery:


• Moderate thromboembolic risk:
2500 international units subcutaneously once a day, beginning 1 to 2 hours before surgery
• High thromboembolic risk:
may be administered as a subcutaneous injection the evening before surgery and once a day postoperatively at a dose of 5000 IU per injection



dalteparin 


Indicated for Deep vein thrombosis after Hip replacement surgery:


• Day of surgery-preoperative start
Subcutaneous administration of 2500 international units within two hours of surgery
• Postoperative period
2500 international units subcutaneously 4 to 8 hours after surgery thereafter 5000IU every day



Media Gallary

Deep vein thrombosis

Updated : July 9, 2024




DVT stands for deep vein thrombosis, blood clot formation in the deep veins, mainly in the limbs but also in the arms, mesentery, and brain. It is a common and critical health issue and has been classified as a VTE disease.

It is ranked as the third most significant contributor to cardiovascular-related fatalities, attributed to heart attacks and strokes. While pulmonary embolisms are not always observed in the patients, repletion of clot formations and the occurrence of the “post-thrombotic syndrome” dramatically impact the health conditions and quality of life.

The occurrence of DVT and the rate at which this condition presents can be influenced by region, distribution of the people, and access to health care services. DVT has higher prevalence rates in Western civilization. It is an ailment that equally cuts across the sexes, with a higher prevalence in women during pregnancy and soon after childbirth. It is possible for anyone of any age, but its prevalence is higher among the old age group. The condition is prevalent among older people.

It was indicated that women might have a slightly higher prevalence of DVT than men, especially during pregnancy, because of hormonal changes and the degree of venous stasis. The gender difference is insignificant, although the results lean more toward the females. There are several reasons patients admitted to hospitals are at a higher risk, Including mobility issues, surgery, and existing conditions. In acute care hospitals measures such as use of blood thinners or compression tights are used to minimize occurrences of hospital acquired DVT.

Thrombosis can be considered as an adaptive process that has the function of stopping bleeding and sealing the injured blood vessels. Fibrinolysis is seen as an opposing force to check thrombosis or to prevent the condition from getting worse. Venous thrombosis is generally initiated by factors and Virchow’s triad present in varying capacities involving the patient.

However, the above-named factors combined lead to an early contact of thrombus with the endothelium which leads to the local release of cytokines and adhesion of WBCs to the endothelium layer.

New developments of thrombosis directly depend on the interplay between the coagulation and thrombolytic systems. Lower limb deep vein DVT below the knee is most seen, which typically begins from the areas of low blood flow, particularly from the soleal sinuses located behind the blood venous pockets.

Obesity: Obesity is known to cause venous stasis, and it exposes one to DVT.

Cancer: Patients diagnosed with cancer are more susceptive to the formation of DVT because of substances that liberate clotting factors.

Genetic Factors: There are those who have inherited genes that can cause formation of DVT, and these genes may be inherited from parents to children.

Inflammatory Conditions: Several diseases such as inflammatory bowel disease and vasculitis are among the diseases that predispose a patient to develop DVT.

Varicose Veins: Patients with varicose veins are likely to have an increased risk of developing DVT because of changes in blood circulation patterns in the affected veins.

The overall outcome in patients with deep vein thrombosis is usually better if the condition is detected early, and the right treatment is started as soon as possible. This may help prevent the growth of the clot or the risk of further problems that may be life threatening.

Complete understanding of the patient’s medical and family history and occurrences, events, or circumstances that may contribute to the predisposition to developing deep vein thrombosis. Common risk factors include surgery, trauma, cancer, prolonged immobility, smoking, obesity, hormonal contraceptives, or if he has a family history of this condition or DVT. Joint replacement and primary abdominal operations are some of the operations to put a patient at a higher risk of deep vein thrombosis.

D-dimer Test

Ultrasound

Venography

MRI or CT Venography

Cancer

Heart Disease

Respiratory Disease

Obesity

Inherited Blood Clotting Disorders

Previous DVT or Pulmonary Embolism (PE)

Acute Presentation:

Signs are manifested acutely, and the severity of the imaginal stage’s symptoms can be high.

Common acute symptoms include:

Local edema of one leg or one arm.

Soreness is accompanied by pain, commonly in the calf muscles.

Umbilical hernia or bruise-like discoloration of the skin on the leg.

A sensation of warmth is felt in the concerned leg.

Cellulitis

Ruptured Baker cyst

Superficial thrombophlebitis

Vasculitis

The main strategies in the management of deep vein thrombosis are the prevention of the clot, minimization of the occurrence of complications, and prevention of the reappearance of a clot. It usually involves the brief use of anticoagulation medication heparin and is followed by oral anticoagulation Warfarin or direct oral anticoagulant (DOACs). In extreme situations, thrombolytic agents will be administered to dissolve the clot.

Using compression bandages, raising the legs, and pain treatment will help ease the symptoms and decrease the size of the affected limbs. Meticulous non-pharmacological interventions like early mobilization may be recommended; nevertheless, patients with recurrent DVT may need to be put on lifelong anticoagulation. In the case of DVT, preventive measures involve patient education, regular observation, and appropriately designed treatment regimens that would help prevent the occurrence of other complications.

Mobility and Exercise

Encourage Regular Movement: Make sure that people, particularly desk-bound employees or travellers, stand up and walk around at least every hour.

Exercise Programs: Indicate walking activities and other forms of exercises to be done on the legs such calf movements, leg exercising and massages.

Workplace Adjustments

Ergonomic Workstations: Ensure standing desks or ergonomically convertible desks so that the employees stand during their working time.

Break Reminders: Similarly, the employees may be reminded to take a break and stand up from their seats using apps or Alarms to circulate.

Travel Recommendations

Frequent Stops: For people, who travel long distances by plane, by car, etc., suggest getting up and stretch from time to time.

Compression Stockings: It is recommended to wear compression stockings to enhance blood circulation in the legs.

Hydration

Promote Hydration: Ensure that water is easily accessible to the patient and that they drink enough, because lack of proper hydration raises the threat of formation of blood clots.

 

Heparins

Unfractionated Heparin (UFH): Given by intravenous or subcutaneous route, UFH increases the action of antithrombin that helps neutralize thrombin and other substances causing clot formation.

Low Molecular Weight Heparin (LMWH): Some are enoxaparin that is sold under the brand name Lovenox and dalteparin sold under fragmin brand. LMWH is administered subcutaneously and has a better predictable effect on anticoagulation than UFH.

Warfarin (Coumadin): It’s an oral anticoagulant that helps in reducing the synthesis of vitamin K dependent clotting factors. Moreover, Warfarin causes adverse effects and needs daily monitoring of the patient’s blood levels commonly known as the International Normalized Ratio (INR).

Factor Xa Inhibitors: These include rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa). These drugs block the enzyme activity of Factor Xa, which is essential for forming a blood clot.

Direct Thrombin Inhibitors: Dabigatran (Pradaxa) is an example of such factors or variables influencing prescription. This one directly interferes with thrombin activity; it will not allow the transformation of fibrinoge