deep vein thrombosis and post-thrombotic syndrome · deep vein thrombosis and post-thrombotic...
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Deep Vein ThrombosisDeep Vein Thrombosisandand
PostPost--Thrombotic Syndrome Thrombotic Syndrome
Angela BrowneVascular Sonographer
Vascular Ultrasound NorthWhangarei
New Zealand
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Deep Vein Deep Vein ThrombosisThrombosis
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AnatomyAnatomy
Peroneal
Anterior Tibial
Popliteal Vein
(Superficial) Femoral Vein
External iliac Vein
(Common) Femoral Vein
Posterior Tibial
Deep Femoral Vein (Profunda Femoris)
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Proximal Proximal vsvs Distal DVTDistal DVT
Proximal Femoral/Popliteal veins = “Above knee”
Distal Tibial/Peroneal veins Gastrocnemius/Soleal veins = “Below knee”
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What is Deep Vein Thrombosis?What is Deep Vein Thrombosis?
Formation of thrombus within the deep veins of the upper or lower limb
Primary pathology of venous system Results in significant morbidity and mortality Inpatients
48 per 100,000 develop DVT 23 per 100,000 develop PE Inpatient mortality from VTE = 12%
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IncidenceIncidence
1-2 per 1000 per year 2/3 are DVT 1/3 PE Risk doubles every decade after age 40
Major complications Post thrombotic syndrome (PTS) Death (PE) Bleeding (Warfarin)
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Surgery 20% Trauma 12% PHx - DVT / PE 25% Immobility (Hospital or Nursing Home) 8% Lower Extremity paresis 3% Cancer 4-6% Hormone replacement therapy 2% Oral Contraceptive pill 3% Inherited Thrombophilia
Factor V Leiden Protein C, S deficiency Lupus
Risk FactorsRisk Factors
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Pregnancy Heart Disease Obesity Sepsis Age Gender (Female > Male)
Sedentary occupation Seated Immobility Thromboembolism Syndrome (SIT)
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PathogenesisPathogenesis
Virchow’s triad (1856)
Stasis Venous Injury Hypercoagulability
Location Valve pockets Site of venous injury Calf usually 1° site
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Symptoms of DVTSymptoms of DVT
Swelling Pain, Tenderness Pitting Oedema Distension of superficial vessels Positive Homan’s sign Shortness of breath Cutaneous erythema
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Clinical AssessmentClinical Assessment
Large differential diagnosis Ruptured Baker’s cyst Cellulitis Haematoma Compartment syndrome Superficial thrombophlebitis Lymphoedema CHF Adenopathy
Need standardised procedure…
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WellWell’’s Criterias Criteria
-2Alternative diagnosis (as likely or > that of DVT)
1Collateral superficial veins (non varicose)
1Previous DVT documented
1Pitting edema (greater in the symptomatic leg)
1Calf swelling >3 cm compared to the asymptomatic leg
1Entire leg swelling
1Localized tenderness along the distribution of the deep venous system
1Recently bedridden for >3/7 or major surgery <4/52
1Paralysis or recent plaster immobilization of the lower extremities
1Active cancer (treatment ongoing, or within 6/12 or palliative)
ScoreClinical Features
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Byproduct of Fibrinolysis Diagnoses thrombotic activity Non-specific in diagnosis of DVT
-ve D-dimer = DVT unlikely +ve D-dimer = DVT or other coagulable state
Other conditions cause raised D-dimer Active cancer Pregnancy Infection Post-surgery Inflammatory processes Trauma
DD--dimerdimer
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Well’s Score
Duplex ultrasound scanDuplex ultrasound scan
Score ≥2High Probability
D-dimer on way to scan
Score <2Low Probability
D-dimer <200 D-dimer >200
No scan necessary
AlgorithmAlgorithm
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Duplex Duplex UltrasoundUltrasound
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Combination of conventional imaging and doppler flow information
What is Duplex Ultrasound?What is Duplex Ultrasound?
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Advantages of UltrasoundAdvantages of Ultrasound
Accurate Cost effective Non-invasive No ionizing radiation No nephrotoxic contrast No contraindications Portable Assessment of blood flow and anatomy “Real-time” examination Patient friendly
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PurposePurpose
Compressibility
Visualisation of thrombus Differentiate acute vs. chronic
Assessment of venous flow Spontaneous, Phasic, Augmentation
Valve cusp movement
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Limitations of UltrasoundLimitations of Ultrasound
Accuracy Highly accurate when performed by experienced operator(s)
Sensitivity: 97%, Specificity 96% from groin down
Any imaging test is only as strong as its weakest linkPatient, Equipment, Technique, or Operator
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EquipmentEquipment
Colour duplex ultrasound High definition imaging Appropriate transducer frequency
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Ultrasound AppearancesUltrasound Appearances
NORMAL
Echo-free lumen
Size – slightly larger than artery
Compressible
Spontaneous flow
Phasic flow
Augmentation with compression and release
ABNORMAL
Echogenic material within lumen
Distended veins
Non-compressible
Absent / diminished flow
Continuous flow
Dampened / absent flow with augmentation
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Venous CompressionVenous Compression
VeinVein
ArteryArtery
NormalNormal AbnormalAbnormal
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Compressed vein
V
AA
A
V Non-compressible vein
A
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Spontaneous flowSpontaneous flow
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AugmentationAugmentation
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Chronic thrombosisChronic thrombosis
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Treatment of Proximal DVTTreatment of Proximal DVT
5 days LMWH (Clexane) until INR 2.0 – 3.0
Warfarin therapy 3-6 mths
Class 2 graduated compression stockings (below knee) for 1-2 years
NOT white TED stockings
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Graduated Compression Higher pressure at ankle Promote cephalad flow of blood
Reducing ambulatory venous pressure: Compress varicose veins Prevent pooling at ankle Reduce oedema
Compression TherapyCompression Therapy
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Level of compression at the ankle European Standard
1 – 18-21 mmHg 2 – 25-32 mmHg 3 – 36-48 mmHg 4 – 48+ mmHg Travel – 8-15mmHg
Compression ClassesCompression Classes
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TED antiTED anti--embolism stockingsembolism stockings
18 mmHg Prevention of DVT intra and post-operatively
Manufacturers Recommendation:“For use in the non-ambulant convalescing
patient”
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NOT designed for ambulant use
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2 year 2 year RandomisedRandomised Controlled Trial, 2003Controlled Trial, 2003
180 patients Class 2 graduated compression hose 1-2 years post DVT Significant reduction of PTS risk of up to 50%
Recommendation: Recommendation: Prescribe compression therapy for DVT.
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LongLong--term effects of DVTterm effects of DVT
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Calf muscle pumpCalf muscle pump
Veins are pliable Constrict & dilate over wide range Contraction of Gastrocnemius and Soleus muscles Blood expelled into Popliteal V. Valve closure prevents reflux More valves in calf than thigh
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Calf muscle pump at restCalf muscle pump at rest
Veins fill via arterial inflow @ 1-2ml per second
Normal venous refill time at rest is approx 2 minutes
Valve failure = high volume reflux = venous refill time is 20-40 seconds
Leads to stasis in dependent veins
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Post Thrombotic Syndrome (PTS)Post Thrombotic Syndrome (PTS)
Long term sequelae of DVT Up to 80% of patients within 1-2 years of DVT event Chronic venous obstruction or valvular reflux Failure of calf muscle pump Venous hypertension
Valve leaflets damaged
Chronic Venous Insufficiency
Deep Venous Reflux
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Determinants of PTSDeterminants of PTS
Extent of DVT Rate of recanalisation (fibrosis) Venous valve function Recurrent DVT
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SymptomsSymptoms
Pain Oedema Hyperpigmentation (7-23%) Ulceration (4-6%) Lipodermatosclerosis (champagne glass leg) Heaviness Cramps Itchiness Numbness or tingling Dilatation of superficial veins Redness
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Differential DiagnosisDifferential Diagnosis
PVD Obesity Compartment syndrome Chronic Venous Insufficiency due to varicose veins Lymphoedema May-Thurner syndrome CHF
Diagnosis by duplex ultrasound
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Treatment OptionsTreatment Options
Prevention better than cure Adequate Rx of DVT
Valves permanently damaged Valve reconstruction
Prevention of complications Graduated Class 2 compression stockings Regular exercise Elevate limbs while seated
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TakeTake--home messageshome messages
Assessment and management of DVT within the community (as services allow)
Awareness of possible long-term complications of DVT
Compression Therapy
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ReferencesReferences Bernardi E and Prandoni P. The post-thrombotic syndrome. Current Opinions in Pulmonary Medicine 2000;volume 6:pages 335-42. P. Prandoni, A.W.A. Lensing, M.H. Prins, M. Frulla, A. Marchiori, E. Bernardi, D. Tormene, L. Mosena, A. Pagnan, and A. Girolami. Below-Knee Elastic
Compression Stockings To Prevent the Post-Thrombotic Syndrome. A Randomized, Controlled Trial. Annals of Internal Medicine. 2004; 141: 249-256). Sanjeev Chunilal, Hematology, North Shore Hospital, Auckland www.vascular.co.nz http://www.podiatrytoday.com/article/3335 http://www.venous-info.com/handbook/hbk01c.html Non-pharmaceutical measures for prevention of post-thrombotic syndrome; Kolbach DN, Sandbrink MWC, Hamulyak K, Neumann HAM, Prins MH http://www.inate.org/en/1/2/6/23/default.aspx Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003; 349: 1227–1235 Alexander, Leos & Katz, Am Surg, 2002 68(12) Beasley R, Raymond N, Hill S, Nowitz M, Hughes R. eThrombosis: the 21st century variant of venous thromboembolism associated with immobility. Eur Respir
J. 2003;21:374–6.
ThankThank--you for your attentionyou for your attention
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