AN INVESTIGATION OF DEEP VEIN THROMBOSIS BASED ON CLINICAL AND SONOGRAPHIC EVIDENCE

Thandiwe Murape 2014

THE VENOUS SYSTEM

Acts as a reservoir to hold blood. Acts as a conduit to return blood to

heart and lungs. Is composed of single tissue layer but

large veins have an internal elastic membrane.

Blood travels from end-capillary venules for eventual delivery to the heart & lungs (The Fundamental of Phlebology, 2014)

http://www.vectorstock.com/royalty-free-vector/venous-system-vector-826048

http://education-portal.com/academy/lesson/what-are-veins-functions-lesson-quiz.html#lesson

WHAT IS DEEP VEIN THROMBOSIS (DVT)• DVT is the formation of a blood clot in the

deep leg veins. It is a very serious health condition that can proceed to pulmonary embolism which is life threatening.

• It commonly occurs in the lower-limb veins but can also occur in the upper limbs.

• Signs of DVT include pain, swelling and erythema (Rumack, 2011)

• DVT maybe caused by: -• - Previous history of DVT

- In-dwelling venous catheters/surgery- Injury to the vein wall - Malignancy +/- chemotherapy- Immobilisation - Pregnancy- Coagulation abnormalities (Thrush & Hartshorne, 2010)

http://www.sirweb.org/patients/deep-vein-thrombosis/

http://www.lymphedemapeople.com/thesite/lymphedema_deep_venous_thrombosis.htm

DIAGNOSTIC MODALITIES

Duplex Ultrasound is the preferred

method of imaging DVT because it is

cheap and readily available.

Other diagnostic methods include: -

- CT scan

- MRI

- Venography

- Lung Ventilation perfusion scan (used

for pulmonary embolism diagnosis)

- Other test include the D-Dimer blood

test

(National Heart, Lung and Blood

Institute)

CASE STUDY

A 47 year old man presented with pain

in the right calf

Previous history of varicose veins and

DVT in his early 20s.

Strong family history of DVT and strokes

Clinical signs included pain in calf with

very mild swelling and limping.

Not on blood thinners

A recent overseas holiday.

http://thehealthscience.com/showthread.php?840181-Bedside-Ultrasonography-in-Deep-Vein-Thrombosis

… PATHOLOGY

On examination, the CFV, LSV (upper

thigh) and the FV compressed adequately

but on Colour Doppler there was little flow

even with augmentation.

Examination was extended to the IVC, CIV

and EIV to rule out any possible thrombus.

An investigation of the LSV continued

from the ankle and a heterogenous

thrombus of moderate echogenicity was

seen in the lower leg.

… PATHOLOGY

Lower leg veins also involved; SSV, Med

Gastrocs and Pop veins.

These veins were not compressible and

there was partial to no blood flow on

Colour Doppler.

Thrombosed varicose veins were also seen

in the medial aspect of the lower leg.

Patient had a noticeable small lump in the

medical aspect of the lower leg and he felt

pain with probe pressure during

compression.

Thrombosis in LSV lower leg- no blood flow

Varicose vein in the lower leg, med aspect

…PATHOLOGY

Visualisation of thrombosis in the SSV prompted further investigation to the origin of the vessel, the pop vein.

Thrombosis was found in the distal pop vein and was partially compressible with little colour flow.

Examination was presented to radiologist for evaluation.

Given his history, an urgent report was written for patient to take to his GP for further discussion on treatment.

WORK SHEET FOR THE EXAMINATION

Worksheet indicating thrombosed veins.

PITFALLS AND LIMITATION OF ULTRASOUND

Compression of ultrasound has potential to cause thrombus to break off the vein walls

leading to pulmonary embolisation ( Zwiebel & Pellerito, 2005).

Obese patients – difficult to evaluate veins in the groin region and adductor canal

region

Pregnant patients

Swollen /fat legs

(Allan et al, 2006)

http://www.environmentalhealthnews.org/ehs/news/2012/ob-gyns-and-environmental-health

DISEASE PROCESS

If DVT is not treated, severe

complication may occur which include

Pulmonary Embolism and postphlebitic

syndrome (Rumack,2011)

- Thrombus may break off and travel to

the heart then the lungs then block

- A combination of DVT and PE is

referred to as Venous Thromboembolism

(VTE).

http://www.medindia.net/patients/patientinfo/pulmonary-embolism-and-deep-vein-thrombosis.htm

TREATMENT

DVT treatment begins immediately after diagnosis to reduce the risk of the clot breaking off and extend further to the heart and lungs. Immediate treatment may

reduce the risk of post thrombotic syndrome. Depending on location or severity of DVT, treatments may be done at home or in

hospital.

Anticoagulants are used as treatment of DVT such as heparin and warfarin.

Heparin is administered intravenously and acts immediately which warfarin is

administered orally and take days to be effective.

Regular blood tests and ultrasound are important for monitoring effects of treatment.

Management of DVT include

- elevation the affected leg whenever possible

• Use of graduated compression stockings

• Prevention of long periods of immobility.

(http://www.phlebology.com.au/deep-vein-thrombosis)

REFERENCE

Carol M., Rumack., Stephanie R., Wilson., William J., Charboneau and Deborah Levine. 2011. Diagnostic Ultrasound. 4th edition. USA. Elsevier Mosby.

Paul L., Allan., Paul A., Dubbins., Myron A., Pozniak and Norman W., McDicken. 2006. Clinical Doppler Ultrasound. 2nd edition. China. Churchill Livingstone Elsevier.

Abigail Thrush and Tim Hartshorne. 2010. Vascular Ultrasound, How, Why and When. 3rd edition. China. Churchill Livingstone Elsevier.

Ulrike M., Hamper and Robert M., DeJong, and Leslie M., Scoutt. 2007. Ultrasound Evaluation of the Lower Extremity Veins. Radiologic Clinics of North America 45 (3): 525-547.

The Australasian School of Phlebology. Deep Vein Thrombosis. Retrieved on 30 October 2014 from: http://www.phlebology.com.au/deep-vein-thrombosis

National Heart, Lung and Blood Institue. DVT Diagnosis. Retrieved on 30 October 2014 from

http://www.nhlbi.nih.gov/health/health-topics/topics/dvt/diagnosis.html