Thrombosis Research (2009) 123 Suppl.

4, S30S34

intl.elsevierhealth.com/journals/thre

Pathophysiology of venous thrombosis

Jos
e A. L
opez*, Junmei Chen
Puget Sound Blood Center and University of Washington, Seattle, Washington, USA

KEYWORDS
Deep vein thrombosis
(DVT)
Tissue factor
Cancer-associated
thrombosis
von Willebrand factor
Virchows triad
Microvesicle

Abstract
Using Virchows triad as framework, it is clear that alterations in any of its
components (blood composition, the vessel wall, and blood ow) can inuence
the propensity for the development of venous thromboembolism. Each can also
inuence the others in ways that enhance or reduce thrombotic propensity. While
past work has concentrated on blood components that inuence thrombogenicity,
their inuences generally are manifest only after the thrombotic process has begun,
and it is initiation of thrombosis on the vessel wall that is the least well understood.
This brief review attempts to link risk factors such as stasis and cancer to the
mechanisms that initiate thrombosis.
2009 Elsevier Ltd. All rights reserved.

Introduction
For many years, the underpinning of our understanding of the pathophysiology of venous
thrombosis has been Virchows triad, which posits
that venous thrombosis can be produced by
changes in blood composition, blood ow, or
alterations in the blood vessel wall. Of these
three, by far the best studied has been blood
composition, likely a consequence of the ease of
obtaining blood. The mechanisms by which blood
stasis and/or changes to the blood vessel wall
predispose to venous thrombosis are much less
clear, as is the relationship between stasis and
changes in the blood vessel wall.
The blood vessel wall
In arterial thrombosis, there is a clear relationship
between blood vessel injury and the formation of
a thrombus. The thrombi that precipitate myocardial infarction, for example, are usually preceded
* Corresponding author. Jos
e A. L
opez. Puget Sound Blood
Center, Research Division, 921 Terry Ave, Seattle, WA 98104,
USA. Tel.: +1 206 398 5930; fax: +1 206 587 6056.
E-mail address: josel@psbcresearch.org (J.A. L
opez).

by rupture of an atherosclerotic plaque, a process

that exposes adhesive ligands for platelets, such
as von Willebrand factor (VWF) and collagen [1],
and also tissue factor (TF), the plasma membrane
cofactor that initiates coagulation by binding
blood coagulation factor VIIa [2].
The processes that initiate venous thrombosis
are much less certain. What is clear is that
they are very different from those initiating
arterial thrombosis. Whereas platelets make up
the core of arterial thrombi and are the cellular
components closest to the vessel wall [3], in
venous thrombi brin appears to be the substance
attaching the thrombus to the vessel wall, with
platelets attaching to the brin downstream [4,5].
Nor is gross vessel wall injury a prerequisite for
venous thrombosis, as it is for arterial thrombosis.
In a classic autopsy study by Sevitt et al. [5], no
gross vessel wall injuries were identied in 49 of
50 lower extremity thrombi from 41 autopsies,
even though almost all of the thrombi were
attached to the vessel wall.
What would allow thrombi to attach to a
normally non-thrombogenic endothelium? Clues
arise from two conditions frequently associated

0049-3848/ $ see front matter 2009 Elsevier Ltd. All rights reserved.

Pathophysiology of venous thrombosis

with thrombosis: inammation and stasis. Local
inammation is characterized by activation of
endothelium. Acutely, endothelial activation results in release of granules called Weibel Palade
bodies, which contain VWF and membrane-bound
P-selectin. Both proteins can remain attached
to the endothelial surface, P-selectin because it
spans the surface membrane, and VWF because
it binds endothelial surface proteins, including
P-selectin. Both proteins have the capacity to bind
leukocytes, P-selectin by engaging PSGL-1 [6] and
VWF through both PSGL-1 and aMb2 integrins [7].
Leukocytes, in particular monocytes, are the cells
in contact with blood that are most readily able
to synthesize TF [8].
The link between local inammation and
thrombosis has been appreciated for more than
a century, as highlighted by the use of the term
thrombophlebitis to designate an inamed vein
that has thrombosed. In this case, the relationship between thrombosis and inammation is
reciprocal. In most cases, thrombosis precedes,
and presumably causes, the inammation. In
other cases, such as with intravascular catheters,
the vein becomes inamed before the onset
of thrombosis, with the inammatory process
presumably inciting the thrombotic event.
Stasis
Stasis itself can promote endothelial activation,
in that way predisposing to thrombosis. The
evidence for a relationship between stasis and
thrombosis is overwhelming. First, it is well
established that the risk for DVT increases in
parallel with the time that a patient is bedridden [9]. Second, studies have shown that DVT is
much more common in the paralyzed limb of
hemiplegic patients than in the unaffected limb,
but equally common in the two limbs of paraplegic
patients [10]. Finally, risk of DVT in hospitalized
patients decreases as the patients begin to walk
or with pneumatic leg compression [11].
What factors link blood stasis to risk for DVT?
Stasis has many effects that can tip the balance
toward thrombosis. For example, lack of ow
or low ow allows the accumulation in large
vessels of prothrombotic substances (prominently
thrombin) which normally are washed downstream
where they are inactivated. In the case of
thrombin, the protein is normally washed from
the lower extremities into the capillary bed of the
lung, which has an enormous surface area coated
with anti-thrombotic substances such as thrombomodulin and heparan sulfate proteoglycans, both
of which function to prevent further coagulation.

S31
Thrombomodulin binds thrombin and converts it
from a potent procoagulant to an anticoagulant,
a function that it carries out by cleaving protein C
to its activated form, which then degrades
the activated forms of factors V and VIII [12].
Heparan sulfates promote thrombin inactivation
by antithrombin by accelerating the thrombin
antithrombin interaction through both allosteric
and spacial means [13].
Stasis also leads to rapid desaturation of
hemoglobin in the resident erythrocytes, which
stimulates hypoxia responses in leukocytes,
platelets, and endothelial cells. In a classic study
of 2 patients and 8 dogs, Hamer et al. [14]
measured the PO2 of blood in valve pockets
under static conditions and found that the
blood became rapidly hypoxic, but the PO2 rose
to the level found in luminal blood when
the valve pockets emptied at short intervals.
Because the endothelium on the valve cusps
depends on luminal oxygen, it can rapidly become
hypoxic when blood ceases to ow. This condition
predisposed to thrombus formation after as little
as 2 hours of nonpulsatile ow. Hypoxia likely
initiates thrombosis in several ways. One way
is through activation of the endothelium and
Weibel Palade body exocytosis. Closse et al. [15]
showed that endothelial cells started to express
surface P-selectin within 30 minutes of exposure
to hypoxia. Activation of the endothelium would
also account for the observations of deposits
of platelets, leukocytes, and brin within the
valve cusps, a likely precursor of full-blown
thrombosis [15]. Such rapid externalization of
P-selectin would by necessity be accompanied
by secretion of VWF. As mentioned already,
VWF is capable of binding not only platelets,
but leukocytes [16] and erythrocytes [17] as well.
This is particularly true of newly released VWF,
which is much larger than the form normally
found in plasma (and hence called ultralarge VWF,
abbreviated ULVWF). This form of VWF is not only
larger than the usual plasma form, it is also much
more adhesive [18]. Conversion of the large, sticky
form of VWF to the smaller and less adhesive
form of the molecule appears to require that
VWF be unfolded by the owing blood, exposing
the site for cleavage by the metalloprotease,
ADAMTS13 [19]. Thus, stasis would not only favor
the hypoxic activation of endothelial cells in the
vessel wall, it would also permit a cell-bound,
hyperadhesive form of VWF to persist long enough
to allow the adhesion of blood cells.
A relationship between VWF and venous thrombosis is well known. Non-O blood group genotypes,
VWF levels, and factor VIII levels are all

S32
risk factors for the development of DVT [20 23].
Individuals with non-O blood groups have higher
levels of VWF than those of the O blood group [24],
a consequence of increased clearance of O-group
VWF [25]. Higher VWF levels also correlate with
higher factor VIII levels; factor VIII must associate
with VWF to be protected from rapid degradation
and persist in the circulation. Until now, the
DVT risk associated with non-O blood groups and
higher VWF levels has largely been ascribed to
higher factor VIII levels, probably because VWF
does not inuence any in vitro test of blood
coagulation. However, one might expect VWF to
be important in DVT independent of its role as a
factor VIII carrier because of its ability to mediate
the attachment of blood cells to the vessel wall.
Further, elevated levels of VWF may in some
cases be an indication of systemic endothelial
activation.
Hypoxia also stimulates TF synthesis from
monocytes within a time-course relevant to
venous thrombosis [26]. Concomitant with increased synthesis of TF by monocytes is enhanced
TF release from the cell surface in association
with membrane microvesicles. The TF density
on these vesicles per membrane area is much
higher than it is on the monocytes themselves,
a consequence of TF localization to membrane
lipid rafts and selective vesicle budding from raftrich regions [27]. TF-bearing microvesicles have
been demonstrated to contribute to experimental
arterial thrombosis in mice [28] and to improve
clotting times in hemophilic mice [29]. TF-bearing
microvesicles alone may not initiate coagulation
under usual circumstances, perhaps because the
TF on the vesicle may be encrypted or because the
small surface area of microvesicles could limit assembly of other coagulation reactions. Monocytederived microvesicles may also lack the proper
machinery to efciently carry out the coagulation
reactions downstream of TF/FVIIa activation of
factor X. The prothrombinase complex, which
contains factor X, is efciently assembled on the
surfaces of platelets, perhaps in part because
platelets possess a factor Xa receptor [30]; such a
receptor is unlikely to be found on microvesicles.
In any case, the ability of TF to initiate thrombosis increases greatly when the micovesicles
associate, and fuse, with activated platelets [27]
or endothelium, a process made possible by the
presence of P-selectin on these cells, which
serves to dock the microvesicles [28,31]. After
docking, the microvesicles fuse with the cells
in a phosphatidylserine-dependent process, which
incorporates TF into the cells plasma membrane.
The net result of this process is to allow all of

J.A. L
opez, J. Chen
the reactions of blood coagulation to take place
on the surface of a single cell specialized to
promote coagulation, with the product of one
reaction being deposited on the membrane where
it can participate in the subsequent reaction in
the cascade.
Cancer and venous thrombosis
Cancer is a powerful risk factor for the
development of venous thrombosis, with an
estimated 20% of cancer patients experiencing
thrombosis at some time during the course of their
disease [32]. Even this number may underestimate
the degree to which cancer patients are aficted
by thrombosis, as autopsy studies have found
venous thrombi in up to 60% of patients dying
with cancer [33]. It was rst noted by Armand
Trousseau, the French physician for whom the
syndrome of cancer-associated thrombosis is
named, that cancer causes a special alteration of
the blood, his recognition of the role of cancer in
producing a hypercoagulable state [34]. Patients
with advanced cancer often have many risk factors
for thrombosis, including concomitant infectious
illnesses, prolonged bed rest with resultant stasis,
indwelling central venous catheters, or direct
vascular compression or invasion by the tumors.
Nevertheless, thrombosis is often the presenting
symptom of patients with cancer, indicating that
cancers can inuence the blood to tip the
hemostatic balance in favor of thrombosis. Tumors
may do this by directly releasing procoagulant
substances, or by signaling other cells such as
monocytes, macrophages and endothelial cells
to produce such substances. Membrane blebbing
from cancers ex vivo and in experimental
animals was described long ago [35], as was their
possession of elevated procoagulant activity [36].
It is now widely appreciated that constitutive
microvesicle shedding is a common feature of
cancerous cells [37,38].
Tissue factor (TF) has been reported in
association with many cancers, including adenocarcinomas of the pancreas, stomach, colon,
ovary, lung, brain and breast [39]. In addition,
TF production and associated disseminated intravascular coagulation (DIC) is a hallmark of
acute promyelocytic leukemia, being a marker of
the differentiation state of the leukemic cells.
TF-bearing microvesicles have now been found
in the blood of patients with cancer and
associated with thrombosis [40 46], in one case
producing a orid thrombotic syndrome [40]. It
can be assumed that many mucin-producing
tumors generate microvesicles that also carry

Pathophysiology of venous thrombosis

mucins. Cancer-associated mucins can function
as selectin ligands [47], endowing the cancer
microvesicles with the ability to transfer TF to
P-selectin-expressing cells.

S33

[18]

Conicts of interest: Dr. L

opez and Dr. Chen have
no conicts of interest.

[19]

References

[20]

[1] Chen J, L
opez JA. Interactions of platelets with
subendothelium and endothelium. Microcirculation
2005;12:235 46.
[2] Tilley R, Mackman N. Tissue factor in hemostasis and
thrombosis. Semin Thromb Hemost 2006;32:5 10.
[3] Friedman MH, Brinkman AM, Qin JJ, Seed WA.
Relation between coronary artery geometry and the
distribution of early sudanophilic lesions. Atherosclerosis
1993;98:193 9.
[4] Paterson JC, McLachlin J. Precipitating factors in venous
thrombosis. Surg Gynecol Obstet 1954;98:96 102.
[5] Sevitt S. The structure and growth of valve-pocket
thrombi in femoral veins. J Clin Pathol 1974;27:517 28.
[6] Andrews RK, L
opez JA, Berndt MC. Molecular mechanisms
of platelet adhesion and activation. Int J Biochem Cell
Biol 1997;29:91 105.
[7] Pendu R, Terraube V, Christophe OD, Gahmberg CG,
de Groot PG, Lenting PJ, et al. P-selectin glycoprotein
ligand 1 and beta2-integrins cooperate in the
adhesion of leukocytes to von Willebrand factor. Blood
2006;108:3746 52.
[8] sterud B, Bj
orklid E. The tissue factor pathway in
disseminated intravascular coagulation. Semin Thromb
Hemost 2001;27:605 17.
[9] Gibbs NM. Venous thrombosis of the lower limbs
with particular reference to bed-rest. Br J Surg
1957;45:209 36.
[10] Warlow C, Ogston D, Douglas AS. Deep venous thrombosis
incidence and
of the legs after strokes. Part I
predisposing factors. Br Med J 1976;1:1178 81.
[11] Turpie AG, Gallus A, Beattie WS, Hirsh J. Prevention of
venous thrombosis in patients with intracranial disease
by intermittent pneumatic compression of the calf.
Neurology 1977;27:435 8.
[12] Esmon CT, Gu JM, Xu J, Qu D, Stearns-Kurosawa DJ,
Kurosawa S. Regulation and functions of the protein C
anticoagulant pathway. Haematologica 1999;84:363 8.
[13] Quinsey NS, Greedy AL, Bottomley SP, Whisstock JC, Pike
RN. Antithrombin: in control of coagulation. Int J Biochem
Cell Biol 2004;36:386 9.
[14] Hamer JD, Malone PC, Silver IA. The PO2 in venous valve
pockets: its possible bearing on thrombogenesis. Br J Surg
1981;68:166 70.
[15] Closse C, Seigneur M, Renard M, Pruvost A, Dumain P,
Belloc F, et al. Inuence of hypoxia and hypoxia
reoxygenation on endothelial P-selectin expression.
Thromb Res 1997;85:159 64.
[16] Bernardo A, Ball C, Nolasco L, Choi H, Moake JL, Dong JF.
Platelets adhered to endothelial cell-bound ultra-large
von Willebrand factor strings support leukocyte tethering
and rolling under high shear stress. J Thromb Haemost
2005;3:562 70.
[17] Wick TM, Moake JL, Udden MM, Eskin SG, Sears DA,
McIntire LV. Unusually large von Willebrand factor
multimers increase adhesion of sickle erythrocytes to

[21]

[22]

[23]

[24]

[25]

[26]

[27]

[28]

[29]

[30]
[31]

[32]
[33]

human endothelial cells under controlled ow. J Clin

Invest 1987;80:905 10.
Arya M, Anvari B, Romo GM, Cruz MA, Dong JF,
McIntire LV, et al. Ultralarge multimers of von Willebrand
factor form spontaneous high-strength bonds with the
platelet glycoprotein Ib IX complex: studies using optical
tweezers. Blood 2002;99:3971 7.
L
opez JA and Dong JF. Cleavage of von Willebrand
factor by ADAMTS-13 on endothelial cells. Semin Hematol
2004;41:15 23.
Koster T, Blann AD, Briet E, Vandenbroucke JP,
Rosendaal FR. Role of clotting factor VIII in effect of von
Willebrand factor on occurrence of deep-vein thrombosis.
Lancet 1995;345:152 5.
Tsai AW, Cushman M, Rosamond WD, Heckbert SR, Tracy
RP, Aleksic N, et al. Coagulation factors, inammation
markers, and venous thromboembolism: the longitudinal
investigation of thromboembolism etiology (LITE). Am J
Med 2002;113:636 42.
Ohira T, Cushman M, Tsai MY, Zhang Y, Heckbert SR,
Zakai NA, et al. ABO blood group, other risk
factors and incidence of venous thromboembolism: the
Longitudinal Investigation of Thromboembolism Etiology
(LITE). J Thromb Haemost 2007;5:1455 61.
Larsen TB, Johnsen SP, Gislum M, Moller CA, Larsen H,
Sorensen HT. ABO blood groups and risk of venous
thromboembolism during pregnancy and the puerperium.
A population-based, nested case control study. J Thromb
Haemost 2005;3:300 4.
Gill JC, Endres-Brooks J, Bauer PJ, Marks Jr WJ,
Montgomery RR. The effect of ABO blood group
on the diagnosis of von Willebrand disease. Blood
1987;69:1691 5.
Gallinaro L, Cattini MG, Sztukowska M, Padrini R,
Sartorello F, Pontara E, et al. A shorter von Willebrand
factor survival in O blood group subjects explains how
ABO determinants inuence plasma von Willebrand factor.
Blood 2008;111:3540 5.
Lawson CA, Yan SD, Yan SF, Liao H, Zhou YS, Sobel J,
et al. Monocytes and tissue factor promote thrombosis
in a murine model of oxygen deprivation. J Clin Invest
1997;99:1729 38.
del Conde I, Shrimpton CN, Thiagarajan P, L
opez JA.
Tissue-factor-bearing microvesicles arise from lipid rafts
and fuse with activated platelets to initiate coagulation.
Blood 2005;106:1604 11.
Falati S, Liu Q, Gross P, Merrill-Skoloff G, Chou J,
Vandendries E, et al. Accumulation of tissue factor
into developing thrombi in vivo is dependent upon
microparticle P-selectin glycoprotein ligand 1 and platelet
P-selectin. J Exp Med 2003;197:1585 98.
Hrachovinova I, Cambien B, Hafezi-Moghadam A, Kappelmayer J, Camphausen RT, Widom A, et al. Interaction
of P-selectin and PSGL-1 generates microparticles that
correct hemostasis in a mouse model of hemophilia A.
Nat Med 2003;9:1020 5.
Tracy PB, Nesheim ME, Mann KG. Platelet factor Xa
receptor. Methods Enzymol 1992;215:329 60.
Rauch U, Bonderman D, Bohrmann B, Badimon JJ,
Himber J, Riederer MA, et al. Transfer of tissue factor
from leukocytes to platelets is mediated by CD15 and
tissue factor. Blood 2000;96:170 5.
Donati MB. Cancer and thrombosis. Haemostasis
1994;24:128 31.
Ambrus JL, Ambrus CM, Mink IB, Pickren JW. Causes of
death in cancer patients. J Med 1975;6:61 4.

S34
[34] Trouseau A. Phlegmasia alba dolens. Lectures on clinical
medicine, delivered at the Hotel Dieu, Paris, 3rd edition.
Vol. 4. New Sydenham Society 1872; 280 332.
[35] Dvorak HF, Van DeWater L, Bitzer AM, Dvorak AM, Anderson
D, Harvey VS, et al. Procoagulant activity associated with
plasma membrane vesicles shed by cultured tumor cells.
Cancer Res 1983;43:4434 42.
[36] Dvorak HF, Quay SC, Orenstein NS, Dvorak AM, Hahn P,
Bitzer AM, et al. Tumor shedding and coagulation. Science
1981;212:923 4.
[37] Carr JM, Dvorak AM, Dvorak HF. Circulating membrane
vesicles in leukemic blood. Cancer Res 1985;45:5944 51.
[38] Taylor DD, Lyons KS, Gercel-Taylor C. Shed membrane
fragment-associated markers for endometrial and ovarian
cancers. Gynecol Oncol 2002;84:443 8.
[39] Rao LV. Tissue factor as a tumor procoagulant. Cancer
Metastasis Rev 1992;11:249 66.
[40] del Conde I, Bharwani LD, Dietzen DJ, Pendurthi U,
Thiagarajan P, L
opez JA. Microvesicle-associated tissue
factor and Trousseaus syndrome. J Thromb Haemost
2007;5:70 4.
[41] Tilley RE, Holscher T, Belani R, Nieva J, Mackman N. Tissue
factor activity is increased in a combined platelet and

J.A. L
opez, J. Chen

[42]

[43]
[44]

[45]

[46]

[47]

microparticle sample from cancer patients. Thromb Res

2008;122:604 9.
Davila M, Amirkhosravi A, Coll E, Desai H, Robles L, Colon
J, et al. Tissue factor-bearing microparticles derived from
tumor cells: impact on coagulation activation. J Thromb
Haemost 2008;6:1517 24.
Zwicker JI. Tissue factor-bearing microparticles and
cancer. Semin Thromb Hemost 2008;34:195 8.
Lechner D and Weltermann A. Chemotherapy-induced
thrombosis: a role for microparticles and tissue factor?
Semin Thromb Hemost 2008;34:199 203.
Tesselaar ME, Romijn FP, Van der Linden IK, Prins FA,
Bertina RM, Osanto S. Microparticle-associated tissue
factor activity: a link between cancer and thrombosis?
J Thromb Haemost 2007;5:520 7.
Khorana AA, Francis CW, Menzies KE, Wang JG, Hyrien O,
Hathcock J, et al. Plasma tissue factor may be
predictive of venous thromboembolism in pancreatic
cancer. J Thromb Haemost 2008;6:1983 5.
Wahrenbrock M, Borsig L, Le D, Varki N, Varki A. Selectin
mucin interactions as a probable molecular explanation
for the association of Trousseau syndrome with mucinous
adenocarcinomas. J Clin Invest 2003;112:853 62.