DEEP VEIN THROMBOSIS

Dairion Gatot, Savita Handayani

Hematology -Onkology Medic Division

Internal Departement of Medical Faculty of North
Sumatera University/Haji Adam Malik General
Hospital,
Medan 2013
KASUS
 DEEP VEIN THROMBOSIS
DVT PROBLEM IS NOT DEATH

SEQUALE
& COMPLICATION

PERMANENT BLOOD VESSEL

DAMAGE OF INFERIOR
EXTREMITY
POST THROBOSIS OF VEIN INSUFISIENCY

POST PHLEBITIS SYNDROMA

PULMONAL EMBOLI
PULMONAL HIPERTENSION
 DVT:
PATOGENESIS
Thrombus Generation and Extension
Pathogenesis of Thromboembolism
 Pulmonary embolism
can occur at any site in the lung vascularisation

Small VTE & large VTE ??? PE

 DVT:
DIAGNOSIS and
DIFFERENTIAL
DIAGNOSIS
 Diagnosis of DVT
1. History of illness: Symptoms (+) or (-)
Risk Factors: Medical & Surgery
2. Physical examination:
Pitting edema of the leg
Pain
No clear signs or symptoms (subocclusive
thrombus)
3. Laboratory & Radioimaging examinations:
D-dimer
Veno/Phlebo-graphy (Gold Standard)
Compression/ Dupplex ultrasonography (96
97 %) for sympt. Prox. DVT
Duplex scan
Impedance Plethysmography
 CAUSES of EDEMA of the LOW
EXTREMITIES (differential diagnosis)
ACUTE EDEMA CHRONIC EDEMA

Deep vein thrombosis (DVT) Venous abnormalities:

Superficial Thrombophlebitis - post thrombotic syndrome/
Cellulitis post phlebitic syndrome
Joint effusion/Haemarthrosis - chronic vein insufisiency
Fractures - lipodermatosclerosis
Arthritis - venous obstruction / suppression
Dermatitis Lymphedema: - tumors
- infections
- trauma, dll
Diseases : - hemangioma
- congenital
Others: = heart failure
- idiopathic edema in women
 DVT >< AIL
Diagnotic: Symptom and Sign

DVT AIL
Symtom (stasis) (ischemia)
- edema pain:
usually unilateral - thromboemboli: onset akut
- silent DVT - thrombotic: slowly
- pain dan hard (intermittent claudication)

Simtom & - pain - 6 Ps: pain, pallor, pares-

sign - pitting edema thesia,paralysis,pulseless-
- flebitis:inflamasi ness, poikylothermia
- dilatasi v.superfisial - awal: nyeri & parestesia
- sianosis (ileofemoral) - palpasi : arteri pulse (-)
DIAGNOSTIC APPROACH
of
DVT
 RISK FACTORS of
SUSPECTED DVT
Risk factor scoring systems:
- the Wells score for suspected DVT
(7 objective + 1 subjective factors)
- the Geneva score for suspected DVT
(objective factors: blood gases analysis)

Low risk group

Intermediate risk group
High risk group
 The WELLS SCORE for patients
clinically SUSPECTED DVT
Wells clinical prediction score for DVT Points

Cancer +1
Paralysis or recent immobilization +1
Bedridden > 3 days, or surgery / trauma < 4 weeks +1
Pain or palpitation of the deep veins +1
Edema of thigh and calf +1
Pitting edema (symptomatic side only) +1
Alternative diagnosis as least as likely DVT - 2

Clinically probability:
Low 0
Intermediate 1-2
High 3
 LABORATORY TESTS for DVT
A. D-dimer (cutoff value 500 ug/L):
- D-dimer < 500 ng/ml excluding acute DVT or PE
- negative predictive value for DVT & PE: 98 %
- especially in low & intermediate risk groups
- highly sensitive, but no specific: post surgery, DIC,
inflamation, infection, necrosis, cancers, etc
D-dimer (+)
- ELISA VIDAS DD: quick & accurate result
(sensitivity:98100%)

B. Other hemostasis lab tests:

- underlying disease:hereditary/acquired thrombophilia
(AT III & Protein C deficiencies , APS, etc)
to determine the duration of anticoagulants
 Radioimaging examinations:

PLETHYSMOGRAFI

VENOGRAFI CONTRAS (Golden standard)

USG (USG Kompresi, Duplex USG, Colour flow

doppler imaging)

-DUPLEX ULTRASOUND:
Sensitiviti 93%, spesificiti 98% (average 97%)

SPIRAL COMPUTED TOMOGRAFI VENOGRAFI

& MRI.
MANAGEMENT of DVT
 MANAGEMENT
A. Acute Treatment of DVT
B. Duration of Anticoagulant Administration
to prevent recurrent DVT (localized DVT)
to prevent acute distant consequences (PE)
to prevent chronic local consequences:
- venous valve damage / destruction
- chronic valve insufficiency (CVI)
- Post thrombotic / Post phlebitic syndrome
(PTS / PPS)
C. Treatment of Underlying Causes (Risk/ Trigger Factors)
 MANAGEMENT
1. General Measures:
- elevation of the feet
- compression with elastic stocking
& intermittent pneumatic compression
- early mobilization

2. Medications:
a. Heparin: UF-heparin or LMWH
b. Warfarin (oral anticoagulant)
c. Fibrinolytic agents
c. Others
3. Surgery: in recurrent / chronic DVT