Updated: 1/2/2021

Deep Venous Thrombosis

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Snapshot
  • A 45-year-old woman presents to the emergency room for pain in her left calf. She reports flying back to the United States from Australia 2 days ago. Her flight was nonstop, making it a > 12-hour flight. She states having not worn any compression stockings and notes some swelling in the lower extremities bilaterally after the flight. She has a past medical history of hypertension and diabetes and currently takes oral contraceptive pills. Her vital signs are normal. On physical exam, her left calf is 2 cm larger in circumference than her right calf. It is also erythematous and warm with pitting edema. Her D-dimer levels are elevated.
Introduction
  • Clinical definition
    • blood clot in the deep veins, typically of the lower extremities
  • Epidemiology
    • incidence
      • increases with age
    • location
      • lower extremities
    • risk factors
      • immobility
      • hospitalization
      • surgery
      • thrombophilia
      • malignancy
      • trauma
      • state of elevated estrogen
        • patients on estrogen for hot flashes
          • when patients develop a DVT, the hormone replacement therapy should be discontinued and alternative treatment should be started
            • e.g., SSRI and SNRI 
  • Pathogenesis
    • Virchow triad puts patients at risk for DVTs
      • venous stasis
        • e.g., from long trips or bed rest
      • hypercoagulability
        • e.g., from malignancy or oral contraceptives
      • endothelial damage
        • exposed collagen will trigger the clotting cascade
        • usually secondary to lower limb trauma
  • Associated conditions
    • pulmonary embolism
Presentation
  • Symptoms
    • lower extremity pain and swelling
  • Physical exam
    • examination of the affected extremity
      • redness
      • warmth
      • Homan sign
        • calf tenderness with passive dorsiflexion of the foot
        • however, this is not a very useful sign
    • shortness of breath
      • may indicate pulmonary embolism
Imaging
  • Compression ultrasound with Doppler
    • indications
      • all patients
      • diagnostic gold standard
    • findings
      • clot formation in deep venous system
Studies
  • Labs
    • D-dimer
      • high sensitivity
      • low specificity
      • often used to rule out DVT
  • Making the diagnosis
    • based on clinical presentation and imaging
Differential
  • Cellulitis
    • distinguishing factors
      • no clot found on ultrasound
      • patients may have systemic signs, such as a fever
      • D-dimer is negative
Treatment
  • Management approach
    • most patients undergo anticoagulation for 3-6 months
    • however, if the DVT is unprovoked with no identifiable cause, or if risk factors are persistent, patients may require longer periods of anticoagulation for prophylaxis of future DVTs
  • Conservative
    • appropriate prophylaxis
      • indication
        • all patients at risk for DVTs
      • modalities
        • compression stockings for long flights
        • frequent ambulation
  • Medical
    • direct oral anticoagulants
      • drugs
        • rivaroxaban 
        • apixaban
      • indication
        • for outpatient management
        • useful given once/day dosing and no monitoring 
    • low-molecular-weight heparin (LMWH)
      • indications
        • initial therapy
        • patients with normal renal function 
    • unfractionated heparin  
      • indication
        • initial therapy
        • patients with contraindications to LMWH
          • end stage renal disease
        • can be used as "bridge" to therapeutic warfarin dose
        • appropriate if > 72 hours after recent surgery
    • warfarin
      • indications
        • long-term anticoagulation 
  • Operative
    • inferior vena cava (IVC) filter placement
      • indication
        • patients with contraindications to anticoagulation
Complications
  • Pulmonary embolism
  • Phlegmasia alba dolens 
    • considered a progression from a simple DVT
    • pain, swelling, and pallor from calf all the way up the thigh

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Questions (6)
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(M2.CV.16.39) A 63-year-old male with a history of type II diabetes, hypertension, and chronic kidney disease (CKD) stage IV presents to his primary care physician complaining of new onset swelling and calf tenderness in his right lower extremity. The patient has just returned from a trip to Europe for work. Examination of the extremity is shown in Figure A. The patient is referred to the Emergency Department, where he undergoes a right lower extremity duplex ultrasound shown in Figure B. Laboratory values are shown in Figure C. What is the next best step in management?

QID: 104679
FIGURES:
1

Treatment with unfractionated heparin

40%

(2/5)

2

Initiate warfarin therapy

0%

(0/5)

3

Aspirin and clopidogrel therapy

0%

(0/5)

4

Treatment with low molecular weight heparin

60%

(3/5)

5

Placement of an inferior vena cava filter

0%

(0/5)

M 7 D

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(M3.CV.15.43) A 46-year-old woman presents to the emergency department with 1 day of painful leg swelling. She is otherwise healthy and takes only oral contraceptive pills. The patient does not regularly follow up with her primary doctor. Her temperature is 98.0°F (36.7°C), blood pressure is 122/78 mm Hg, pulse is 70/min, respirations are 13/min, and oxygen saturation is 99% on room air. Lower extremity examination shows mild calf swelling on her left leg, but otherwise is unremarkable. An ultrasound is performed as seen in Figure A. Which of the following is the most appropriate course of action?

QID: 103334
FIGURES:
1

Alteplase

0%

(0/3)

2

Heparin

67%

(2/3)

3

Observation

0%

(0/3)

4

Rivaroxaban

0%

(0/3)

5

Warfarin

33%

(1/3)

M 11 E

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(M2.CV.14.41) A 62-year-old Nigerian woman arrived 2 days ago to the US to visit her adult children from Nigeria. She is now brought to an urgent care center by her daughter for leg pain. Her right leg has been painful for 24 hours and is now causing her to limp. She denies any fevers, chills, or sweats and does not remember injuring her leg. She tells you she takes medications for hypertension and diabetes and occasionally for exertional chest pain. She has not had any recent chest pain. The right leg is swollen and tender. Flexion of the right ankle causes a worsening of the pain. Doppler ultrasonography reveals a large clot in a deep vein. Which of the following is the most appropriate course of action?

QID: 104047
1

Serologic tests for hypercoagulability

0%

(0/21)

2

Initiation of warfarin

0%

(0/21)

3

Initiation of heparin

29%

(6/21)

4

Treatment with tissue plasminogen activator

0%

(0/21)

5

Initiation of heparin followed by bridge to warfarin

67%

(14/21)

M 7 E

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Evidence (9)
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