How to Approach a Patient with Venous Thrombosis · How to Approach a Patient with Venous...

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How to Approach a Patient with Venous Thrombosis

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Stephan Moll, MDUNC Chapel Hill, NC

ISTH Advanced Training CourseAtlanta, Nov 3, 2016

ISTH Advanced Training CourseDubai, UAE

Research Support/P.I. No conflicts

Employee No conflicts

Consultant• Boehringer-Ingelheim• Janssen Pharmaceuticals• Stago Diagnostics

Major Stockholder No conflicts

Speakers Bureau No conflicts

Honoraria No conflictsScientific Advisory Board No conflicts

Off-label use of a drug or medical device: None

Disclosures

- 2 -

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20 Teaching points

History

Diagnostic Testing

Treatment

1

2

3

Content

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Inpatient consult:

“Quick curbside: How long would you anticoagulate a 64 year

old man with a basilic vein DVT after a phlebotomy stick?”

VTE History

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Arm Clots – Basics of Anatomy

Deep Veins

Brachial veins

Axillary vein

Radial veins Ulnar veins

Subclavian veinAxillary vein

(a deep vein)Brachial vein (a deep vein)

Superficial Veins

Cephalic vein

Basilic vein

Cephalic vein Basilic vein

Median forearm vein

Median cubital veinMedian cephalic

vein

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MD call:

“Quick curbside: Superficial clot in the right leg superficial

femoral vein; not very symptomatic. My plan was to observe.”

VTE History

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Common iliac veinInternal iliac veinExternal iliac veinCommon femoral vein

Greater saphenous vein(GSV; medial thigh + calf) Deep femoral vein

Lesser saphenous vein(LSV; in back of calf)

Femoral vein (Superficial femoral vein)

Gastrocnemius vein

Soleus veinAnterior tibial vein

Peroneal veinPosterior tibial vein

Popliteal vein

Superficial veins Deep Veins

Proximal veins

Distal veins

Leg Clots – Basics of Anatomy

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Know arm and leg venous anatomy

Take home point #1

Basics

Teaching point

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Imaging

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“Acute” = acute or subacute (day to wks, up to 3 months)

Dilated vein

“spongy” appearance

Non-hyperechoic intraluminal material

Caveats

Diagnosing recurrent DVT

Doppler Ultrasound Caveats

Decision is conglomerate of new clinical

symptoms, DD, Doppler US [Bates SM.ACCP guidelines, Chest 2012;141:351S-418S]

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1. Chronic or acute appearing?

(acute: spongy, hypo-echogenic, dilated vein)

2. Comparison to previous Doppler US study

3. How big is the clot?

Doppler Ultrasound Caveats

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Size of the clot: “Brachial vein DVT”

Phone call to Doppler tech who did the study (or senior

tech):

“0.5 cm clot, partially occlusive, behind a vein valve”

Doppler Ultrasound Caveats

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Caveats

CT Scan Caveats

If CTA results do NOT match pre-test clinical

assessment: CTA is wrong in ca. 50 % of cases

Review CTA with best radiologist

[Stein P. NEJM 2006;354:2317-27]

Acute vs chronic PE

- sub-segmental PE

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Radiological Imaging

CTEPH Screening

1. CXR

2. CTA

3. VQ scan

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VQ scan can NOT differentiate between acute and chronic

VQ abnormalities frequently persist for months

(of 157 PE patients, 66 % had VQ abnormality at 3 months)[Wartski M et al. J Nucl Med 2000;41:1043-8]

VQ Caveats

VQ Scan

CTA is insensitive to detect chronic PE (CTEPH)

VQ scan is test of choice

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Know limitations of Doppler ultrasound and CTA

Take home point #1

Basics

Teaching point

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History

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3. Patient preference

2. Risk for Bleeding

(a)..., (b..., (c) …

1. Risk of recurrent VTE

(a)..., (b)..., (c)...

Conglomerate decision of:

a)….., (b)….., (c)…..

0 10

Warfarin “Hate Factor”

Blood Thinner “Dislike Factor”

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Teaching points

VTE: R leg prox DVT in 3-2011. VTE risk factors: (a)... (b)…, (c)…

Arterial thromboembolism: wedge-shaped L renal infarct. Arterial thromboembolic and arteriosclerosis risk factors: (a)..., (b)..., (c)...

Assessment

Define clot.

List clot risk factors: (a)…, (b)…, (c) …

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Teaching points

Assessment

Define clot.

List clot risk factors: (a)…, (b)…, (c) …

“Warfarin Hate Factor”

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History

Step back! First question: Does pt really need to be on long-term

anticoagulation?

1. “Blood Clot” in the history – Review: symptoms; hospitalization?

Treatment? risk factors – of each episode.

2. Obtain previous Doppler/CTA report, d/c summary.

3. Then decision: “superficial clot” vs “DVT”, proximal or distal.

4. List all VTE risk factors: (a)…., (b)…., (c)….

Inpatient: Came in on warfarin – GI bleed. Consult: “When to restart

anticoagulation?”

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Question/revisit the indication/diagnosis!• In the patient on long-term anticoagulation: Detailed h/o each clot.

Get objective records.

Teaching points

Reviewing the History

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Question or revisit the indication/diagnosis!• In the patient on long-term anticoagulation: Detailed h/o each clot.

Get objective records.• “Protein C, S, AT deficiency; APLA syndrome”• “Previous leg clot”: Was it DVT or superficial clot? Prox. or distal?

Teaching points

Reviewing the History

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• “There is no family history of bleeding or clotting”.

• “Nobody in the family had a clot”

Obtain a detailed family history.

Teaching point

Family History

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Social History

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Examination

Mid-calf circumference: R > L by 2 cm

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1. Stockings (30/40 mm Hg)

2. CT or MR venogram

3. Angioplasty, stenting

4. Home compression pump

5. Pain Clinic, gabapentin

6. Disability assistance

Postthrombotic Syndrome

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1. Good history

2. 3 flights of stairs with pulse oximeter

3. Cardiac echo

4. VQ

History and Work-up After PE

Pulmonary HTN Clinic

6 min walk test

Pulmonary pressure

measurements and angiogram

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1. PTS: 30/40 mm stockings; venogram + stenting

2. Recognize post-PE syndrome and CTEPH

Teaching points

After a DVT or PE

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VTE due to major transient risk factor

Woman with unprovoked VTE

Woman with VTE on hormones

Long-term

3 months

• PE• DVT

Man with unprovoked VTE

Non-major transient risk factor

• PE• DVT

Strong Throm

bophilia

D-dim

er

+

-

[Choosing Wisely®; Hicks LK, et al. Hematology Am SocHematol Educ Program. 2014;2014: 599-603]

ACCP, AHA, ISTH, BJH, ACF

LABSVTE: Duration of Anticoagulation

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VTE due to major transient risk factor

Woman with unprovoked VTE

Woman with VTE on hormones

Long-term

3 months

• PE• DVT

Man with unprovoked VTE

Non-major transient risk factor

• PE• DVT

Strong Throm

bophilia

D-dim

er

+

-

[Choosing Wisely®; Hicks LK, et al. Hematology Am SocHematol Educ Program. 2014;2014: 599-603]

ACCP, AHA, ISTH, BJH Teaching point

Recurrence triangle

LABSVTE: Duration of Anticoagulation

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4. … if you don’t know how to interpret test or what to do with results.

3. … while patient is on an anticoagulant.

1. … during an acute thrombotic episode.

2. … a hospitalized patient.

Do NOT test ….

LABSThrombophilia Testing

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LABSLab Testing

[Moll S. J Thromb Thrombolys 2015;39:367-378]

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Teaching points

• Be clear whom to test and when to test (“4 rules”)• Be aware of influence of anticoagulants on thrombophilia labs

LABSLab Testing

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3. Patient preference

“Warfarin Hate Factor”

2. Risk of Bleeding

(a)…., (b)…., (c) …..

1. Risk of recurrent VTE

(a)…., (b)…., (c) …..

LABSSummary: Duration of Anticoagulation

Conglomerate decision of:

ISTH Advanced Training CourseDubai, UAE[http://files.www.clotconnect.org/DVT_and_PE.pdf]

Patient Education

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Patient Education

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LABSAdditional Things to Mention…

1. Baseline f/u Doppler ultrasound: when stopping anticoagulation.[Ageno W et al. JTH 2013; 11: 1597–1602]

2. “Long-term” anticoagulation = extended = lifelong. But:

Re-evaluation every so often (once per year).

3. Offer and encourage clinical trial participation.

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LABSSummary – 3 Key Points

He is the a)…, b..., (c) ... guy;

with the “Recurrence triangle”;

and the “Warfarin hate factor”.

Dr. Moll from UNC:

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Comments?

Questions?

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