Upload
amir-mahmoud
View
43
Download
0
Tags:
Embed Size (px)
Citation preview
Venous Thrombo-Embolism
• Clinical entity, lethal, recurrent.
• Hospitalized and non hospitalized persons.
• Long term complication:
a. Chronic thrombo-embolic pulmonary hypertension
b. Post thrombotic syndrome
Pulmonary Hypertension
• Group I no known cause or inherited.
• Group II with left heart disease.
• Group III associated with lung diseases.
• Group IV thrombo-embolic
• Group V by various other diseases
Post thrombotic syndrome
• Due to damage of venous valves and venous hypertension.
• Leg edema, skin changes( hyperpigmentationlipodermatosclerosis), pain and stasis ulcer
• Compressing stocking for two years.
• Early ambulation.
Incidence of TVE
• 10-20 % in medical hospitalized patients.
• 15-40 % in surgical hospitalized patients.
3rd most common cuase of hospital related death in USA
DVT
• Aim of management is to prevent PE & PTS.
• Popliteal vein and above 50 % estimated risk.
• Below(calf vein) 25 %
Inherited Hyper-coagulability.
• Factor V leiden
• Prothrombin gene mutation (G20210A)
• Protein C and protein S deficiency
• Anti thrombin deficiency
• Hyperhomocysteinemia
• Elevated factor VIII
Aquired Hyper-coagulability.
• Immobilization• Surgery• Trauma• Pregnancy• OCP & HRT• Malignancy• Antiphospholipid
syndrome (lupus anticoagulant & anticardiolipin antibodies).
• HIT• Myeloproliferative
disorders• Smoking• Obesity• Inflammatory bowel
disease• CVP and pacemakers• Nephrotic syndrome.
Signs of DVT
• Increased warmth
• Tenderness
• Edema
• Presence of dilated veins
• Erythema
• Cyanosis/gangrene
Phlegmasia cerulea dolens
• Complete occlusion of venous outflow.
• Malignancy, HIT, hypercoagulable state.
• Capillary bed hypertension (massive limb swelling).
• Ischemia and necrosis.
• Vascular emergency.
Phlegmasia cerulea dolensTREATMENT
• Leg elevation.
• Anticoagualtion
• Thromolysis
• Thrombectomy (Surgical or cathter based).
• Fasciotomy (compartmental syndrome).
Pretest probability (Wells score)Clinical feature Score
Active cancer. 1
Paralysis, paresis, recent plaster immobilization of LL. 1
Recently bed ridden > 3d or major surgery in last 4 weeks. 1
Localized tenderness along distribution of deep vein system. 1
Entire leg swollen. 1
>3cm difference in calf circumference. 1
Unilateral pitting edema. 1
Collateral non-varicose superficial veins. 1
More likely alternative diagnosis -2
-2 -1 0 /1 2 / 3 4 5 6 7 8 Add 1 if previously documented DVT
-2 -1 0 1 / 2 3 4 5 6 7 8
Tools
• Venography was the gold standard.
• Duplex ultrasound.
• D-Dimer.
• MRI. Pelvic, IVC, mesenteric veins
• CT. Pelvic, IVC, mesenteric veins
Venography
• Was/ has been/ used to be …… gold standard.
• Filling defects intra-luminal.
• Abrupt cutoff
• Non filling of the deep system
• Collaterals.
• Contrast /radiology hazards
Duplex ultrasound
• 95 % sensitivity and 98 % specificity.
• Non-compressibility is diagnostic but difficult in iliac and abductor canal.
• Venous distension, decreased or absent spontaneous flow.
• Difficult with recurrent DVT.
• Pelvic mass cause non-compressibility of common femoral vein
Treatment
• Goal: relief symptoms
• Prevent PE, CTPH, PTS.
• Start anticoagulation at once
• Heparin 80 IU/Kg bolus> 18 U/kg/h IVI
• LMWH
• Fondaparinux.
• Oral anticoagulation.
Fondaparinux
• Indirect Xa inhibitor
• FDA approved for DVT prophylaxis.
• 2.5 mg prophylactic.
• Once daily subcutaneous injection.
• Contraindicated in less than 50 kg in prophylaxis @ orthopedic and abdominal surgery.
Fondaparinux
• FDA approved for acute DVT & PE treatment.
• < 50 kg 5 mg
• 50-100 kg 7.5 mg
• > 100 kg 10mg
• Contraindicated in severe renal impairment.
Thrombolytic therapy
• In only elected cases (threatened limb)
• Preferably locally via catheter.
• May be for extensive acute proximal DVT.
Vena caval interruption
IVC filter insertion is indicated if
Contraindicated anticoagulation.
Complication from anticoagulation.
Recurrent thrombo-embolization despite proper anticoagulation.
Vena caval interruption
IVC filter insertion may be indicated if
• Massive pulmonary embolism
• Ileocaval DVT.
• Free floating proximal DVT.
• Cardiac or pulmonary insufficiency.
• High risk anticoagulation as in frequent fall.
• Poor compliance.
Duration of treatment
Dependant on the risk of recurrence.
• Idiopathic DVT
• Hypercoagulable state.
• malignancy.
Duration of treatment
Dependant on the risk of recurrence.
• Old age
• Male sex
• obese
• Elevted D-dimer levels.
• Permanent IVC filter placement.
Duration of treatment
• 3 months of INR 2-3 for 1st DVT due to transient cause.
• 6-12 months of INR 2-3 for 1st idiopathic DVT.
• For life if recurrent unexplained DVT.
• For life with active malignancy or gene mutation.
Upper limb DVT
• Often related to CVP and pacemaker insertion.
• Thoracic outlet syndrome.
• Hyper-coagulant states including malignancy.
• Same anticoagulation duration.
• Thrombolysis for younger patients with effort thrombosis.
Superficial venous thrombosis
• Frequently after IV line in upper limb.
• May occur spontaneously.
• Generally no anticoagulation.
• Unless propagated to deep system or spontaneous.
• Heparin/ LMWH/Fondaparinux/ VKA
• Four weeks.
Post thrombotic syndrome
• Due to damage of venous valves and venous hypertension.
• Leg edema, skin changes( hyperpigmentationlipodermatosclerosis), pain and stasis ulcer
• Compressing stocking for two years.
• Early ambulation.
Heparin induced thrombocytopenia
• 3-5 % unfractionated heparin.
• < 1 % LMWH.
• Immunoglobulin G antibody to heparin. platelet factor 4 complex.
• 5-14 day after exposure to heparin.
• Isolated or thrombotic.
• Stop any heparin