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Deep Vein Thrombosis (DVT)

Medicine > Cardiovascular

Background Knowledge 🧠

Definition

  • Formation of a blood clot (thrombus) in the deep venous system, commonly in the lower extremities, causing partial or complete occlusion of a blood vessel.

Epidemiology

  • DVT is the most common form of venous thromboembolism (VTE).

Pathophysiology

  • Disruption of blood flow → Accumulation of clotting factors → Thrombus formation → Potential embolisation.
  • There are three factors (Virchow’s triad) that predispose to the development of thrombosis:
    • Stasis of blood flow
    • Endothelial injury
    • Hypercoagulability

Risk Factors

  • Medical conditions: Cancer, heart failure, inflammatory disorders.
  • Surgery: Especially orthopaedic, pelvic, or abdominal surgery.
  • Immobility: Long-haul flights, bed rest.
  • Medications/Therapies: Oral contraceptives, hormone replacement therapy.
  • Others: Trauma, pregnancy, family history, obesity, thrombophilia.

Clinical Features 🌡️

Clinical Features

  • Local: Unilateral leg swelling, pain, tenderness, erythema, palpable cord.
  • Systemic: Fever.
  • Many cases of DVT are asymptomatic.

Investigations 🧪

Investigations

  • If DVT is suspected, the Wells Score is calculated to evaluate the clinical probability of DVT and guide subsequent clinical investigations.
  • D-dimer: Sensitive but not specific.
    • Other conditions (e.g malignancy, pneumonia) can similarly cause an elevated D-dimer, therefore not diagnostic.
  • Ultrasound: First-line imaging modality.
  • Venography: Gold standard but rarely used.

Management 🥼

Management

  • Anticoagulation: Low molecular weight heparin (LMWH), warfarin (vitamin K antagonist) , direct oral anticoagulants (DOACs).
    • If ultrasound scan cannot be performed within 4 hours, interim anticoagulants (e.g. apixaban or rivaroxaban) started immediately in cases of suspected DVT (based off Wells Score).
    • In cases of confirmed DVT, NICE recommends treatment of oral anticoagulants for at least three months.
  • Thrombolysis: In select cases.
  • Compression stockings: To reduce the risk of post-thrombotic syndrome.
  • Inferior vena cava filter: For those who can’t receive anticoagulation.

Prognosis

  • Following treatment, many DVTs will resolve with no complications.

Complications

  • Pulmonary embolism (PE): Life-threatening complication.
  • Post-thrombotic syndrome.
  • Bleeding (from anticoagulation).

Key Points

  • High clinical suspicion is vital, as many DVTs may be asymptomatic or present subtly.
  • Anticoagulation is the mainstay of treatment.
  • Consider PE in any patient with a confirmed or suspected DVT, especially if they exhibit respiratory symptoms (e.g. shortness of breath).

References

Schulman, S., Konstantinides, S., Hu, Y. and Tang, L. V. (2020) ‘Venous Thromboembolic Diseases: Diagnosis, Management and Thrombophilia Testing: Observations on NICE Guideline [NG158]’, Thromb Haemost,120(8), pp. 1143-1146.

NICE (2020). Overview | Venous thromboembolic diseases: diagnosis, management and thrombophilia testing | Guidance | NICE. [online] www.nice.org.uk. Available at: https://www.nice.org.uk/guidance/ng158

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Risk factors for venous thrombosis include:

This is a hypercoagulable state.

Massive transfusion can lead to a bleeding tendency due to depletion of platelets and coagulation factors.


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