Deep Venous Thrombosis (DVT) Of The Lower Extremity


Article Author:
Michael Schick


Article Editor:
Luigi Pacifico


Editors In Chief:
Dustin Constant
Donald Kushner


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
2/28/2019 8:27:34 AM

Introduction

Deep Vein Thrombosis (DVT) is a major cause of morbidity and mortality, and sequelae range from venous stasis to pulmonary embolism (PE). DVT occurs when a thrombus (thrombus) forms in one of the deep veins of the body.

Etiology

Virchow's triad of venous stasis or turbulence, coagulopathy, and endothelial injury highlight the major risk factors for developing a DVT. Other known and common risk factors include malignancy; recent surgery; immobilization; estrogen therapy, especially when combined with tobacco abuse; history of previous DVT or PE; and strong family history.[1][2][3][4][3]

Epidemiology

DVT is a common problem in the primary care, acute care, and inpatient setting. It is not clear what the actual incidence is, but DVT is found in about 80 out of 100,000 cases. One out of 20 people will develop a DVT sometime during their lifetime. DVTs account for approximately 600,000 hospitalizations per year in the United States. DVTs occur more commonly in those older than 40 years old. There is an increased incidence in the male and African American populations.

Pathophysiology

Venous stasis, endothelial damage, or inflammation are typically present and lead to a hypercoagulable state. Activation of the clotting cascade, as well as aggregation of platelets and blood cells, occurs simultaneously to form a thrombus. The thrombus can cause complete or partial occlusion of the vein leading to venous stasis, lymphedema, and possibly ischemia to surrounding tissue. A DVT can propagate and lead to PE.

History and Physical

Specific historical features that assist in the diagnosis of a DVT are those related to DVT risk factors and include a history of cancer, exogenous estrogen therapy, recent surgery, smoking tobacco, previous history of DVT, immobility, age, history of a hypercoagulable state, and other comorbidities. Patients often will present with a chief complaint of unilateral leg swelling and discomfort. Be mindful to ask about symptoms related to a PE as well, such as chest pain, shortness of breath, and syncope.

The physical exam most commonly demonstrates unilateral extremity swelling, warmth and discomfort over the vein, and, perhaps, a palpable "cord" where the DVT is located.

Evaluation

Clinical decision rules such as the Pulmonary Embolism Rule-Out Criteria (PERC) and the Wells Criteria should be employed with the patient presenting with a possible DVT. Risk stratification is crucial in deciding diagnostic and management options. Patients who meet PERC criteria may need no further testing, whereas those who do not meet PERC criteria and are low probability based on the Wells Criteria may be candidates for rule-out with a D-dimer. The D-dimer test is sensitive, but not specific, and should be used selectively in the low-probability patient who does not have other confounding diagnoses that could produce a false positive test. The test also should be used with caution, perhaps with different cut-off values in the elderly.[5][6][7][8]

Imaging modalities available to evaluate for DVT include diagnostic ultrasound, vascular studies, CT venograms, and point-of-care ultrasound (POCUS). The POCUS exam is described below.

Rapid diagnosis or rule-out by the emergency provider can expedite necessary treatment, reduce the length of stay, and is particularly useful where access to 24-hour ultrasound is unavailable. There is evidence that emergency practitioners can perform a two-point compression exam at the two highest probability sites for identifying a DVT: femoral and popliteal veins. However, recent literature suggests a two-region approach where clinicians do serial compression testing may greatly improve diagnostic sensitivity without greatly increasing diagnostic time. This point-of-care ultrasound exam should be used with other clinical decision rules and is perhaps most useful in those patients with high and low pre-test probability.

With the patient supine in the frog-leg position, apply approximately 20 to 30 degrees of reverse Trendelenburg to increased venous distention. Place the high-frequency linear transducer (5 to 10 MHz) in the transverse plane at the anatomical location of the inguinal ligament. Just distal to the inguinal ligament, the common femoral vein can be visualized. Apply direct pressure to the vein. The complete collapse of the vein indicates there is not a presence of a DVT. Continue distally along the femoral vein to where the greater saphenous vein and deep femoral vein deviate from the common femoral vein. Complete compression of all venous structures at these levels rules out a proximal DVT.

Next, proceed to the popliteal region. Laterally rotate the leg, flex the knee, and place the high-frequency transducer transversely in the popliteal fossa. The popliteal vein typically resides just anterior to the popliteal artery. Apply a compressive force once again and observe for complete compression. Compress the areas just proximal and distal to the popliteal fossa as well to complete the two-region technique.  

If DVT studies are negative, repeat testing may be required in one to two weeks to rule out a propagating calf DVT further. Alternatively, sending a D-dimer test may be adequate in certain patient populations.  

Typical laboratory tests also should be sent to evaluate for coagulation status, blood count, and renal function.[9][10]

Treatment / Management

There are many options available to manage DVT. The first decision that should be made is whether the patient will require hospital admission or can be discharged on anticoagulation. This is a complex decision that depends on many factors including patient adherence to medication, insurance issues, the reliability of follow-up, renal function, comorbidities and concomitant medications, the risk of falling, and how ill the patient appears. The traditional treatment option is to use heparin or low-molecular-weight heparin and bridge to warfarin therapy. This often requires hospital admission, but in some healthcare settings, may be managed as an outpatient. New anticoagulants such as the direct antithrombin inhibitors are also options, but the use of these medications must be made on an individual basis.  

Inferior vena cava (IVC) filters have been used historically to avoid the propagation of DVTs in the pulmonary artery. Based on current literature, it is unclear if IVC filters prevent PEs, and therefore, they are falling out of favor. They may still be indicated in specific clinical situations.

Pearls and Other Issues

The two-region ultrasound examination will commonly miss calf DVTs. Complete compression of the veins is the only measure that rules out DVTs. Doppler and color may be used but are not necessary for this evaluation. This is a safe and rapid exam that does not lead to DVT propagation.

Enhancing Healthcare Team Outcomes

Deep vein thrombosis is a common occurrence in hospitalized patients. The condition has no specific signs and symptoms and to prevent the high morbidity and mortality, it is best managed by a multidisciplinary team that consists of a nurse practitioner, hematologist, internist, and pharmacist. Prompt diagnosis and treatment are key. Today there are many treatment options but some type of anticoagulation therapy is required. The condition is best treated by prophylaxis with unfractionated heparin or LMWH. Compression stockings and early mobility after surgery are essential. For those treated promptly, the outlook is good but the postphlebitic syndrome is known to occur in a significant number of patients. [11][12](Level V)


Attributed To: Contributed by Michael Schick DO

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Deep Venous Thrombosis (DVT) Of The Lower Extremity - Questions

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A patient with no prior history of deep venous thrombosis presents with unilateral swelling of the right lower extremity after a recent prolonged plane flight. The patient is found to have a below-the-knee deep venous thrombosis associated with the calf. There is no contraindication for anticoagulation therapy. What is the appropriate therapy for this patient?



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At a minimum, how long should a first episode deep venous thrombosis of the calf be treated with anticoagulation in most patients?



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What is the annual risk of major hemorrhage when treating a deep venous thrombosis with oral anticoagulant therapy?



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In a patient with an uncomplicated deep vein thrombosis, what is the duration of treatment with warfarin?



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Which of the following is not true of a deep vein thrombosis?



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Which of the following is a risk factor for a deep vein thrombosis?



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After a successful pinning of a hip fracture, a 60-year-old grandmother complains on the 7th postoperative day of leg pain. She should be examined for which likely complication?



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A 66-year-old woman complains of left calf pain and swelling following an uncomplicated right hemicolectomy for colon cancer. An ultrasound confirms the presence of a deep vein thrombosis (DVT) of the calf. Which of the following statements is true?



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64-year-old postoperative patient develops swelling and pain in the left leg consistent with deep venous thrombosis. Which of the following statements regarding duplex imaging of the lower extremity is TRUE?



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What is the best treatment regimen for a postoperative deep venous thrombosis?



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Which is not a risk factor for a lower extremity deep venous thrombosis?



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Which of the following is the correct statement about the Homan sign?



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Which of the following is a potential sign of deep venous thrombosis?



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Which of the following is an increased risk for an air traveler?



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A therapist is about to work with a patient after a total hip replacement but notes that the calf is painful, red, swollen, and warm to touch. Select the best option.



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A patient has a severe stroke and has been on bedrest for more than a week. During a physical exam, you note that the left lower extremity is swollen, red, and tender. What is the most likely diagnosis of concern?



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A patient presents for therapy after a CVA. There is slight edema of the leg on the affected side. The patient has a history of a DVT and is on warfarin. After checking with the physician, which of the following would be an appropriate recommendation?



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A patient with spinal cord injury is at risk for a deep venous thrombosis. Which of the following statements is correct?



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A patient has a complicated post-operative course after surgery for diverticulitis. While in a subacute nursing facility, the patient notes pain, swelling, redness, and increased warmth of the left calf. Which of the following tests would be the least appropriate?



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A patient has had a left total knee replacement 48 hours ago. A physical therapist starts treatment and notes redness, swelling, and pain at the left calf. Select the appropriate management.



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A 32-year-old female presents with left calf swelling and pain. Which question would be least important?



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Which pretest best predicts the probability for diagnosing deep vein thrombosis?



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The 2-region deep venous thrombosis (DVT) rule out by ultrasound technique involves what two regions?



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How is a deep venous thrombosis (DVT) diagnosed with ultrasound?

Attributed To: Contributed by Sonoran Ultrasound LLC, DVT lecture 2008



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Deep vein thrombosis of the calf is:



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A nurse is caring for a client with a deep vein thrombosis. The client has 8/10 pain, 3+ edema, redness, and intact circulation on assessment of the right lower extremity. What are essential interventions for the delivery of care to this client? Select all that apply.



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Deep Venous Thrombosis (DVT) Of The Lower Extremity - References

References

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