deep vein thrombosis

1. MANAGEMENT OF DVT
DR SANJAY H SHARMA
SPECIALIST A&E
KHOULA HOSPITAL

2. DEEP VEIN THROMBOSIS
• PASSENGERS, WHO SIT IMMOBILE FOR
HOURS ON LONG DISTANCE FLIGHTS ARE
PRONE TO DEEP VEIN THROMBOSIS IN THE
LEG.
• DVT MAY GIVE RISE TO MILD PAIN OR
TIGHTNESS IN THE CALF MUSCLES.
• DVT CAN BE ASYMPTOMATIC
• THROMBUS DISLODGED CAUSES
PULMONARY EMBOLISM.
• PREVENTIVE MEASURE INCLUDES
STRECHING OF LEGS EVERY HOUR.

3. VIRCHOWS TRIAD
ENDOTHELIAL INJURY
THROMBOSIS
ABNORMAL
BLOOD FLOW HYPERCOAGULABILITY

4. THROMBOSIS
• VIRCHOWS TRIAD
• 1. ENDOTHELIAL INJURY
• INJURY TO ENDOTHELIUM CAN BE CAUSED
BY
• ATHEROSCLEROSIS
• HYPERTENSION
• HYPERCHOLESTEROLEMIA
• RADIATION INJURY
• SMOKING

5. ALTERATION IN BLOOD FLOW
• STASIS IS A MAJOR FACTOR IN
DEVELOPMENT OF VENOUS THROMBI.
• NORMAL BLOOD FLOW IS LAMINAR ,
CELLULAR ELEMENTS FLOW CENTRALLY
AND PLASMA IN PERIPHERY.
• STASIS AND TURBULENCE DISRUPTS
LAMINAR FLOW OF BLOOD
• PREVENT DILUTION OF ACTIVATED
CLOTTING FACTOR.

6. STASIS AND TURBULENCE
CONTRIBUTE TO THROMBOSIS
• CAUSES ARE
• ULCERATED ATHEROSCLEROSIS
• ANEURYSMS
• MYOCARDIAL INFARCTION “: DUE TO
REGIONS OF NON CONTRACTILE
MYOCARDIUM THERE IS STASIS OF BLOOD
WHICH HELPS IN FORMATION OF MURAL
THROMBUS.
• MITRAL VALVE STENOSIS
• ATRIAL FIBRILLATION

7. HYPERCOAGULABILTY
• PRIMARY CAUSES:
• MUTATION IN THE FACTOR V GENE WHICH
CAUSES FUNCTIONAL DEFICENCY OF
PROTEIN C.
• SECONDARY CAUSES:
• CCF
• TRAUMA
• ORAL CONTRACEPTIVES
• SMOKING
• OBESITY

8. VENOUS THROMBOSIS
• IS ALWAYS OCCLUSIVE
• THE THROMBUS OFTEN CREATES A LONG
CAST OF THE VEIN LUMEN .
• VENOUS THROMBI FORM IN SLOWLY
MOVING VENOUS BLOOD , THEY TEND TO
CONTAIN ERYTHROCYTES THEREFORE
KNOWN AS RED OR STASIS THROMBI.
• 90 % OF CASES AFFECTS THE VEINS OF
LOWER LIMB.

9. FATE OF THROMBUS
• IF A PATIENT SURVIVES , THROMBI
UNDERGO COMBINATION OF FOLLOWING
FOUR EVENTS:
1. PROPAGATION : THE THROMBUS
ACCUMULATE MORE PLATELET AND FIBRIN
, OBSTRUCTING VESSEL.
2. .EMBOLIZATION : THROMBI MAY
DISLODGE AND BE TRANSPORTED TO
OTHER SITES IN THE VASCULATURE.
3. .DISSOLUTION: THROMBI MAY BE
REMOVED BY FIBRINOLYTIC ACTIVITY.
4. .ORGANIZATION AND
RECANALIZATION : THROMBI MAY
INDUCE INFLAMMATION AND FIBROSIS

10. DEEP VENOUS THROMBI
• DEEP THROMBI IN THE LARGER LEG VEINS
ARE MORE SERIOUS AS THEY CAN
EMBOLIZE.( POPLITEAL, FEMORAL AND
ILIAC VEINS)
• DVT CAN CAUSE EDEMA OF FOOT AND
ANKLE AND PRODUCE PAIN AND
TENDERNESS
• HALF OF CASES ARE ASYMPTOMATIC.
• VENOUS OBSTRUCTION IS COMPENSATED
BY OPENING COLLATERALS.
•

11. DVT OCCURS IN VARIERTY OF
CLINICAL SETTINGS
• CARDIAC FAILURE:DUE TO VENOUS STASIS
• TRAUMA , SURGERY, BURNS RESULTS IN
REDUCED PHYSICAL ACTIVITY.
• ADVANCED AGE, BED REST,
IMMOBILIZATION INCREASES RISK OF DVT.
• REDUCED PHYSICAL ACTIVITY DIMINISHES
THE MILKING ACTION OF MUSCLES IN THE
LOWER LEG AND SO SLOWS VENOUS
RETURN.

12. CLINICAL FEATURES OF DVT
• VENOUS THROMBOSIS MAY OCCUR IN
WOMEN TAKING ORAL CONTRACEPTIVES.
• ENFORCED BED REST AFTER SURGERY.
• CARDIAC FAILURE ALSO LEADS TO VENOUS
STASIS AND THROMOSIS.
• AFFECTED LIMB IS SWOLLEN, TENDER ,
WARMER THEN NORMAL
• DILATED SUPERFICIAL VEINS MAY BE SEEN
WHICH DO NOT COLLAPSE AFTER
ELEVATION.
•

13. CLINICAL FEATURES
• FORCEFUL DORSIFLEXION OF THE FOOT
WILL CAUSE PAIN IN THE CALF MUSCLE
( HOMAN SIGN)
• SOMETIMES EXTENSION OF DVT UPWARDS
TO THIGH MAY LEAD TO TENDER , HARD .
PALPABLE FEMORAL VEIN .
• PULMONARY EMBOLISM MAY BE FIRST
CLINICAL MANIFESTATION OF DVT

15. OPERATION FOR DEEP VEIN
THROMBOSIS
• ILIOFEMORAL VENOUS
THROMBECTOMY
• CAVAL CLIPPING
• INSERTION OF
UMBRELLA FILTER

16. OPERATION FOR POST
THROMBOTIC SYNDROME
• SAPHANEOUS TRANSPOSITION
• PROFUNDA FEMORIS TRANSPOSITION
• CAVAL AND ILIAC VEIN BYPASS
GRAFTING
• PLASTIC VENOCUFFS
• AUTO GRAFT INSERTION

17. REFERENCES
• ROSEN’S EMERGENCY MEDICINE 5TH
EDITION
• DAVIDSON’S PRINCIPLE AND
PRACTICE OF MEDICINE 16TH EDITION
• HUTCHISON’S CLINICAL METHODS 19TH
EDITION

18. REFERENCES
• CLINICAL ANATOMY BY RICHARD S SNELL
7TH EDITION
• BASIC PATHOLOGY BY KUMAR AND
ROBBINS 6TH EDITION
• CUNNIGHAMS ANATOMY 15TH EDITION
• GENERAL SURGICAL OPERATION BY RM
KIRK 5TH EDITION
• MEDICAL PHYSIOLOGY BY GUYTON 10 TH
EDITION