1. DVT & PE
Deep vein thrombosis
&
Pulmonary embolism

2. Deep vein thrombosis
 A form of thrombophlebitis
 Incidence- ~1 per 1000 persons per year
 Commonly affects leg veins (L>R)-
popliteal, femoral, pelvic
 Virchow’s triad-
 Decreased blood flow- stasis
 Damage to vessel wall
 Hypercoagulability
 Complication-
 Pulmonary embolism
 Post-phlebitic syndrome

3. DVT- risk factors
 Recent surgery
 Hospitalization
 Advanced age
 Obesity
 Immobilization
 Thrombophilia- AT-
III/protein C or S
deficiency
 Pregnancy
 Estrogen containing
OCP
 Tobacco use
 Prolonged economy
class air travel
 Cancer
 Infection

4. DVT-clinical presentation
 Underlying risk factors
 Symptoms
 Pain, swelling, redness of leg
 Superficial vein dilatation
 Signs
 Edema, tender veins
 Homan’s sign- calf pain on dorsiflexion of foot
 Acute DVT may cause impaired circulation
cold extremity, absent pulse, even gangrene

5. DVT- diagnosis
D-dimer level- a FDP
Duplex ultrasonography, with
compression
CT venography (iliocaval DVT)

6. DVT- management
 Mostly out-patient, using LMWH
 Hospitalization recommended-
 B/L DVT
 Extensive proximal DVT
 CRI
 CHF
 Cancer
 Recent immobility
 Low body weight

7. Anticoagulation
 Low molecular weight heparin (LMWH)
 Fondaparinux
 Unfractionated heparin- requires
hospitalization & monitoring (aPTT)
Dose- 80 U/kg bolus18 U/kg/hr infusionmonitor aPTT
 Long-term Warfarin- at least 3 months
Dose- 5 mg OD x 3 daysmonitor PT
 Life-long for life-threatening/recurrent DVT
 Monitor PT/INR- 2-3 times normal

8. Other Rx options
 Thrombolysis for extensive proximal
clot, increases risk of bleeding
 Intermittent pneumatic compression-
(IPC) if heparin CI or post-op.
 IVC filter- reduces PE, used in patients
with ICH, potentially prothrombotic

9. DVT- prevention
 LMWH/UFH in hospitalised patients with risk
factors for DVT
 LMWH post-op.
 IPC after knee/hip surgery
 Elastic compression stockings during long-
haul flights
 Heparin/LMWH/Warfarin in at risk pregnancy
 Early mobilization

10. Post-phlebitic syndrome
 Occurs in ~15% patients with DVT
 Consequences-
 Edema
 Pain
 Cramps
 Venous claudication
 Skin pigmentation
 Dermatitis
 Ulceration

11. Pulmonary embolism
 Commonly embolism from DVT
 Risk more with proximal DVT
 Risk factors- as for DVT
 Clot obstructs pulmonary arterial circulation &
strains right ventricle

12. PE- diagnosis
 Risk factors ± DVT
 Symptoms-
 Mostly silent
 ~15% of sudden deaths attributable to PE
 May cause sudden SOB, pleuritic chest pain,
hemoptysis
 Signs
 Tachypnea, cyanosis, pleural rub, low-grade fever
 RV strain- loud P2, LPSH, raised JVP

13. PE- diagnosis
 Investigations-
 CBC, PT/aPTT, LFT, RFT- for R/F
 CxR- mainly to rule out other pathology
 ECG- tachycardia, RV strain, R/O MI
 ECHO- RV dysfunction, R/O MI
 D-dimer ± US- for DVT
 CT pulmonary angiography- for PE Dx
 V-Q scan- contrast allergy/CI

14. PE- treatment
 Anticoagulation
 LMWH/Fondaparinux/Heparin
 Warfarin x minimum 3 months, lifelong if recurrent
 Thrombolysis
 PE with hemodynamic instability
 PE with RV dysfunction on ECHO

 Surgical thrombectomy

15. H.I.T
 Heparin induced thrombocytopenia
 An immune reaction to Heparin/LMWH
 Paradoxical increase in arterial/venous
thrombosis, with thrombocytopenia
 Can occur upto 100 days after exposure
 Rx-
 Stop Heparin/LMWH
 Anticoagulation with direct thrombin inhibitors (monitor aPTT)-
lepirudin, argatroban, bivaluridin- until platelet count
stabilizes
 Long-term Warfarin