Deep vein thrombosis

The Phlebology Clinic / Venous thrombosis / Deep vein thrombosis

Venous thrombosis (DVT) in a pregnant woman.

Introduction

Deep vein thrombosis (deep venous thrombosis, DVT) is a significant public health problem, annually affecting approximately 2-3 persons per 1000 in the general population. In the group of people over 80 years of age, the incidence increases significantly, reaching 6 cases per 1,000 people per year. It is estimated that in Poland, deep vein thrombosis is diagnosed in approximately 60-80 000 people each year.

Blood transport in the venous system, particularly in the lower limbs, is a complex biomechanical process that defies the force of gravity. Efficient venous blood flow is possible due to the precise heart as a suction and pressure pump, the negative pressure generated intra-abdominal, the muscular-articular pump and the venous valves that prevent venous blood from backflowing. Disruption of this balance, for example due to prolonged immobilisation, can initiate a pathological process. Venous stasis, a consequence of slowed blood flow, combined with additional risk factors, can initiate a thrombotic process.

Three factors are particularly important for the development of deep vein thrombosis:

blood rheological disorders (e.g. increased plasma viscosity in dehydration states);
hypercoagulability in the course of comorbidities;
vascular endothelial damage.

Epidemiological studies indicate that approximately 50% cases of deep vein thrombosis develop during hospitalisation or up to 90 days after the patient's discharge from hospital. The co-occurrence of the above factors can activate the coagulation cascade, leading to the formation of a thrombus in the lumen of a venous vessel. Early recognition and implementation of appropriate treatment is crucial for prognosis.

Description of the condition

Deep vein thrombosis is the abnormal and uncontrolled coagulation of blood in the venous vessels, leading to their complete or partial occlusion. As a result, the blood flow is blocked or at least severely impaired - the more serious for the patient, the greater the vessel occlusion. Deep vein thrombosis of the lower extremities is the most common cause of acute pulmonary embolism, thus being a key ingredient in the so-called 'green'. venous thromboembolism.

Venous thrombosis can affect anyone. It can appear after just one hour of sitting still, after intense sport, after a minor injury to a limb, after or during pregnancy or as a result of hormonal medication. There are no rules. The process of thrombus formation can be very dynamic and last only an hour, or it can build up over a long period, manifesting itself in a gradual increase in discomfort. Often, thrombus formation is facilitated by dehydration.

Deep vein thrombosis is usually a complication of venous insufficiencybut can also develop in patients who have not previously reported venous problems. The vast majority of deep vein thrombosis cases are accompanied by characteristic symptoms, facilitating correct diagnosis and implementation of appropriate treatment. Unfortunately, there are also cases of disease with scanty symptoms from the deep veins of the lower limbs (so-called clinically silent), where the disease is diagnosed only after an episode of acute pulmonary embolism, with a mortality rate of up to 30%.

Main symptoms of deep vein thrombosis it:

swelling of the limb - It is usually unilateral and appears quite suddenly. The leg (this is the most common location of venous thrombosis) may (but need not) be noticeably thicker than the other;
pain in a limb (local or generalised)) - can vary in character; it is most often intensified when walking, is dull or spreading and typically occurs with calf pressure;

redness and increased skin heat at the site of a thrombus (a symptom often present in cases of coexisting superficial thrombophlebitis)
Homans symptom - calf pain during dorsiflexion of the foot (a symptom that is quite insensitive and specific);
increased skin tension - it becomes shiny and taut
visible dilatation of superficial veins (secondary sign, indicating redistribution of the venous circulation);
pressure soreness of the calf (Moyer's symptom) - like Homans' sign has limited diagnostic value in deep vein thrombosis due to its low sensitivity and specificity in detecting DVT.

**Deep vein thrombosis of the left lower limb. Proximal form involving runoff from the popliteal veins to the left external iliac,**

If deep vein thrombosis is suspected, a doctor should be consulted immediately. It is important to remember that trivialised and untreated (or poorly treated) deep vein thrombosis can lead to dangerous complications, including life-threatening pulmonary embolism.

Risk factors that increase the risk of deep vein thrombosis

prolonged immobilisation of the limb (> 3 days)
surgery performed within the last 3 months
malignant tumour (active or undergoing treatment)
obesity (BMI values > 30)
Pregnancy and the puerperium (during pregnancy the risk of DVT is 4-6 times higher; in the puerperium even 15-35 times higher)
use of oral contraceptives or HTZ
a previous history of deep vein thrombosis or pulmonary embolism (the risk of recurrence is 30-50 times higher compared with people who have never had an episode of venous thrombosis)
over 60 years of age
long journey (> 4-6 hours)
the presence of venous insufficiency, including varicose veins of the lower limbs
superficial thrombophlebitis
lower limb injuries
congenital thrombophilias (hypercoagulabilities)
Antiphospholipid syndrome (the most common form of acquired hypercoagulability causing a 5-10 fold increase in the risk of DVT)
dehydration
heart failure associated with venous stasis
sepsis and severe infections

**Immobilisation of the leg in a plaster dressing significantly increases the risk of deep vein thrombosis even despite thromboprophylaxis.**

Mechanism of formation

Abnormal (too slow) venous blood flow is considered a necessary but usually insufficient factor for the development of venous thrombosis. The initiating factor of the coagulation process is damage to the inner surface of the vessel wall. It can be caused by trauma, or by chronic venous hypertension (a chronic lesion leading to an inflammatory response). If other additional risk factors are present - e.g. excessive blood density or viscosity (e.g. due to dehydration), or congenital or acquired coagulation disorders (so-called trombophilia), the likelihood of venous thrombosis increases significantly.

In a large proportion of cases, a specific provoking factor for venous thrombosis can be identified. Often this is trauma to the lower limb and its immobilisation in a plaster dressing or in an orthosis, which is why, in the statistics of the causes of deep system venous thrombosis, a significant percentage are patients after orthopaedic treatment. Another large group is made up of bedridden, non-walking patients and those subjected to prolonged immobilisation due to work or travel. A provoking factor can be cancer (including oncological treatment), taking hormonal drugs, pregnancy or, finally, thrombophilias, both congenital and acquired. In many cases, however, it is not possible to establish an obvious provoking factor, which can have a significant impact on the management of the patient, e.g. the duration of thrombosis treatment or recommendations for so-called recurrence prophylaxis.

Recognition and diagnosis

The formation of a thrombus in the lumen of a venous vessel results in impaired blood flow or complete closure of the vessel. The result is congestion - redness or bruising and painful swelling in the area from which blood is not drained by the clotted (obstructed) vein. However, if the area of congestion is small, or if there is not complete closure of the vessel, or the outflow through another vessel (e.g. a twin vein) remains preserved, the complaints may be mild and easy to overlook.

If the thrombosis involves a large vessel, e.g. the iliac or femoral vein (the so-called 'thrombosis'), the patient will be able to get a better result. proximal thrombosis), through which blood flows from all or almost all of the lower limb, the severity of swelling, bruising or redness and pain is usually greater and more characteristic. Typical symptoms increase the likelihood of correctly diagnosing the disease and implementing appropriate treatment. On the other hand, however, venous thrombosis of large vessels is associated with a much higher risk of life-threatening pulmonary embolism.

The diagnosis of the disease is based on the assessment of potential risk factors, the presence of the listed clinical symptoms and the results of imaging studies and laboratory tests.

The primary imaging study used in the diagnosis of venous thrombosis is the ultrasound examination (USG) with so-called compression tests with simultaneous assessment of flow using Doppler mode (colour coding + spectral mode).

Among laboratory tests, an important auxiliary test is the determination of D-dimer levels, i.e. breakdown products of fibrin (one of the components of a thrombus). It is worth noting that an elevated result of this assay, although it may suggest thrombosis, does not conclusively establish its presence, especially for results slightly above the upper range of the standard.

**Proximal venous thrombosis can involve the venous segment from the level of the popliteal vein up to the iliac vein drain.**

Among the additional tests, an important role in confirming or excluding thrombophilia genetic and biochemical tests. Among genetic tests, the most important are tests for the presence of thrombophilic variants of genes encoding coagulation factors - the F2 (prothrombin) and F5 (so-called Leiden variant)and, among the biochemical ones, the detection of the presence of cardiolipin autoantibodies, lupus anticoagulantlevel determination antithrombin III, C and S proteins, and homocysteine. Although tests of this type are not routinely performed in the case of a first episode of venous thrombosis with an obvious risk factor (i.e. provoked), they are recommended in patients after so-called unprovoked thrombosis, especially with an aggravating family history, as helpful in planning further management after thrombosis treatment. In such patients, exclusion of thrombophilia allows termination of therapy, while in the case of confirmation, indefinite thromboprophylaxis should be considered.

Treatment methods

Treatment of most patients with deep vein thrombosis, thanks to the availability of modern anticoagulants, can be safely managed at home, with the proviso, however, that the Patient should be urgently referred to hospital if worrying symptoms occur or worsen. In the case of patients with large proximal thromboses (with a high risk of embolic complications and the risk of developing a cyanotic swelling of a limb) treatment is usually carried out in a hospital setting.

In the first stage of treatment (usually for a few days or so), a heparin - most commonly administered in the form of subcutaneous injections, less often as an intravenous infusion. In the next stage, heparin is replaced by oral medication and such treatment is continued for at least three months. In the last stage, instead of the initial stage of treatment with heparin, the following is implemented immediately oral anticoagulant treatment (rivaroxaban, apixaban, dabigatran, edoxaban). After 3 months, it is implemented long-term treatment, the duration of which (3-6 months) depends on the clinical situation. Antithrombotic treatment beyond 6 months is defined as prolonged secondary prevention. It is used in patients with deep vein thrombosis of undetermined cause (so-called idiopathic), with persistent risk factors or with recurrent DVT.

In some cases, pharmacological treatment may be combined with the removal of embolic material by surgical methods or, more commonly minimally invasive methods so-called interventional radiology. However, a significant limitation to their use is the high cost of treatment and the availability of equipment and specialists with relevant experience in this type of treatment.

An important adjunct to pharmacological treatment in deep vein thrombosis is the use of compression garments (so-called compression therapy). Compression stockings or knee-length socks improve the patient's comfort by reducing congestion and swelling in the limb, thereby also reducing pain. It has been observed that the use of compression therapy during thrombosis treatment (and thereafter) reduces the risk of the occurrence and extent of permanent venous damage (in what is known as the 'thrombolysis'). post-thrombotic syndrome).

Percutaneous venous stenting - how does the procedure work?

Mostly
questions asked

Suspicion thrombophilia (hypercoagulability) after two miscarriages is most justifiable, as thrombophilias are a recognised cause of recurrent miscarriages through impaired blood supply and microthrombus formation in the placental vessels. Diagnosis of thrombophilia is recommended precisely after two or more miscarriages in the first trimester or one in the second trimester. It is particularly important to exclude antiphospholipid syndrome (an example of a highly prothrombotic secondary thrombophilia), factor V Leiden mutations and prothrombin gene mutations. Importantly, the detection of thrombophilia makes it possible to initiate appropriate treatment in the next pregnancy (low-molecular-weight heparin and aspirin are most commonly used together), which significantly improves prognosis. The use of anticoagulant prophylaxis together with compression therapy significantly increases the chances of pregnancy delivery in women with thrombophilia.
The symptoms listed may suggest deep vein thrombosis of the left lower limb with pulmonary embolism. With a significant risk factor in the form of hormonal contraception, this makes this diagnosis strongly likely. In such a situation, waiting for the symptoms to resolve spontaneously can be very risky. It is best to visit a hospital emergency department to rule out (or confirm) pulmonary embolism on an angio-CT scan.
Pain, a feeling of heaviness and swelling in the legs may be a symptom of deep vein thrombosis, although bilateral occurrence is rather unlikely. Determination of D-dimer levels can be helpful in ruling out thrombosis, but an ultrasound examination of the lower limb veins should be performed first and foremost.
Venous stenting in venous thrombosis and post-thrombotic syndromes, is a rather broad topic. The stenting procedure requires an experienced team and should only be performed in qualified centres. Venous stenting is most commonly used in the following clinical cases:
- May-Thurner syndrome complicated by proximal venous thrombosis;
- recurrent venous thrombosis despite appropriate anticoagulant treatment;
- severe post-thrombotic syndrome unresponsive to conservative treatment;
- Massive hip thrombosis with life-threatening consequences (in the course of "phlegmasia coerulea dolens", i.e. painful cyanotic oedema)
Patients are more likely to have a successful stent procedure: young age, in good general condition, with no contraindications to long-term anticoagulant treatment and with confirmed patency of the peripheral deep veins (with adequate inflow). In the case of early interventions, the best results are obtained when the unblocking is carried out up to 14 days after the onset of symptoms.
Risk of occurrence genetically determined thrombophilia depends on the degree of consanguinity of those family members with the disease. This is greatest when both parents have had thrombophilia, although even then it is possible that their offspring will be healthy. Diagnostic tests for thrombophilia can clarify any doubts, but a negative result does not guarantee that, for example, after a long flight or a limb fracture and its immobilisation in a plaster cast, thrombosis will not occur. Therefore, appropriate prophylaxis and periodic follow-up ultrasound examinations of the venous system are important.

Czy zakrzepica żył głębokich jest groźna?
Tak, zakrzepica żył głębokich jest poważnym schorzeniem, które może prowadzić do groźnych powikłań. Głównym zagrożeniem związanym z ZŻG jest ryzyko wystąpienia zatorowości płucnej, która może być stanem zagrażającym życiu.

Related issues

Vascular laboratory. Venous embolisation.

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