Thromboembolic disease The Phlebology Clinic / Venous thrombosis / Thromboembolic disease Introduction Description of the condition Risk factors Recognition and diagnosis Treatment methods Frequently asked questions Introduction Venous system man is a fascinating interconnected systemin which blood in the lower parts of the body - especially the legs - overcomes gravity thanks to the precise cooperation of the venous valves and the muscular-articular pump. However, this perfect mechanism can fail. Today's sedentary lifestyle poses a serious threat to our venous system. Long hours at work, long plane or car journeys - these are everyday situations that significantly slow down blood flow, leading to venous stasis, which is dangerous for us. The situation becomes particularly dangerous when further risk factors are added: damage to the blood vessel wall dehydration significantly increases blood density diseases that increase blood clotting Under such conditions, the coagulation system may become over-activated, forming a clot (thrombus) - a potentially lethal threat to your health and life. The most dramatic scenario? It occurs when a blood clot that has formed in a vein breaks off and travels downstream to the lungs, causing a pulmonary embolism - an immediate life-threatening condition, often requiring immediate medical intervention. Description of the condition Venous thromboembolism (CVD) involves uncontrolled blood clotting and thrombus formation in the venous vessels, leading to their closure. The result is a blockage of blood flow - all the more dangerous for the patient, the larger the vessel has become blocked. The disease occurs in the form of deep vein thrombosis and acute pulmonary embolism. The latter is usually a complication of thrombosis of the deep veins of the lower limbs, from which all or part of the thrombotic material is carried downstream to the heart, from where it then travels to the pulmonary arteries, causing their partial or complete occlusion. Venous thromboembolism is most often a serious complication of venous insufficiency, but it can also occur in patients without previous significant venous complaints, e.g. after trauma, surgery (especially orthopaedic or gynaecological surgery) or after a long aeroplane journey (flight of more than 6 h). Cases of thrombotic disease with scanty symptoms from the deep veins of the lower limbs (so-called clinically silent), where the disease is only diagnosed after acute pulmonary embolism, may be life-threatening for the patient. According to various statistics, there are approximately 30,000 cases of pulmonary embolism in Poland each year. 10-15% of these end in the patient's death, as only in about 20% cases is the disease correctly diagnosed and properly treated. The combination of HAPE with cancer increases the risk of death threefold. According to statistics, up to one in three patients immobilised due to a lower limb injury can develop deep vein thrombosis, with the incidence of thrombosis in patients after a femoral neck fracture reaching as high as 60%. Among patients undergoing orthopaedic surgery, even despite routine use of thromboprophylaxis, the incidence of deep vein thrombosis after knee arthroscopy is approximately 7%, while it reaches 36% after hip replacement surgery. The incidence of deep vein thrombosis in patients treated in intensive care units is similarly high, with approximately 32% cases. Risk factors for thromboembolism extensive surgery, especially orthopaedic surgery prolonged immobilisation (>3 days) cancer including therapy history of venous thrombosis pregnancy and post-partum period severe obesity (BMI >30) varicose veins of the lower limbs lupus and other autoimmune diseases nephrotic syndrome infections injuries sedentary lifestyle long journeys (>4-6 hours) dehydration hormonal factors: oral contraception or HTZ. Long air travel (more than 4-6h) is a factor that can cause clinically silent (asymptomatic) pulmonary embolism. Mechanism of formation It is accepted that an abnormal, excessively slow flow of venous blood is a necessary, but usually not sufficient factor for the development of venous thrombosis. Only damage to the inner surface of the vessel wall, whether by trauma, chronic venous hypertension or inflammation, can initiate the intravascular coagulation process. If other, additional risk factors are present - e.g. excessive blood density or viscosity, or congenital or acquired coagulation disorders (so-called 'coagulation disorders') - the risk factors may be reduced. thrombophilias), the likelihood of venous thrombosis increases significantly. In a significant proportion of cases, an obvious provoking factor for the occurrence of venous thrombosis can be identified. This is very often trauma to the lower limb and its immobilisation, e.g. in a plaster dressing or in an orthosis (hence the high percentage of patients after orthopaedic treatment in the statistics). Another large group is made up of bedridden, non-walking patients, including those subject to prolonged immobilisation due to work or travel. The provoking factor may be a diagnosed cancer (including oncological treatment), pregnancy, taking hormonal drugs or thrombophilias, either congenital or acquired. Sometimes, however, it is not possible to establish the provoking factor, which may have an impact on further management, including, for example, the duration of treatment or subsequent recommendations to prevent recurrence, i.e. so-called secondary thrombosis prophylaxis. In approximately 15-30% cases of pulmonary embolism, no direct cause can be established. Particular attention should be paid to the often overlooked source of embolism - the pelvic venous system. This phenomenon is particularly common in women in labour, in whom advanced pelvic venous insufficiency, leading to large venous stasis and secondary venous thrombosis, is quite common. Recognition and diagnosis The diagnosis of thromboembolism is based on the assessment of potential risk factors, the presence of clinical signs typical of venous thrombosis and pulmonary embolism, and the results of imaging studies and laboratory tests performed. Venous thrombosis Diagnostic process venous thrombosisof which deep vein thrombosis begins with a thorough clinical assessment of the patient using a Wells scale (photo opposite). The doctor initially analyses the symptoms present, such as swelling of the limb, pain, redness of the skin and the presence of risk factors for venous thrombosis. Based on this information, he or she determines the initial likelihood of thrombosis. The next step is to mark D-dimer levels in the blood. This is particularly important in patients with a low or intermediate clinical probability of deep vein thrombosis. A normal D-dimer level is highly likely to rule out venous thrombosis, while an elevated value requires additional imaging studies to confirm the presence of a thrombus in the venous bed. The primary imaging modality for the diagnosis of deep vein thrombosis is Doppler ultrasound using a compression test. Doppler ultrasound quickly and accurately visualises the thrombus in the lumen of the venous vessel and assesses its effect on blood flow. In this examination, it is also very often possible to assess the 'age' of the thrombus and the potential risk of its detachment (experienced phlebologists and ultrasonographers can do this). In rare, particularly diagnostically difficult cases, phlebography or CT venography (less commonly veno-MR in acute conditions) can be performed to assess the extent of the lesions in the so-called 'thrombus'. high (proximal) thrombosis involving the iliac vessels and the inferior vena cava. Wells scale Assessment of clinical probability of deep vein thrombosis according to the Wells Scale. © Department of Phlebology Pulmonary embolism Diagnostics pulmonary embolism begins with a clinical assessment using validated scales (Wells or Geneva). The physician analyses the presence of symptoms typical of pulmonary embolism, such as: sudden shortness of breath, chest pain, coughing or hemoptysis. The presence of risk factors and the results of basic investigations, including ECG recording, are also important. As with deep vein thrombosis, the designation of D-dimer levels in the blood plays a key role in the diagnostic process, especially in patients with low or intermediate clinical probability. A normal D-dimer result with a low clinical probability can safely exclude pulmonary embolism. The most important imaging study in the diagnosis of pulmonary embolism is the computed tomography angiography of the pulmonary arteries (so-called angio-CT of the pulmonary arteries). This examination allows direct visualisation of embolic material (detached thrombus) in the pulmonary arteries. An alternative method is ventilation-perfusion lung scintigraphy, which is particularly useful in patients with contraindications to angio-CT. However, the availability of this type of examination is limited and it is used relatively rarely. In exceptional situations - in patients with severe pulmonary embolism (e.g. jam rider) - a classic pulmonary arteriography can be performed, during which embolic material can be glided endovascularly. In patients with confirmed pulmonary embolism, it is important to assess the the right ventricular workload. This is an indicator that is of great prognostic importance. Markers of myocardial damage (troponin), natriuretic peptides (NT-proBNP) and echocardiography (cardiac ECHO) are used for this purpose. The results of these tests influence the selection of an appropriate treatment strategy. It should be emphasised that the diagnosis of venous thromboembolism should be carried out according to well-defined algorithms, taking into account the individual clinical situation of the patient and the availability of particular diagnostic methods in a given centre. It takes place in most cases in a hospital setting. Treatment methods Treatment of patients with venous thromboembolism (VTE) in large proximal thromboses and with severe pulmonary embolism is always carried out in the hospital setting. Some patients may even require cardiac surgery, or at least endovascular treatment, involving removal of the thrombus from the occluded pulmonary artery. 'Lighter' cases can be treated at home, but with the proviso that the Patient should report urgently to hospital if worrying symptoms develop or worsen. In the first stage of treatment (usually for a few days or so), a low-molecular-weight heparin causing prolongation of the prothrombin time - most often administered by subcutaneous injection, less often as an intravenous infusion. In the next stage, heparin is replaced by oral anticoagulants and such treatment continues for at least three months. More recently, oral treatment is being implemented immediately instead of the initial heparin treatment step. An important adjunct to pharmacological treatment of venous thromboembolism, especially in deep vein thrombosis, is the use of compression products (compression therapy). Compression stockings or knee-length socks improve patient comfort by reducing congestion and swelling in the limb, thereby also reducing pain. It has been observed that the use of compression therapy during the treatment of venous thrombosis (and thereafter) reduces the risk of the occurrence and extent of permanent venous damage (in what is known as the 'VTE'). post-thrombotic syndrome). D-dimer: a simple blood test in the diagnosis of venous thrombosis. Do you suspect venous thrombosis in yourself? See how a simple blood D-dimer determination can help rule it out? See what you need to know about it! Mostlyquestions asked I have a sedentary job and travel frequently and am concerned about pulmonary embolism. Should I (should I) do any tests to protect myself from the disease? Sedentary work increases the risk of venous thrombosis, but also of venous insufficiency. It is advisable to check the capacity of the veins of lower limbs in an ultrasound Doppler examination, while for long journeys or sedentary work, one should provide prophylactic stockings or compression knee socks. Good hydration and periodic physical activity or gymnastics should also not be forgotten. I have a sedentary job and travel frequently and I am worried about pulmonary embolism. Should I (should I) take any medication to protect myself from the disease? Long immobilisation - sedentary work or long journeys (especially air travel over 4-6h) indeed increase the risk of venous thrombosis and pulmonary embolism, and prophylactic use of anticoagulants may reduce this risk. However, the possible side effects of such drugs should be taken into account, as well as the fact that they do not eliminate other adverse effects of immobilisation - such as venous stasis and oedema. Therefore, a much more optimal solution, which has a multidirectional effect (on all the symptoms mentioned), is the use of prophylactic compression stockings or knee socks. It is also worth remembering to keep the body well hydrated and to do periodic physical activity/gymnastics. My gynaecologist recently changed my hormonal contraception. I've had a slightly swollen left calf for a few days, and since yesterday I've been coughing a bit and getting tired more easily. Should I do some tests or wait until the discomfort subsides on its own? 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. For the past 2 days I have had swollen both calves, a feeling of heavy legs and minor pain. Should I (should I) have my D-dimer levels tested? 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. There have been cases of venous thrombosis and pulmonary embolism in my family. Can I also develop this disease? The risk of genetically determined thrombophilia (hypercoagulability) depends on the degree of consanguinity of those family members with the disease. It is highest when both parents have had venous thrombosis, 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, the symptoms of thrombosis will not appear. Therefore, appropriate prophylaxis and periodic follow-up ultrasound examinations of the venous system are important. Related issues 01 / Venous thrombosis 02 / Deep vein thrombosis 03 / Superficial thrombophlebitis Modern vein treatment We offer treatment both on an outpatient basis and in day ward admissions. The stay is of short duration. The patient spends between 1 and 5 hours in the Clinic. Make an appointment
