DVT

• What is a DVT?

  Thrombus within a deep vein
• What are the RFs of DVT?

  Immobility

  Recent surgery

  Long haul travel

  Pregnancy

  Hormone therapy with oestrogen (COC, HRT)

  Malignancy

  Polycythaemia

  SLE

  Thrombophilia

  Obesity

  Pregnancy

  Previous VTE

  Smoking

  Varicose veins
• Pathophys - DVT

  Altered blood flow in adjacent venous valves -> changes in blood flow/composition/endothelium (Virchow's triad) -> prothrombotic environment -> venous thrombosis formation (platelets centrally & RBCs/fibrin exteriorly) -> DVT formation
• What are the signs & symptoms of DVT?

  Unilateral leg pain

  Unilateral leg swelling (usually confined to calves)

  Discolouration of affected leg (cyanosis, diffuse erythema)

  Superficial veins become distended

  Increased temp in affected leg

  Tenderness on palpation of deep veins

  Difference in calves > 3cm (measured 10cm below tibial tuberosity)
• What should be done if DVT is suspected?

  2 level DVT Wells score
• What is included in a 2-level DVT Wells score?

  Active cancer = +1

  Paralysis, paresis or recent plaster immobilisation of lower extremities = +1

  Recently bedridden for > 3 days OR major surgery within 12 wks = +1

  Localised tenderness along deep venous system = +1

  Entire leg swollen = +1

  Calf swelling at least 3cm = +1

  Pitting oedema = +1

  Collateral superficial veins (non-varicose) = +1

  Previous DVT = +1

  Alternative diagnosis at least as likely as DVT = -2

  Score

  • 2 or more = DVT likely
  • 1 or less = DVT unlikely
• DVT likely (from Wells score)

  Proximal leg USS within 4 hrs

  • +ve = DVT + start anticoag
  • -ve = D-dimer (if -ve consider alternate diagnosis)

  If proximal leg USS cannot be done within 4 hrs -> anticoag (DOAC) whilst waiting (USS within 24 hrs)

  If scan -ve, but D-dimer +ve = stop anticoag & offer proximal leg USS 6-8 days later
• DVT unlikely (from Wells score)

  D-dimer within 4 hrs (if not possible start anticoag (DOAC))

  • -ve = consider alternative diagnosis
  • +ve = proximal leg USS within 4 hrs
• What are the DDx of DVT?

  Cellulitis

  Superficial thrombophlebitis

  Dependent oedema

  Liver cirrhosis/nephrotic syndrome

  Ruptured Baker's cyst

  Trauma
• What is the management of DVT?

  Anticoagulation

  • DOAC (apixaban/rivaroxaban)
  • if severe renal impairment (< 15 ml/min) -> LMWH

  Length of anticoag

  • provoked VTE = 3 months
  • unprovoked VTE = 6 months
  • active cancer = 3-6 months
• What are the possible complications of DVT?

  PE

  Post-thrombotic syndrome