VTE and PE

• What causes VTE?

  A blood clot (thrombus) develops in the circulation usually secondary to blood stagnation or hypercoagulable states.
• Once a thrombus has developed it can travel (embolise) from the deep veins through the right side of the heart and into the lungs where it becomes lodged in the pulmonary arteries. This blocks blood flow to the areas of the lungs and is called a pulmonary embolism.
• What are the 9 risk factors for VTE?

  Immobility

  Recent surgery

  Long haul travel

  Pregnancy

  Hormone therapy with oestrogen

  Malignancy

  Polycythaemia

  Systemic lupus erythematosus

  Thrombophilia
• What 2 options are there for VTE prophylaxis? What are their contraindications?

  Low molecular weight heparin - enoxaparin. Contraindicated in patients already on anticoagulation.

  Anti-embolic compression stockings. Contraindications include peripheral arterial disease.
• What is the presentation of a DVT?

  Unilateral calf/leg swelling

  Dilated superficial veins

  Tenderness to the calf

  Oedema

  Colour changes to leg
• How do you measure calf circumferace? What is significant?

  10cm from tibial tuberosity

  3cm is significant
• What does wells score do?

  Predicts the risk of a patient presenting with symptoms having a DVT or PE.
• If wells score result is likely, what happens next?

  Leg vein ultrasound scan
• If wells score result is unlikely then what do you do?

  D-dimer

  Then if that is positive do leg vein ultrasound scan
• What conditions can cause a raised D-dimer?

  Pneumonia

  Malignancy

  Heart failure

  Surgery

  Pregnancy
• If the ultrasound scan is negative but D-dimer is positive and wells score is likely, what happens next?

  Repeat scan in 6-8 days later
• What is the first line imaging for PE?

  CTPA
• What is the initial management for DVT/PE? What can be used as an alternative?

  Start treatment dose apixaban or rivaroxaban immediately

  LMWH as alternative
• What can you use for log term anticoagulation post-VTE?

  DOAC - apixaban, rivaroxaban, edoxaban, dabigatran - contraindicated in renal impairment where creatinine clearance is less than 15ml/min, antiphospholipid syndrome and pregnancy.

  Warfarin - INR target 2-3, first line in antiphospholipid syndrome.

  LMWH - first line in pregnancy.
• How long do you continue anticoagulation for after VTE?

  3 months with reversible cause

  3-6 months in active cancer

  Long term for unprovoked VTE, recurrent VTE or an irreversible underlying cause (e.g. thrombophilia)
• What can be used as an alternative to anticoagulation post-VTE?

  Inferior vena cava filter
• When patients have their first VTE without a clear cause, what do they need to be assessed for?

  Cancer
• What is Budd-chiari syndrome?

  Obstruction to the outflow of blood from the liver caused by thrombosis in the hepatic veins or inferior vena cava. It is associated with hypercoagulable states e.g. myeloproliferative disorders.
• What is the classic triad of Budd-chiari syndrome?

  Abdominal pain

  Hepatomegaly

  Ascites
• What imaging investigation would you used to diagnose Budd-chiari syndrome?

  Doppler ultrasonography
• Give 4 treatment options for Budd-chiari syndrome

  Anticoagulation - LMWH and warfarin

  Endovascular procedures - thrombolysis or angioplasty

  Transjugular intrahepatic postosystemic shunt (TIPS)

  Liver transplant