Venous Disease - Dove

What is DVT?

Thrombus in deep vein involving venous VALVE CUSP & venous BRANCH POINTS of calf, thigh or pelvis

What is Virchow’s triad?

Etiology of DVT including hypercoagulopathy, stasis, & endothelial damage/dysfunction

What is Hypercoagulopathy?

Increased circulating tissue actvation factor & decreased plasma antthrombin and fibrinolysis (obesity, cancer)

What is Stasis?

From any mechanism retarding or obstructing venous return (immobility)

What is Endothelial damage?

Surgery, external injury, vein catheters, smoking, & HTN

How does clinical presentation of DVT vary?

• Anatomical distribution

• Extent

• Degree of occlusion

Symptoms of DVT?

• Absence to red massive swelling on one leg

• Cyanosis with impending venous gangrene

What are the patterns of Thrombosis?

• Isolated calf vein (distal)

• Femoropopliteal

• Iliofemoral thrombosis

How does limb edema present in DVT?

Unilateral or bilateral of the thrombus extends to pelvic vein

What are the most common signs/symptoms of DVT?

• Leg pain, leg Pain, edema, erythema, tenderness, low grade fever, & prominent superficial veins

• Pain with passive dorsiflexion of the foot (Homan’s sign)

• Peripheral cyanosis

Who is most likely to have small, asymptomatic, distal, non-occlusive thrombi?

Post-op patients

What is a Pulmonary embolism?

A life-threatening manifestation of venous thromboembolism that occurs when a portion of the clot from a DVT breaks off, travels to the right heart, & lodges in the pulmonary vasculature

What are signs of a Pulmonary embolism?

• Tachypnea (>20/min)

• Tachycardia

• Decreased breath sounds

• Rales

• Jugular vein distension

• Accentuated pulmonic component of the 2nd heart sound

What are symptoms of a Pulmonary embolism?

• SOB at rest or effort

• Pleuritic chest pain

• Cough

• Orthopnea - SOB while lying flat

• Symptoms of DVT

  • Calf or thigh pain or swelling

  • Wheezing

  • Hemoptysis (coughing up blood)

How do you test for Wells/simplified wells clinical scores?

• Clinical signs and symptoms of DVT

• Alternative diagnosis less likely

• Heart rate >100

• Previous DVT/PE

• Immobilization (>3 days) or surgery in the previous 4 weeks

• Malignancy

• Hemoptysis

What are biomarkers of PE?

• D-dimer

• Troponin

• Natriuretic peptides

What is D-dimer?

An EXTREMELY SENSITIVE BIOMARKER OF ACUTE PE that is formed as a result of acute thrombosis and is a fibrin degrada\on product - gold standard for acute PE

What are Troponoin I & T levels?

Most sensitive & specific biomarkers of myocardial injury

What are Natriuretic peptides?

Valuable in evaluating a hemodynamically significant pressure on the right ventricle due to a large PE

ECG signs of PE?

• T-wave inversion in lead V1

• ST elevation in lead aVR

• Atrial arrhythmias & fibrillation

DDX for DVT?

• Cellulitis

• Baker’s cyst

• Soft tissue injury to calf

• Achilles tendon rupture

• Venous HTN

• Hypoalbuminemia

• Abdominal/pelvic tumors

DDX for PE?

• Acute coronary syndrome

• Stable angina

• Acute pericarditis

• CHF

What is inherited DVT?

• Facor V leiden

• Prothrombin gene mutation G20210A

• Antithrombin deficiency

• Protein C deficiency

• Protein S deficiency

What is acquired DVT?

• Cancer

• Birth control

• Hormone replacement therapy

• Pregnancy

• Obesity

• Heparin-induced thrombocytopenia

What is inherited PE?

• Facor V leiden

• Prothrombin gene muta<onG20210A

• Antithrombin deficiency

• Protein C deficiency

• Protein S deficiency

• HYPERHORMOCYSTERNIA

What is acquired non-provoking PE?

• Age

• Venous insufficiency

• Obesity

• Rheumatologic disease

• Previous venous thromboembolism

• Antiphospholipid antibody syndrome

What is acquired provoking PE?

• Surgery/trauma

• Cancer

• Prolonged immobility

• Estrogen/ pregnancy

• What is used as an uIndwelling catheter

What is used as an initial screening test with increased levels seven days post DVT?

D-dimer

What is used to detect smaller emboli & replaced the ventilation-perfusion & pulmonary angiography?

CT scan/venography

What is highly specific & sensitive for femoral & popliteal vein thrombosis but is only 50% sensitive for calf DVT?

Venous duplex ultrasound

What measures changes in calf blood volume & gives false positives in pre-existing venous disease, heart failure, & PAD?

Impedence plethysmography

What is an alternative to CT & has high sensitivity & specificity?

MRI/venography

What is gold standard, limited by pain, phlebitis, rxn to contrast, & difficult to perform in patients with edema or are obese?

Contrast venography

Treatment for DVT?

• Anticoagulation to prevent further thrombosis, PE, post-phlebitis syndrome, & chronic thromboembolic pulmonary hypertension

• TRANSIENT RISK usually for 3 months

• IDIOPATHIC RISK for 3-6 months

What are the drugs of choice for DVT?

• Fondaparinux

• Unfractioned heparin

• Low molecular weight heparin

• Dabigatran

• Warfarin

• Rivaroxaban, apixaban

What is Fondaparinux?

ANTICOAGULANT medication to prevent venous thromboembolism, to treat DVT, and to improve survival following MI

What is Unfractioned heparin?

Intravenous infusion, initial dose based on the patient’s weight followed by continuous infusion per hour - USED IN RENAL INSUFFICIENCY

What is Low molecular weight heparin?

• Outpa\ent treatment

• Commonly used as bride with warfarin

• Reduced dose in renal pa\ents

What is Dabigatran?

Used to treat DVT and PE in adults and children 3 months of age and older who have been treated with an injectable blood thinner

What is Warfarin?

Dual therapy due to delayed deple\on vitamin K dependent coagulation factors - INR Goal 2.5

What is Rivaroxaban, apixaban?

Used as a monotherapy, no coagulation therapy

What are non-pharmacological interventions for DVT?

• IVC - used in patients with PROXIMAL DVT if coagulant therapy is ineffective

• Graduated compression stockings (GCSs) - reduce risk of DVT

• Intermittent pneumatic compression (IPC) - a garment that fits around the legs and is intermittently INFLATED AND THEN DEFLATED IN A CYCLIC MANNER with compressed air via an electrical pneumatic pump

What does total hip arthroplasty & total knee arthroplasty use?

• Low molecular weight heparin

• Rivaroxaban, apixaban

What does hip fracture surgery use?

• Low molecular weight heparin

• Unfractioned heparin

• Fondaparinux

What type of prophylaxis is used in non-ortho surgeries?

• Low molecular weight heparin is preferred, but unfractioned heparin is used in patients with renal insufficiency

• Fondaparinux used in patients with heparin induced thrombocytopenia - use for a few days or until patients can ambulate or discharge from the hospital

Management of high risk PE - respiratory support:

• Aggressive management of hypoxemia and hypercapnia

• Oxygen supplementation – through nasal cannula or face mask

• High Flow Nasal Cannula (HFNC) – non-invasive method of administering high oxygen concentration and flows

Management of high risk PE - fluid management:

Administration of fluids for the resuscitation of patients in shock is common & prevalent

Management of high risk PE - hemodynamic support:

• Judicious fluid resuscitation

• Inotrope/vasopressor support

• Correction of underlying cause

What pharmacological support is used for PE?

• Vasopressors

• Inotropes

• Pulmonary arterial vasodilaton

What are Vasopressors?

To increase SVR and eventually MAP and prevent RV ischemia

What are Inotropes?

Secondary to the use of vasopressors, and is mainly aimed at resolving a low cardiac output state, after blood pressure had been stabilized

What is Pulmonary arterial vasodilation?

Inhaled nitric oxide - inducing an increase in cardiac output in patients with INCREASED RIGHT VENTRICULAR AFTERLOAD

What is Surgical pulmonary embolectomy (SPE)?

• Option for patients with SUBMASSIVE PE at high risk for adverse outcomes or with contraindications to fibrinolysis

• First-line treatment rather than as rescue therapy

What are indications for Surgical pulmonary embolectomy (SPE)?

• Contraindication to Lytic Therapy

• Clot in Transit

• Large PFO or ASD

• Moderate to Severe Right Ventricular Dysfunction

• Failed Catheter Directed or Systemic Thrombolysis