A.47 Thrombophlebitis of Deep Veins Flashcards
A.47 Thrombophlebitis of Deep Veins
Etiology
- Previous history of Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) (30x increased risk)
- Prolonged immobility (e.g., post-surgery, long-distance flights, trauma) (20x increased risk)
- Age over 60 years
- Cancer or malignancy
- Hereditary thrombophilia (notably factor V Leiden)
- Pregnancy or use of estrogen-containing contraceptives
- Obesity
- Tobacco use
- Intravenous drug use
- Nephrotic syndrome
- Inadequate thrombosis prophylaxis or failure to adhere to preventive measures
A.47 Thrombophlebitis of Deep Veins
Pathophys
The Virchow Triad
- Hypercoagulability: Increased platelet adhesion and thrombophilia (e.g., Factor V Leiden mutation), use of oral contraceptives, and pregnancy.
- Endothelial Damage: Inflammatory or traumatic injuries to blood vessels can activate clotting factors through exposure to subendothelial collagen.
- Venous Stasis: Conditions such as varicosity, external pressure on the extremity, immobilization (e.g., hospitalization, prolonged bed rest, long flights, or bus rides), and local application of heat.
A.47 Thrombophlebitis of Deep Veins
Clinical
- Asymptomatic Presentation: Many cases may not display noticeable symptoms.
Localized Ulceration:
- Commonly affects the deep veins of the legs, thighs, or pelvis.
May present as:
- May-Thurner Syndrome: Compression of the left iliac vein by the right iliac artery and a lumbar vertebral spur (occurs in > 20% of adults).
- Symptoms include swelling and a feeling of tightness or heaviness.
Skin Changes:
- Warmth, erythema, and potential discoloration.
Pain and Tenderness:
- Possible tenderness in the calf, described as:
- Homans’ Sign: Pain on dorsiflexion of the foot.
- Meyer Sign: Pain when pressure is applied to the calf.
Superficial Vein Characteristics:
- Distal pulses are typically normal.
- General Symptoms of Pulmonary Embolism:
- Fever, dyspnea, chest pain, dizziness, and weakness.
A.47 Thrombophlebitis of Deep Veins
DX
Assessment for Suspected DVT: The diagnostic approach is guided by the Wells score. Compression ultrasound and D-dimer levels are the primary diagnostic tests.
Diagnostic Approach for DVT:
If DVT is suspected, start with a Calcified Wells Score.
Confirm DVT through compression ultrasound.
If DVT is not detected, proceed accordingly.
A.47 Thrombophlebitis of Deep Veins
Wells Criteria
Medical History
Active cancer +1
Previously documented DVT +1
ImmobilizationParalysis or recent immobilization of lower extremity +1
Recently bedridden (≥ 3 days) or major surgery (within 12 weeks) +1
Clinical Symptoms
Tenderness along the deep venous system +1
Swelling of the entire leg +1
Calf swelling > 2 cm compared to asymptomatic calf +1
Unilateral pitting edema in symptomatic leg + 1
Major (non-varicose) superficial veins +1
Differential Diagnosis
Alternative diagnosis that is at least as likely as DVT -2
A.47 Thrombophlebitis of Deep Veins
Further Diagnoistic Tests
Venography (Angiography)
- Most accurate method for assessing calf veins and valve competency.
- Indications: Obesity, severe edema, abnormal results from prior tests.
CT Scan
- For suspected PE or underlying malignancy.
Thrombophilia Screening
- Coagulation Studies
- Indications: Young patients, unusual thrombus location, positive family history.
- Tests should be conducted 2 weeks after discontinuing anticoagulation.
General Tumor Screening
- Indications: Idiopathic thrombosis (especially in patients > 50 years).
- Tests include: CBC, renal function tests, LFTs, urinalysis, and chest X-ray.
- Additional screenings (e.g., colonoscopy, mammogram, DRE).
A.47 Thrombophlebitis of Deep Veins
TX
Anticoagulation
Acute Therapy
- Heparin Bolus plus constant heparin infusion for 4–5 days
- Option: UFH or LMWH
- Alternatively: Fondaparinux
- Target: Achieve and maintain an aPTT of 1.5–2.5 times the control value or upper normal limit.
- Initiate warfarin once aPTT is therapeutic.
Secondary Prophylaxis
- Warfarin with a target INR of 2.0–3.0.
Duration of Treatment:
- First thrombosis: usually 3–6 months
- For confirmed thrombophilia and recurrent thrombosis: extended duration.
- OR direct factor Xa inhibitor (e.g., rivaroxaban, apixaban)
- Regular monitoring of coagulation parameters is not required, promoting patient compliance.
- Duration of treatment: at least 3 months.
A.47 Thrombophlebitis of Deep Veins
Thrombolysis
Goal: Achieve faster resolution of thrombosis.
Used for: Severe response to anticoagulation, PE with hemodynamic instability, and consideration for acute proximal DVT of the leg.
Agents: Streptokinase, urokinase, tPA.
Catheter-directed thrombolysis: The thrombolytic agent is administered directly at the site of obstruction via a venous catheter.
A.47 Thrombophlebitis of Deep Veins
Thrombectomy
- Procedure: Intravenous thrombus removal via catheter.
- Indications:
- Inadequate response to anticoagulation.
- Extensive thrombus formation.
- Phlegmasia cerulea dolens (obstruction of all veins in one extremity with risk of arterial flow).
- Note: Surgical intervention is required in severe cases.
A.47 Thrombophlebitis of Deep Veins
Inferior Vena Cava Filter (Greenfield Filter)
- Indicated for patients with DVT at high risk of developing PE who have contraindications to anticoagulation.
A.47 Thrombophlebitis of Deep Veins
Prevention
- Regular Exercise: Engage in consistent physical activity.
- Compression Stockings: Use compression stockings and intermittent compression devices.
- Postoperative Care: Early mobilization and initiate anticoagulation with low molecular weight heparin (LMWH) or unfractionated heparin.
- Medication Awareness: Avoid specific medications (e.g., oral contraceptives) in patients with thrombophilia.
