T14 - Trombose Venosa Profunda

Question 1

DVT?

Answer 1

Deep Venous Thrombosis

Question 2

Importance of DVT?

Answer 2

• 3rd cause of cardiovascular mortality afrter MI and Stroke
• Incidence increases two-fold per 20y age increase
• African Americans have an higher incidence, asians lower
• recurrence rate 10% at one year
• post-thrombotic syndrome 20-50%; severe 5-10%

Question 3

Clinical manifestations of DVT?

Answer 3

Asymptomatic
Edema
Pain
Decreased mobililty
Feeling of heaviness
Prominent superficial veins

Question 4

O que pode ocorrer no edema?

Answer 4

Oclusão arterial por compressão do edema, por exemplo em situações em que já existe défice

Question 5

Location of DVT?

Answer 5

• isolated calf 30%
• iliofemoral 30-40%
• iliofemoral DVT is more commonly left-sided
• recanalization rate: 80% calf, 20% iliac
• overall incidence of venous VTE around 25% higher with thle addition of pulmonary embolism (PE)
• upper extremity DVT <5%

Question 6

How to confirm diagnosis of DVT?

Answer 6

• • Clinical assessement and pretest probability score (Wells criteria)
• • D-dimer measurement
• • Duplex ultrasound

– other imaging modalities; MRV, CTV, Venography

Question 7

Disorders that can mimic DVT?

Answer 7

• lymphoedema
• superficial vein thrombosis
• post-thrombotic syndrome
• cellulitis
• ruptured Baker’s cist
• trauma

Question 8

Acute and chronic complications?

Answer 8

• pulmonary embolism
• phlegmasia alba dolens
• phlegmasia cerulea dolens
• venous grangrena
• post-thrombotic syndrome
• chronic thromboembolic pulmonar hypertension

Question 9

Virchow’s triad?

Answer 9

• • increased procoagulant activity in the blood
• • vein wall damage
• • impaired venous flow

Question 10

Aeteological classification?

Answer 10

• • Unprovoked

- - Provoked (transient (major or minor) or presistent)

Question 11

Risk factors for DVT?

Answer 11

Hereditary thrombophilia 
Malignancy
Acquired thrombophilia
Surgery trauma
Estrogens
Compression
Inflammation
Immobility

Question 12

Idade e DVT?

Answer 12

Com idades mais avançadas surgem fatores de risco adquiridos

Question 13

Acquired thrombophilia?

Answer 13

• • Auto-immune diseases (Antiphospholipid syndrome)
• • Malignancy (neoplasia predispõem trombose, umas mais q outras e qualquer clinico que lide com doentes com suspeita de DVT pode estar perante uma primeira manifestação de neoplasia oculta)
• • Inflammatory bowel disease
• • Myeloproliferative disorders
• • Hemolytic anemias
• • Acquired AT deficiency

Question 14

Clinical criteria for Antiphospholipid syndrome?

Answer 14

Vascular thrombosis
- Venous thrombosis 50%
- Arterial thrombosis 
- Embolism 4%
Pregnancy morbidity

Question 15

Laboratory criteria for Antiphospholipid syndrome?

Answer 15

Lupus anticoagulant
Anti-aCL antibodies (cardiolipina)
Anti-B2-GPI antibodies

Question 16

Inherited thrombophilia?

Answer 16

• • VTE (Venous thromboembolism) before 40-50 years of age
• • unprovoked thrombosis at any age
• • recurrent thrombosis at any age
• • thrombosis at unusual or multiple sites
• • strong family history of VTE

Question 17

Etiology of Inherited thrombophilia??

Answer 17

• • Venous thromboembolism (DVT, Pulmonary embolism, VT as unusual sites)
• • Purpura fulminans
• • Obstetric problems
• • Arterial thrombosis

Question 18

Marcadores Laboratoriais de Inherited thrombophilia?

Answer 18

• • Natural coagulation inhibitors deficiencies
• • Raise of levels / function of clotting factors
• • Impaired fibrinolysis

Question 19

Incidence of recurrent VTE?

Answer 19

Unprovoked VTE has a higher predictive value of recurrence than the presence of thrombophilia

Question 20

Who not to test for thrombophilia?

Answer 20

• • unselected patients presenting with a first episode of VTE
• • to assess the thrombotic risk in patients admitted to hospital
• • asymptomatic relatives of those with low-risk thrombophilia
• • center venous catheter-related VTE

Question 21

When should not be tested for Thrombophilia?

Answer 21

• • do not test for thrombophilia at the time of VTE (treatment not influenced by test results, reduction of natural anticoagulants)
• • do not test under anticoagulation therapy (Heparin, AVKs)

Question 22

VTE treatment objectives?

Answer 22

Prevent clot extension, including PE
PREVENT:
- Post-thrombotic syndrome
- Chronic thromboembolic pulmonary hypertension
PREVENTION of recurrence

Question 23

Anticoagulation?

Answer 23

Gold standard treatment for VTE
Active Treatment:
- Initial phase 5-7 days
- Long-term phase 3-6 months
Extended Treatment: 3 months to indefinite

• Warfarin
• Dabigatran
• Edoxaban
• Rivaroxaban
• Apixaban

Question 24

Duration of therapy?

Answer 24

Duration of therapy should be individualized after careful assessment of treatment benefit against risk of bleeding
Shot duration (at least 3 months):
- Proximal DVT associated with risk factors
- Distal DVT
Extended treatment: Unprovoked DVT or DVT associated with permanent risk factors

Question 25

Risk of recurrence?

Answer 25

• • Provoking factor for VTE (major reversible risk factor & persistent or progressive risk factor)
• • Unprovoked VTE (several parameters can be evaluated)
• • Previous (a second episode of VTE has a 50% higher risk of recurrence compared with the first one)

Question 26

Risk of recurrence - unprovoked VTE?

Answer 26

• • Sex (men)
• • Site of TVE (proximal vs distal)
• • D-dimer (1 month after stopping anticoagulation, when positive)
• • Antiphospholipid syndrome
• • Hereditary thrombophilias
• • Post-Thrombotic syndrome

Question 27

Risk of bleeding?

Answer 27

Patient characteristics (>75y, previous bleeding, cancer, hypertension, diabetes, cerebrovascular disease, IR, liver disease)
Antithrombotics
Recent surgery
Frequent falls

Question 28

Anticoagulation + what?

Answer 28

• • compression: elastic stockings
• • inferior vena cava filter
• • early thrombus removal
• surgical thrombectomy
• catheter-directed thrombolysis
• pharmacomechanical catheter directed thrombolysis