Venous Thromboembolism (VTE) - Deep Vein Thrombosis (DVT)

Question 1

What is Deep Vein Thrombosis?

Answer 1

When a thrombus develops in the venous circulation.

Question 2

Clinical Presentation of DVT (5).

Answer 2

Unilateral :

1. Calf/Leg Swelling.
2. Dilated Superficial Veins.
3. Calf Tenderness (over Site of Deep Veins).
4. Oedema.
5. Colour Changes to Leg.

Question 3

What is Significant Leg Swelling and how is it determined?

Answer 3

Measure the circumference of the calf 10cm below the tibial tuberosity - a difference of more than 3cm between the calves is significant.

Question 4

Investigations of DVT (3).

Answer 4

1. Doppler US - required to diagnose DVT.
2. NICE recommend repeating negative US after 6-8 days if positive D-Dimer and Wells Score indicates likelihood.
3. Wells Score.

Question 5

What factors contribute to the 2 Level Wells Score (10)?

Answer 5

1. Active Cancer (6 Months).
2. Paralysis or Immobilisation of Lower Extremities.
3. Bedridden for 3 days or major surgery within 12 weeks.
4. Local tenderness along distribution of deep venous system.
5. Entire Leg Swollen.
6. Calf Swelling 3cm+.
7. Pitting Oedema on Symptomatic Leg.
8. Collateral Superficial Veins (Non-Varicose).
9. Previously Documented DVT.
10. Alternative Diagnosis.

All factors except 10 are 1 point; factor 10 is -2 points.

Question 6

Results of Wells Score.

Answer 6

A DVT is likely if the Wells Score is 2+.

Question 7

Management of DVT if DVT is Likely According to Wells Score (2).

Answer 7

1. Proximal Leg Vein US - Within 4 Hours. If positive, diagnose and anticoagulant. If negative, D-Dimer test. If D-dimer is positive, stop interim therapeutic anticoagulation and offer a repeat scan 6-8 days later.
2. If no scan within 4 hours, D-dimer test and interim therapeutic anticoagulation-DOAC (within 24 hours).

Question 8

Management of DVT if DVT is Unlikely According to Wells Score (2).

Answer 8

1. Perform a D-Dimer within 4 hours. If not possible, start interim therapeutic anticoagulation until result is available.
2. If negative, alternative diagnosis. If positive, proximal leg vein US within 4 hours. If scan is not possible within 4 hours, start interim therapeutic anticoagulation (within 24 hours).

Question 9

Specific Management of DVT.

Answer 9

Symptomatic Iliofemoral DVT and Symptoms Lass Less than 14 Days : Consider Catheter-Directed Thrombolysis (catheter under X-ray guidance into venous system to apply thrombolysis directly into clot).

Question 10

D-Dimer Test (2).

Answer 10

1. Age-Adjusted Cut-Offs used for Patients above the age of 50.
2. NICE Recommend : Point of Care (Finger Prick) or Laboratory Test.

Question 11

Complications of DVT (4).

Answer 11

1. PE.
2. Venous Insufficiency.
3. Recurrent DVT.
4. Post-Thrombotic Syndrome.

Question 12

What can Post-Thrombotic Syndrome present with? (4)

Answer 12

1. Pain.
2. Swelling.
3. Hyperpigmentation, Ulcers, Gangrene, Lipodermatosclerosis (Chronic Venous Hypertension).
4. Dermatitis.