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DeepDeep VenousVenous ThrombosisThrombosis

andand itsits ComplicationsComplications

DeepDeep VenousVenous ThrombosisThrombosis

andand itsits ComplicationsComplications

M.A.Kubtan M.D-F.R.C.S.(U.K)M.A.Kubtan M.D-F.R.C.S.(U.K)

Dept of General SurgeryDept of General Surgery

Al Mouasat University HospitalAl Mouasat University Hospital

DamascusDamascus

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TheThe RoleRole ofof ClottingClotting

In the blood vascular In the blood vascular system the clotting system the clotting

mechanism guards against mechanism guards against the danger of haemorrhagethe danger of haemorrhage

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ThrombosisThrombosis

Is the formation of a solid massIs the formation of a solid mass

( ( ThrombusThrombus ) in the circulation ) in the circulation from the constituents of from the constituents of

streaming bloodstreaming blood

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CausesCauses ofof PhlebothrombosisPhlebothrombosis

Changes in the vessel Wall .Changes in the vessel Wall . Changes in the Blood flow .Changes in the Blood flow . Changes in the composition of Changes in the composition of

the Blood .the Blood .

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Changes in the Vessel Changes in the Vessel WallWall

Pressure on the veins by the Pressure on the veins by the heavy calf tissues when the heavy calf tissues when the patient is immobilised in bed .patient is immobilised in bed .

Local hypoxia due to pressure on Local hypoxia due to pressure on the vessles associated with the vessles associated with immobility .immobility .

Direct trauma by a fracture Direct trauma by a fracture edges .edges .

Ill applied tourniquets and Ill applied tourniquets and plaster of Paris .plaster of Paris .

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TheThe BloodBlood FlowFlow

Stasis (Stasis (The usual cause of venous The usual cause of venous

thrombosisthrombosis)) Increased viscosity of bloodIncreased viscosity of blood In polycythaemia Vera In polycythaemia Vera DehydrationDehydration Eddy CurrentEddy Current

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TheThe CompositionComposition ofof BloodBlood

PlateletsPlatelets ( ( ThrombocytosisThrombocytosis ) ).. Clotting FactorsClotting Factors ..

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PlateletsPlatelets

ThrombocytosisThrombocytosis

Transient Transient ( after Parturition, ( after Parturition, Trauma, Trauma,

Sever Haemorrhage, Sever Haemorrhage, and and

after Splenectomy ). after Splenectomy ).

PersistentPersistent ( Polycythaemia Vera ). ( Polycythaemia Vera ).

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PlateletsPlatelets FunctionFunction

PlateletPlatelet AggregationAggregation .. PlateletPlatelet AdhesivenessAdhesiveness ..

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TheThe RoleRole ofof ClottingClotting MechanismMechanism

The Clotting Time Is shortened after The Clotting Time Is shortened after Sever Haemorrhage .Sever Haemorrhage . Trauma .Trauma . Sever Infections ( Typhoid Fever ).Sever Infections ( Typhoid Fever ). Administration of Corticosteroids .Administration of Corticosteroids . Oral Contraceptive .Oral Contraceptive . Lipaemia shortens the clotting time Lipaemia shortens the clotting time

and inhibits fibrinolysis . and inhibits fibrinolysis .

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VenousVenous ThrombosisThrombosis

Thrombophlebitis .Thrombophlebitis . Phlebothrombosis .Phlebothrombosis .

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is a condition in which there is both inflammation and a blood clot in a vein.

Thrombophlebitis can occur in either superficial or deep

veins.

Thrombophlebitis

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PhlebothrombosisPhlebothrombosis

It is essentially due toIt is essentially due to Stasis .Stasis . It may be caused byIt may be caused by local injurylocal injury to to

the venous endothelium .the venous endothelium . There is no obviousThere is no obvious local infective local infective

elementelement.. It is commonIt is common postoperative postoperative

complictioncompliction Frequently encountered inFrequently encountered in Heart Heart

disease disease ..

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A DVT is a condition where in a blood ,clot (thrombus) forms in a

vein of the deep system.

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PathogenesisPathogenesis ofof PhlebothrombosisPhlebothrombosis

1.1. Primary platelet Thrombus .Primary platelet Thrombus .

2.2. The Coralline Thrombus .The Coralline Thrombus .

3.3. Occluding Thrombus .Occluding Thrombus .

4.4. Consecutive Clot .Consecutive Clot .

5.5. Propagated Clot .Propagated Clot .

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PrimaryPrimary PlateletPlatelet ThrombosisThrombosis

البدئيةالبدئية الصفيحاتالصفيحات خثرةخثرةالشاحبةالشاحبة

Platelet adhere to the vein wall and Platelet adhere to the vein wall and aggregate to form aaggregate to form a pale thrombus .pale thrombus .

This allows clotting factors to accumulate This allows clotting factors to accumulate in the area .in the area .

Promote an increase in thePromote an increase in the fibrin element fibrin element ..

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CorallineCoralline ThrombusThrombusاللوناللون المرجانيةالمرجانية الخثرةالخثرة

AA mixedmixed thrombusthrombus Due to fibrin deposition on the primary Due to fibrin deposition on the primary

platelet thrombus .platelet thrombus . Leads to further platelet depositionLeads to further platelet deposition Consist of alternate layers of fused Consist of alternate layers of fused

platelets and fibrin with entrapped platelets and fibrin with entrapped blood cells .blood cells .

They are bent in the direction of blood They are bent in the direction of blood flow .flow .

Ripple appearance (Line of Zahn ) .Ripple appearance (Line of Zahn ) .

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OccludingOccluding ThrombsThrombsالسادةالسادة الخثرةالخثرة

The growth of coralline The growth of coralline thrombus progressively thrombus progressively occludes the vein .occludes the vein .

Composed of blood clot with Composed of blood clot with smaller platelet element.smaller platelet element.

It is red.It is red.

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ConsecutiveConsecutive ClotClotالمتعاقبةالمتعاقبة الخثرةالخثرة

Once the vein is occluded Once the vein is occluded The stationary column of blood The stationary column of blood

undergoes coagulation forming aundergoes coagulation forming a Consecutive clot Consecutive clot ..

When consecutive clot extend to the next When consecutive clot extend to the next venous tributary it may become venous tributary it may become endothelialised , or there is the endothelialised , or there is the development of more thrombus or clot.development of more thrombus or clot.

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PropagatedPropagated ClotClotالمتماديةالمتمادية الخثرةالخثرة

When clot reaches to the entrance of When clot reaches to the entrance of venous tributary , it may lead to venous tributary , it may lead to formation of another consecutive clot . formation of another consecutive clot .

Stagnation of column of blood above the Stagnation of column of blood above the consecutive clot may produce propagated consecutive clot may produce propagated clot en mass .clot en mass .

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A thrombosis in a deep vein is a much more serious problem than one in a superficial vein. The reason for this is that a piece of the clot in DVT may break off and travel through the deep veins back to the heart, and eventually be pumped by the heart into the arteries of the lung.

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DVTs can occur anywhere in the body but are most frequently found in the deep veins of the legs,

thighs, and pelvis.

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DVT is a common condition that affects almost 2 million Americans each year. Among

patients with DVT, pulmonary embolism will occur in 30%. Pulmonary embolism causes 600,000

deaths each year.

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What Are The Symptoms What Are The Symptoms of a DVTof a DVT

In the affected legIn the affected leg swelling swelling PainPain no symptoms at all unless no symptoms at all unless

the clot dislodgesthe clot dislodges

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CommonCommon SitesSites AffectedAffected byby ThrombosisThrombosis

Deep Veins of the Calf .Deep Veins of the Calf .

It may extend to PTV or the POPV.It may extend to PTV or the POPV.

At the beginning of Femoral Vein .At the beginning of Femoral Vein .

Commonly in Lt CIV due to Commonly in Lt CIV due to pressure from the Rt CIA .pressure from the Rt CIA .

Following Pelvic Operation . Following Pelvic Operation .

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PlsmaticPlsmatic D-dimersD-dimers

Fibrin is the main constituent of a Fibrin is the main constituent of a thrombus.thrombus.

Its formation is rapidly followed by Its formation is rapidly followed by activation of fibrionlytic system leading activation of fibrionlytic system leading to lysis of fibrin clot.to lysis of fibrin clot.

Dissolution of stabilized fibrin releases Dissolution of stabilized fibrin releases specific breakdown products D-dimers specific breakdown products D-dimers (DD).(DD).

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DDDD assayassay asas aa useful first stage useful first stage diagnostic tooldiagnostic tool

Negative result can rule out Negative result can rule out thromboembolic event.thromboembolic event.

False positive ( Specificity 40% ).False positive ( Specificity 40% ). Test used Test used

1. ELISA (Enzyme-linked 1. ELISA (Enzyme-linked

immunosorbant assays ).immunosorbant assays ).

2. Latex tests less sensitive .2. Latex tests less sensitive .

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VenographyVenography

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MRMR

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SpecialSpecial ClinicalClinical TypesTypes

Phlegmasia alba dolens.Phlegmasia alba dolens. Phlegmasia Coerulea dolens.Phlegmasia Coerulea dolens. Trousseu,s Syndrome.Trousseu,s Syndrome. Pregnancy-related thrombosis.Pregnancy-related thrombosis.

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IliacIliac FemoralFemoral VeinVein ThrombosisThrombosis

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Isotope ScanIsotope Scan

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Local CausesLocal Causes i ) lack of Muscular Activity .i ) lack of Muscular Activity .

ii ) Incompetent Valves .ii ) Incompetent Valves . iii ) Pressure from outside ( iii ) Pressure from outside ( Tumours, Ascites Tumours, Ascites

, ,

Plasters and Bandages .) Plasters and Bandages .)

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PredisposingPredisposing FactorsFactors 1.1. Fatal complication of D.V.T.Fatal complication of D.V.T.2. Secondary to non surgical 2. Secondary to non surgical disorders.disorders. Congestive Heart Failure.Congestive Heart Failure. Cerebrovascular Accidents.Cerebrovascular Accidents. Chronic Pulmonary Diseases.Chronic Pulmonary Diseases. Systemic Infection.Systemic Infection. Disseminated Carcinomatosis.Disseminated Carcinomatosis. Miscellaneous.Miscellaneous.

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SizeSize

An emboli prove fatal if it An emboli prove fatal if it measures 1.5 cm in diameter and measures 1.5 cm in diameter and

50 cm or more in length.50 cm or more in length.

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AreasAreas areare commonlycommonly affectedaffected

Rt pulmonary artery is more Rt pulmonary artery is more commonly affected than the left.commonly affected than the left. Lower lobes are more commonly Lower lobes are more commonly affected than the upper lobes.affected than the upper lobes.

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OriginOrigin ofof PEPE

80% 80% originated from iliac and originated from iliac and femoral veins.femoral veins.20% originated from I.V.C. , 20% originated from I.V.C. , Subclavien, Axillary, Internal Subclavien, Axillary, Internal jagular, Cavernous Sinuses of the jagular, Cavernous Sinuses of the Brain, and Cardiac Tumors arising Brain, and Cardiac Tumors arising in the Rt Atrium or Rt Ventricle.in the Rt Atrium or Rt Ventricle.

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PreventionPrevention ofof PEPE

Preventing the occurrence of D.V.T.Preventing the occurrence of D.V.T. Early ambulation.Early ambulation. Elevation of lower extremities.Elevation of lower extremities. Elastic stockings.Elastic stockings. Mechanical compression.Mechanical compression. Anti platelets agents (Aspirin, Anti platelets agents (Aspirin, Dipyridamol).Dipyridamol). S/C LMWHS/C LMWH Insertion of stainless steel Umbrella Insertion of stainless steel Umbrella

( Greenfield).( Greenfield).

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ComplicationsComplications ofof UmbrellaUmbrella

Migration.Migration.Protrusion of struts through the Protrusion of struts through the caval wall.caval wall.Formation of thrombus.Formation of thrombus.Misplacement of the umbrella.Misplacement of the umbrella.Retroperitoneal haemorhage.Retroperitoneal haemorhage.Perforation of duodenum and Perforation of duodenum and ureter.ureter.

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The MassageThe Massage

As a precaution installation of As a precaution installation of the Greenfield umbrella should the Greenfield umbrella should be the treatment of choice to be the treatment of choice to combat the risk of fatal combat the risk of fatal pulmonary embolus whenever pulmonary embolus whenever possiblepossible

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