CASE PRESENTATION

DEEP VEIN THROMBOSIS

Irma Savitri (0806358022)

Radhianie Djan (0806472023)

Resource person:

dr. Murnizal Dachlan, SpB(K)V

SURGERY CLINICAL PRACTICE MODULE

DEPARTMENT OF SURGERY

FACULTY OF MEDICINE

UNIVERSITAS INDONESIA

MAY 2014
 CHAPTER I

CASE ILLUSTRATION
Patient Identity

Name: Ny. L

Date of birth: 18th of October, 1953

Age: 60 years old

Address: Menteng Dalam, Tebet

Education: Completed high school

Marrital status: Married

Religion: Moslem

Medical record number: 392-84-82

Anamnesis

Chief complaint: Swelling of the right leg since 1 week before hospital admission.

History of present illness: Since 1 week before hospital admission patient’s right leg
became swollen. It began on the knee and spread downward to the toe or redness. The
complaint only occured on the right leg. Pain was present with a VAS of 5/10. She felt like
someone was grasping her leg. The pain radiated down to her toe and occured continuously
but its intensity did not increase over time. Patient was still able to walk and undergo normal
activities. Prior to her admission to Cipto Mangunkusumo Hospital, patient had been
hospitalized at MMA Hospital for a week due to nausea and vomiting. The painful leg
swelling occured after approximately four days of hospitalization. Patient underwent
ultrasonography examination and was told that a blood clot was present on her blood vessels.
Patient was referred to Cipto Mangunkusumo Hospital for further therapy.

History of past illness: Patient had a history of controlled hypertension since 10 years ago.
She routinely consumed Captopril and checked her condition to a general practitioner once a
month. Patient has never been hospitalized before and had not undergone surgeries before
History of diabetes, stroke, heart disease, asthma, cancer, and drug/food allergy was denied.

Family history of illness: Family history of hypertension was present. Family history of
diabetes, stroke, heart disease, asthma, cancer and drug/food allergy was denied.
Social history: Patient is a housewife. She has four children, who live separetely from her
and her husband. History of smoking and alcohol consumption was denied.

Physical examination

General condition: Mildly ill

Consciousness: Compos mentis, GCS E4M6V5

Vital signs:

 Blood pressure: 130/90 mmHg

 Heart rate: 88 times/minute, regular, adequate
 Respiratory rate: 18x/minute, symmetrical
 Temperature: 36.50C

General status:

Head: No deformities

Eyes: Anemic conjunctiva -/-, icteric sclera -/-

Oral cavity: Good oral hygiene, uvula in the middle, tonsil T1/T1

Neck: Palpable lymph nodes (-)

Lungs: Vesicular +/+, ronchi -/-, wheezing -/-

Heart: S1 S2 normal, murmur (-), gallop (-)

Abdomen: Flat, supple, tenderness (-), liver and spleen not palpable, tympanic on
auscultation

Extremities: Deformities (-), warm acral, CRT <2 second

Local status: Pitting edema on the right leg (+), pain on palpation (-), redness (-)

Vascular status:

Artery Right Left

A. Femoralis ++ ++
A. Poplitea ++ ++
A. Dorsalis pedis + ++
A. Tibialis posterior + ++
ABI 1 1

Supporting examination:

Laboratory exam:
RSCM:

5/5/2014: Hb 13.2 / Ht 37.3 / Leukocytes 12.800 / Thrombocytes 339.000 / SGOT 121 /

SGPT 147 / Ur 30.3 / Cr 0.85 / D-dimer 2.3/PT/APTT 11.8 (1x) / 28.4 (34x)/ Fibrinogen
504.8 / Electrolyte Na/ 132/ K/ 3.6/ Cl/ 91

06/05/2014: APTT 32.1 (32.5)

08/05/2014: PT 12.6 (12.2) / INR 1.12 / APTT 28.7 (33.5)

10/05/2014: APTT 53.2 (34.3)

11/05/2014: PT 12.7 (12.2) / APTT 38 (33.2)

12/05/2014: APTT 38.7 (32.6)

Radiographic exam:

26/4/2014: Cardiomegaly with elongation of the aorta. No radiographic abnormalities of the

lung.

USG of right leg :

Thrombosis in the femoralis vein, saphena magna vein, and poplitea dextra vein.

Diagnosis:

Deep vein thrombosis of the right leg

Therapy:

Diagnostic plan: Check PT/APTT daily

Therapeutic plan: Compression therapy using stocking, heparin 30.000 unit/24 hours
 CHAPTER II

LITERATURE REVIEW

2. Deep Vein Thrombosis

2.1. Definition

Deep venous thrombosis (DVT) is a manifestation of venous thromboembolism

(VTE). DVT is the presence of coagulated blood, a thrombus, in one of the deep venous
conduits that return blood to the heart. DVT is commonly develops in the large veins of the
legs or pelvic area.

2.2. Epidemiology
DVT (Deep Vein Thrombosis) happens on 10-30 % of every major surgery happens
on patients age above 40 years old. Every year, it happens about every 1 per 1000 people, and
1-5% of them will have a complications that may lead to death. DVT is less commonly found
in children. The ratiof DVT incidence among male and female are 1:1,2.
In Asian patients undergoing surgery, the incidence of venous thromboembolism
(VTE) is believed to be low relative to Western patients. However, in a recent review of
published studies in Asian patients undergoing surgery and not receiving
thromboprophylaxis, the adjusted incidence of total (asymptomatic and symptomatic) deep
vein thrombosis (DVT) was 13% in general surgery, 16% after total hip replacement, 50%
after total knee replacement, and 18% after hip fracture surgery.
In symptomatic DVT patients, the location of thrombosis are commonly found in 10%
on popliteal vein, 42% on popliteal vein and superficial femoralis vein, 35% on proximal
vein, and 5% on superficial femoral or iliaca vein.
2.3. Pathogenesis
 There are three most important factors that involved in the process of thrombosis to the
vessels which commonly known as “Triad of Virchow”. The vein thrombosis is an
intravascular deposit that consists of fibrin, red blood cells and several components of
thrombocyte and leukocyte. The three factors are,
a. Blood vessel walls
The destruction of vein walls can occur due to accidental injury or surgical insults. This
destruction may ease the adhesion of thrombocyte to the subendothel. The adhered
thrombocyte will attached to the fibrinogen which produced thrombocyte agregation that
formed thrombocyte plaque. This will promote blood clotting inside the veins which
leads to thrombus.
b. Blood coagulations
Thrombosis on the vein is prone to happen if there is increased activity of blood
coagulations or decrease activity of fibrinolysis. There are several conditions that
increase coagulations activity such as anti-thrombin III deficiency, protein C deficiency,
plasminogen disorder and few conditions such as myocardial infarction, bedridden for
long time or pregnancy.
c. Stasis, or stagnant blood flow through veins
Slow blood flow on the vein is commonly happens when there is certain area that have
been immobilized (static) for a long period of time. Vein stasis is a predisposition to
cause local thrombosis due to the disruption of clearence mechanism on coagulability
activity which leads to the formation of thrombin easily.

2.4.
Risk Factors
 Age
 Obesity
 Pregnancy
 Immobilization longer than 3 days
 Pregnancy and the postpartum period
 Major surgery in previous 4 weeks
 Long plane or car trips (> 4 hours) in previous 4 weeks
 Cancer
 Previous DVT
 Stroke
 Acute myocardial infarction (AMI)
 Congestive heart failure (CHF)
 Diabetes Mellitus
 Sepsis
 Nephrotic syndrome
 Ulcerative colitis
 Multiple trauma
 CNS/spinal cord injury
 Burns
 Lower extremity fractures
 Systemic lupus erythematosus (SLE) and the lupus anticoagulant
 Oral contraceptives
 IV drug abuse
 Inherited disorders of coagulation/fibrinolysis

2.5. Sign and Symptoms

About half of people with DVT have no symptoms at all. For those who do have symptoms,
the following are the most common and can occur in the affected part of the body, typically
in the leg or calf region:
 Swelling unrelated to the surgical site,
 Pain or tenderness, unrelated to the surgical site and often worse when standing or
walking,
 Redness of the skin,
 Warmth over the affected area

2.6. Diagnosis

A well-validated clinical prediction rule provides a reliable estimate of the pretest

probability of DVT which should, in turn, guide the interpretation of subsequent diagnostic
tests. The value of various diagnostic tests and imaging studies in predicting the presence of
DVT depends on the likelihood of disease in each risk group.
Wells Clinical Prediction Rule for DVT
Clinical feature Points

Active cancer (treatment within 6 months, or palliation) 1

Paralysis, paresis, or immobilization of lower extremity 1
Bedridden for more than 3 days because of surgery (within 4 weeks) 1
Localized tenderness along distribution of deep veins 1
Entire leg swollen 1
Unilateral calf swelling of greater than 3 cm (below tibial tuberosity) 1
Unilateral pitting edema 1
Collateral superficial veins 1
Alternative diagnosis as likely as or more likely than DVT −2
Total points:

Risk score interpretation (probability of DVT): 3 points: high risk (75%); 1 to 2 points: moderate risk (17%);<1
point: low risk (3%).

PHYSICAL EXAMINATION
Although DVT is often clinically silent, it may present with a number of signs,
including calf pain, edema, and venous distention. Homans’ sign1—pain associated with
forced dorsiflexion of the ankle—is often elicited as part of the physical examination of the
person with suspected DVT. However, a diagnosis based solely on the evaluation of clinical
signs has proven unreliable, and specific diagnostic procedures (eg, venography,
ultrasonography) should be performed in the diagnosis of DVT.

When evaluating a patient for Homans’ sign, the patient’s knee should be in the
flexed position. The examiner should forcibly and abruptly dorsiflex the patient’s ankle and
observe for pain in the calf and popliteal region, which constitutes a positive sign
D-DIMER TESTS
Available D-dimer tests vary widely in sensitivity and specificity. Therefore, caution
must be exercised in interpreting the results of these tests. However, one recent study found
that the combination of a low-risk assessment by a validated clinical prediction rule and a
negative second-generation latex agglutination D-dimer assay effectively rules out DVT. In
another recent study, patients with a Wells clinical prediction rule score of less than 2 points
and a negative D-dimer test were less likely to have venous thromboembolism during follow-
up than were patients with a negative ultrasound examination (0.4 percent versus 1.4
percent).

DOPPLER ULTRASONOGRAPHY
Doppler ultrasonography is the most widely used modality for evaluating patients
with suspected DVT. When used in combination with a clinical prediction rule, ultrasound
examination is accurate in predicting the need for anticoagulation. However, a normal
ultrasound study in a high-probability patient requires additional investigation before DVT
can be ruled out.
Ultrasound assessment has several limitations: its accuracy depends on the operator; it
cannot distinguish between an old clot and a new clot; and it is not accurate in detecting DVT
in the pelvis or the small vessels of the calf, or in detecting DVT in the presence of obesity or
significant edema. Causes of false-positive examinations include superficial phlebitis,
popliteal cysts, and abscess.

CONTRAST VENOGRAPHY
Although contrast venography is not performed often, it remains the gold standard
against which noninvasive studies for DVT are compared. The use of contrast venography is
limited by the risk of pain, phlebitis, and hypersensitivity or toxic reactions to contrast agents.
Furthermore, DVT develops in a small number of patients who undergo the procedure.
Conditions such as edema or obesity, which impair venous access, may make the test difficult
or impossible to perform in approximately 10 percent of patients.

EMERGING TECHNOLOGIES
Magnetic resonance imaging (MRI) appears to be at least as sensitive as
ultrasonography in detecting calf and pelvic DVTs. These thromboses are difficult to
compress with ultrasonography and difficult to visualize with venography. However, MRI is
highly operator-dependent, relatively unavailable, and generally more than twice as
expensive as ultrasound examination.

2.7. Management

Treatment goals for deep venous thrombosis include stopping clot propagation and
preventing the recurrence of thrombus, the occurrence of pulmonary embolism, and the
development of pulmonary hypertension, which can be a complication of multiple recurrent
pulmonary emboli.

UNFRACTIONATED HEPARIN
Treatment with unfractionated heparin is based on body weight, and the dosage is
titrated based on the APTT. An APTT of 1.5 to 2.3 times control is desirable.This approach
to heparin therapy has been shown to achieve adequate anticoagulation quickly and safely.
Adverse reactions associated with heparin therapy include bleeding and
thrombocytopenia. The risk of adverse reactions is highest in patients with any of the
following: age greater than 65 years, recent surgery, or conditions such as peptic ulcer
disease, liver disease, occult neoplasia, and bleeding diathesis. Transient thrombocytopenia
may occur in 10 to 20 percent of patients, but major hemorrhagic complications occur in
fewer than 2 percent of patients.
Heparin can be stopped after four or five days of combined therapy with warfarin if the
International Normalized Ratio (INR) of prothrombin clotting time exceeds 2.0.8
LOW-MOLECULAR-WEIGHT HEPARIN
Compared with unfractionated heparin, low-molecularweight (LMW) heparin offers
distinct advantages: it has a longer biologic half-life, it can be administered subcutaneously
once or twice daily, dosing is fixed, and laboratory monitoring is not required. In addition,
some adverse effects of unfractionated heparin, such as thrombocytopenia, appear to be less
likely. In patients with DVT, subcutaneous administration of heparin is at least as effective as
continuous infusion of unfractionated heparin in preventing complications and reducing the
risk of recurrence.
Outpatient management of DVT using LMW heparin for short-term anticoagulation
until warfarin is at a therapeutic level is safe and cost-effective, despite the higher cost of the
heparin. Candidates for outpatient therapy must be hemodynamically stable, without renal
failure, and not at high risk for bleeding. Furthermore, they must have a stable and supportive
home environment, as well as access to daily monitoring until the INR is therapeutic. Like
unfractionated heparin, LMW heparin is given in combination with warfarin for four to five
days. Simultaneous initiation of warfarin and unfractionated heparin or LMW heparin has not
been associated with any clinically important adverse outcomes.
Enoxaparin (Lovenox) was the first LMW heparin approved by the U.S. Food and
Drug Administration (FDA) for the treatment of DVT in a dosage of 1 mg per kg twice daily
or 1.5 mg once daily. Dalteparin (Fragmin), another LMW heparin, is approved only for
prophylaxis of DVT. In clinical trials of DVT treatment, dalteparin has been given in a
dosage of 200 IU per kg per day (single dose or two divided doses). The FDA has approved
the use of tinzaparin (Innohep), in a dosage of 175 anti-Xa IU per kg per day, for the
treatment of DVT.

WARFARIN
Once acute anticoagulation is achieved, warfarin is the drug of choice for long-term
therapy to prevent clot recurrence. A standard warfarin protocol includes starting treatment at
5 mg per day and titrating the dosage every three to seven days to achieve an INR between
2.0 and 3.0. Attempts have been made to maintain patients at an even lower INR (between
1.5 and 2.0), but results have been contradictory. Unless further data show otherwise,
anticoagulation with a standard INR goal of 2.0 to 3.0 should be used. Promising results have
been shown for a protocol in which warfarin is initiated in a dosage of 10 mg per day. An
INR higher than 1.9 was achieved an average of 1.4 days sooner in the patients who received
warfarin according to the 10-mg protocol.

DURATION OF ANTICOAGULATION
The duration of anticoagulation depends on whether the patient has a first episode of
DVT, ongoing risk factors for venous thromboembolic disease, and known thrombophilia.
The most recent evidence-based recommendations from the American College of Chest
Physicians are based on the risk of clot recurrence
HOME TREATMENT – STOCKINGS AND IMAGING
The ACCP recommended initial home treatment instead of hospital treatment for
those with acute leg DVT. In addition to anticoagulation, the ACCP suggested graduated
compression stockings—which apply higher pressure (30–40 mm Hg) at the ankles and a
lower pressure around the knees—for those with symptomatic DVT. Use should begin as
soon as possible after anticoagulation. Existing randomized controlled trials give moderate-
quality evidence that these stockings reduce the risk of post-thrombotic syndrome. Use is
suggested for two years, though inconvenience and discomfort can reduce compliance.
Walking is also suggested over bed rest for those without severe pain or edema.
Instead of anticoagulation, a follow-up imaging test (typically ultrasound) about one
week post-diagnosis is an option for those with an acute isolated distal DVT without a high
risk for extension; if the clot does not grow, the ACCP does not recommend anticoagulation.
This technique can benefit those at a high risk for bleeding. Patients may choose
anticoagulation over serial imaging however, to avoid the inconvenience of another scan if
concerns about the risk of bleeding are insignificant.

2.8. Complication
Pulmonary embolism is the most immediate and significant complication of DVT. PE
has been detected in over 50% of all patients with a documented diagnosis of DVT. Over
80% of patients with confirmed diagnosis of PE have been found to have asymptomatic
DVT. While PE is the greatest cause of mortality associated with DVT, other complications
can also arise, potentially compromising the health of millions of Americans each year.
The two most noteworthy of these complications are recurrent DVT and
postthrombotic syndrome. Up to 30% of patients may experience a recurrent DVT within
eight years of an initial diagnosis.14 This pattern of recurrence is important because it may
contribute to the development of PE and cause additional damage to venous valves,
prompting chronic venous insufficiency. Many patients with recurrent DVT require
prolonged if not lifelong therapy to manage this disease.
Post-thrombotic syndrome (PTS) is another significant complication of VTE that
occurs in approximately 29% of patients with symptomatic DVT within 8 years of the initial
event. PTS commonly develops secondary to venous valve damage, which precipitates
venous hypertension and may compromise the integrity of the vascular system within the
lower extremities. The primary symptoms of PTS include pain, varicose veins, edema,
venous ectasia, induration, and ulceration. Chronic ulceration and impaired mobility due to
debilitating pain may cause disability and negatively impact quality of life.
 CHAPTER III

DISCUSSION

This is a case of a 60-year-old woman with a chief complaint of leg edema accompanied with
pain since 1 week before hospital admission. Based the clinical data, the working diagnosis of
this patient is deep vein thrombosis. The clinical data which supports the working diagnosis
of DVT is painful leg edema found in anamnesis and pitting edema on physical examination.
Homan sign (calf pain on dorsiflexion) which is classically found in DVT, was not present in
this patient. However, it should be noted that absence of the Homan sign does not necessarily
exclude the suspicion of DVTi.

The pathophysiological basis of DVT include stasis of blood flow, endothelial damage, and
hypercoagulabilityii. In spontaneous DVT, hypercoagulability plays a major role. Some
contributing factors to hypercoagulability, such as history of malignancy was asked during
anamnesis, however it was absent in this patient.

Risk stratification of DVT is done using the Well’s criteria. Using the Well’s criteria, a
patient can be categorized into three groups based on their score, which are high probability
of DVT (3-8 points), moderate probability (1-2 points), and low probability (-2-0 points). In
this patient, the Wells criteria can be implemented as follows:

Criteria Score
Paralysis, paresis or recent orthopedic casting of lower extremity (1 point) 0
Recently bedridden (more than 3 days) or major surgery within past 4 1
weeks (1 point)
Localized tenderness in deep vein system (1 point) 0
Swelling of entire leg (1 point) 1
Calf swelling 3 cm greater than other leg (measured 10 cm below the 1
tibial tuberosity) (1 point)
Pitting edema greater in the symptomatic leg (1 point) 1
Collateral non varicose superficial veins (1 point) 0
Active cancer or cancer treated within 6 months (1 point) 0
Alternative diagnosis more likely than DVT (Baker's cyst, cellulitis, muscle 0
damage, superficial venous thrombosis, post phlebitic syndrome, inguinal
lymphadenopathy, external venous compression) (-2 points)
Total score 4
Interpretation High
probability

Regarding the supporting examination, patient was scheduled for a Doppler ultrasonography
to confirm the diagnosis of DVT. Doppler ultrasonography is considered accurate in
detecting symptomatic DVT with no contrainidications. Some ultrasonographical findings of
DVT include lack of spontaneous flow, inability to compress the vein, absence of color filling
the lumen, loss of respiratory flow variation, and venous distentionii. Other imaging
examination that can be used for establishing the diagnosis of DVT is venography, which is
done by injecting contrast media to the deep venous system. Venography was considered a
good test to locate the thrombus, however it is an invasive procedure that comes with the
risks associated with the use of contrastsi.

The results of Doppler ultrasonography in this patient showed that there is thrombosis found
in the femoralis vein, saphena magna vein, and poplitea dextra vein which confirm the
diagnosis of DVT in this patient. This examination have been considered accurate to confirm
the diagnosis of DVT, and conclude that this patient may need the treatment of
anticoagulation.

Regarding the therapy, management of DVT can be broadly categorized into conservative
and invasive management. The primary treatment for acute DVT is low-molecular weight
heparin (LMWH). The dosing strategy for LMWH based on the American Heart
Associationiii is as follows. The initiation dose is 5000 U (intravenous bolus) and continued
with either one of these options: 1) intravenous infusion of 1400 U/h or 2) subcutaneous
injection of ≈17 500 U twice daily. Another option is to use a weight-adjusted dose, which
consists of a continuous intravenous infusion in a bolus dose of 80 U/kg followed by an
infusion at 18 U/kg per hour. this patient was treated with Heparin 30000 unit/24 hour The
patient was is approximately 70 kg and therefore if we follow either the non-weight adjusted
or weight-adjusted dose, treatment of this patient is already in accordance with the guidelines.
Due to the usage of anticoagulants, the patient’s hemostatic parameters, such as PT and aPTT
was monitored daily. The non-pharmacological treatment for this patient is compression
therapy using stocking. Compression therapy is considered useful as it may decrease the
incidence of post-thrombotic syndrome up to 50% in patients with DVT at the popliteal
leveliv.

Invasive treatment of DVT can be done with a main objective to preserve valvular function
and therefore should be conducted in patients with a long life expectancy. The choice of
invasive treatment can be divided into catheter directed trombolysis or surgical
thrombectomy. However, in this patient we have to evaluate the result of the conservative
treatment and obtain the Doppler ultrasonography result first before considering invasive
treatment.
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