Introduction to Deep VeinThrombosis
This section introduces DVT, its clinical presentation, risk assessment scores and diagnostic strategies
In this section:
Introduction
DVT is the formation of a thrombus in the deep veins.1
- Most commonly in the leg either above (proximal) or below (distal) the knee, or less commonly in the upper extremities
- May be spontaneous without a known underlying cause (unprovoked/idiopathic) provoked after events, such as trauma, surgery or acute illness (provoked)
- In the shorter-term, may lead to potentially life-threatening PE
- Long-term complications may include chronic conditions such as PTS
Major veins of the lower limb. The most common type of VTE is DVT, which occurs most frequently in veins deep within the muscles of the leg and pelvis
Diagnosis
Signs and symptoms
Common symptoms of DVT include:2
- Leg pain and tenderness
- Redness
- Oedema (swelling)
Clinical probability scoring
The Wells’ score is commonly used to evaluate the probability of DVT based on a patient’s medical history and physical examination. Clinical judgment plays a critical role because certain DVT risk factors and markers are evident early in the diagnostic process.3,4
| Parameter | Score |
|---|---|
| Active cancer (treatment ongoing or within previous 6 months or palliative) | 1 |
| Paralysis, paresis or recent plaster immobilization of lower extremities | 1 |
| Recently bedridden for more than 3 days or major surgery within 4 weeks | 1 |
| Localized tenderness along distribution of the deep vein system | 1 |
| Entire leg swollen | 1 |
| Calf swelling by more than 3 cm when compared with asymptomatic leg | 1 |
| Pitting oedema | 1 |
| Collateral superficial veins | 1 |
| Alternative diagnosis as likely or greater than that of DVT | –2 |
Although a high Wells’ score indicates a clinical probability of DVT, an objective imaging technique such as compression ultrasonography, CT venography or MRI must be used to confirm or rule out DVT. D-dimer testing can also be used to rule out DVT.
The flow diagrams below indicate the pathway for confirming or ruling out a diagnosis of DVT after the Wells’ score has been determined, as recommended by the American College of Chest Physicians (ACCP)5,6 and in the UK by the National Institute of Health and Care Excellence (NICE).4
Diagnostic imaging
Compression ultrasonography (also called venous ultrasonography or ultrasound) is the most widely used method for evaluating suspected DVT because it is safe and non-invasive.7
Cross-sectional view of the popliteal vein by compression ultrasonography showing partial obstruction of the vessel lumen. This imaging technique renders the thrombus (no flow) as black, whereas areas of blood flow are coloured.
Alternatives to ultrasound are CT venography or MRI:
- CT venography detects both distal and proximal DVT but is invasive, painful and expensive, and is, therefore, usually used when ultrasound does not support the clinical suspicion of DVT but other assessments do9
- MRI employs a powerful magnetic field to generate a high-resolution image of anatomic structures. It is non-invasive, but its use can be limited by a long examination time and a lack of access to equipment10
D-dimer measurements
D-dimer is a protein fragment produced by thrombus degradation and it forms when plasmin dissolves the fibrin strands that hold a thrombus together.11 A highly sensitive D-dimer test has high negative predictive value, meaning that it can be used to effectively rule out DVT in a patient with a negative ultrasound scan.4
References
- Prandoni P, Lensing AWA, Cogo A et al. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med 1996;125:1–7. Return to content
- Blann AD, Lip GYH. Venous thromboembolism. Br Med J 2006;332:215–219. Return to content
- Wells PS, Anderson DR, Bormanis J et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet 1997;350:1795–1798. Return to content
- National Institute for Health and Care Excellence. Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing. Clinical guideline [CG144]. 2012. Available at: http://guidance.nice.org.uk/CG144 [accessed 20 August 2018]. National Institute for Health and Care Excellence. Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing. Clinical guideline [CG144]. 2012. Available at: http://guidance.nice.org.uk/CG144 [accessed 20 August 2018]. Return to content
- Kearon C, Akl EA, Comerota AJ et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141:e419S–e494S. Return to content
- Kearon C., Akl E.A., Ornelas J. et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016;149(2):315-52. Return to content
- Turpie AGG, Chin BSP, Lip GYH. Venous thromboembolism: pathophysiology, clinical features, and prevention. Br Med J 2002;325:887–890. Turpie AGG, Chin BSP, Lip GYH. Venous thromboembolism: pathophysiology, clinical features, and prevention. Br Med J 2002;325:887–890. Return to content
- Stern JB, Abehsera M, Grenet D et al. Detection of pelvic vein thrombosis by magnetic resonance angiography in patients with acute pulmonary embolism and normal lower limb compression ultrasonography. Chest 2002;122:115–121. Return to content
- Saad WE, Saad N. Computer tomography for venous thromboembolic disease. Radiol Clin North Am 2007;45:423–445. Return to content
- Kluge A, Mueller C, Strunk J et al. Experience in 207 combined MRI examinations for acute pulmonary embolism and deep vein thrombosis. AJR Am J Roentgenol 2006;186:1686–1696. Return to content
- Adam SS, Key NS, Greenberg CS. D-dimer antigen: current concepts and future prospects. Blood 2009;113:2878–2887. Return to content
See Also
Peripheral Artery Disease: causes and consequences
See Also
Coronary Artery Disease: causes and consequences
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