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Deep Vein Thrombosis (DVT)

This is where a clot develops in the venous system of the lower legs. Risk factors of it include:

  • Immobility, Recent surgery, Long-haul flights - Very important to ask about this!

  • Pregnancy

  • COCP/HRT

  • Cancer, thrombophilia, polycythaemia, lupus, previous hx

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“Deep Vein Thrombosis” © BruceBlaus (Licensed under CC-BY 3.0) https://creativecommons.org/licenses/by/3.0/


Patients present with:

  • Unilateral warm, swollen, tender calf/thigh

  • Mottled skin

  • Dilated superficial veins

  • Pitting oedema


N.B. Measure calf circumference 10 cm below tibial tuberosity and compare. Difference > 3 cm makes DVT more likely.

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“A deep vein thrombosis of the right leg” © James Heilman (Licensed under CC-BY 3.0) https://creativecommons.org/licenses/by/3.0/


Complications - PE, Stroke (if septal defect), Venous insufficiency


Differentials - Cellulitis, Ruptured baker’s cyst


Wells Score

This score is used to predict the likelihood of a DVT.

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Investigations

Well's score of 0 = DVT unlikely

  • Do D-dimer

    • Negative excludes DVT and no further imaging needed

    • Positive calls for further imaging i.e. Doppler US


Well's score of 1-2 = DVT likely

  • Do high-sensitivity D-dimer

    • Negative excludes DVT and no further imaging needed

    • Positive calls for further imaging i.e. Doppler US


Well's score 3+ = DVT likely

  • D-dimer + Doppler US

    • D-dimer is done to risk-stratify these patients

    • If US positive, treat w/anticoagulation regardless of D-dimer result


N.B. All unprovoked DVTs should be investigated further for any underlying pathology e.g. CT CAP for cancer.


Management

1st line - DOAC e.g. Rivaroxaban, Edoxaban. This is given for 3 months if a provoked PE, or 6 months if an unprovoked PE. If patient is having recurrent PE's, they should be prescribed a DOAC for life.


N.B. LMWH/UFH is usually preferred if the patient has renal impairment.


If a massive DVT, thrombectomy may be done.


IVC filter can be used to reduce the risk of the DVT embolising to cause a PE if recurrent.


Prophylaxis - LMWH, Compression stockings/Pneumatic compression (contraindicated in peripheral arterial disease).


N.B. The compression stockings/pneumatic compression are mechanical forms of thromboprophylaxis as they prevent venous stasis by promoting ouflow. Important to understand this as it does the same resulting job as prophylactic medication, but just in a different way.




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