Topic Review

Lower extremity DVT ; Diagnosis and & Management

2010-04-27 R3

DVT
* Venous thromboembolism (DVT & pulmonary thromboembolism) * DVT: blood clot in deep vein
- Arise from calf vein, ~20% from prox. veins

* 1/1000 in adult(M>F)
1/10,000 in young, 5-6/1000 in older

* Death from VTE in US :300000/year

Definition
* Acute DVT
Within 10 days after initial sx Imaging studies: thrombosis within last 10 days

* Subacute DVT
11-28 days after initial sx Imaging studies: thrombosis within this time interval

* Chronic DVT
More than 28 days after initial sx Imaging studies: thrombosis more than 28 days before

Definition
* Proximal DVT - complete or partial thrombosis of
Pop. vein, FV, DFV, CFV, iliac V, and/or IVC
Femoropopliteal DVT: complete or partial thrombosis of Pop. vein, FV, and/or DFV Iliofemoral DVT: complete or partial thrombosis of any part of iliac V and/or CFV

* Calf Vein DVT - complete or partial thrombosis of

one or more deep calf veins, including ATV, PTV, peroneal V, and/or soleal V

Complication of DVT
* Acute:
Pulmonary embolism Phlegmasia cerulean dolens Phlegmasia alba dolens

* Chronic:
Post-thrombotic syndrome Ch. valve insufficiency

Investigations for diagnosing DVT

Anatomy of lower extremity venous system

* Most believe only proximal DVT needs treatment * But 20% of calf DVT : propagate to more proximal veins

US technique
* Patient preparation & position
Supine, leg in a 30 degree reverse Trendelenburg, knee flexed, leg ext. rotated

* Equipment
High freq.(7-9 MHz) linear transducer B mode imaging Color / Pulse wave Doppler

US technique

* Common Femoral Vein

Begin above inguinal ligament Parallel to long axis of vessel Caudally to follow iliac vein into CFV

US technique

* Common Femoral Vein

US technique

* Common Femoral Bifurcation & Superficial Femoral Vein

Longitudinal exam
At CFV bifur level
More supf. br: superf. FV adjacent to supf. FA Deeper br: deep FV

At the adductor canal

Move transducer to medial side and follow superf. FV until GCM or lesser saphe. V to join Pop. V.

US technique

* Common Femoral Bifurcation & Superficial Femoral Vein

Transverse exam.
Supf. FV
Begun at inguinal lig, go distal 1cm by 1cm Intermittently compressed with transducer

US technique

* Popliteal Vein
Not run parallel to skin, somewhat undulant Rotate pts leg laterally resume longi. scanning of pop. V prox. to insertion of GCM V or lesser saph. V Transverse exam: compressibility

US technique

* Calf Venous trunks & paired branches

Begin at origin from pop. V
proceed caudally into paired PTV & pero. V brs.

PTV & pero. V trunks

Should be performed in longitudinal planes First image: post. approach
transducer : between muscles (border of popliteal space)

Then medial approach

transducer : medial portion of leg longitudinally just posterior to tibia

* Calf Venous trunks & paired branches

US technique

post. approach

medial approach.

US technique

* Calf paired branches

Along medial surface of leg

Post. tibial brs: most supf. pair Pero. brs at ankle: deep & slightly posterior to post. tibial brs ATA, PTA or pero. A:
should be centered btwn corresponding vein pair

post. to tibia just above ankle

Anterolateral approach

Alternate view of calf venous trunks Scan ant. tibia! brs betn tibia and fibula ATVs in near field/ pero. Vs in far field
Flow in anterior tibial trunk courses into caudal end of the pop V. Rotate pts leg internally

Examining paired branches of the calf veins

Examining anterior tibial veins

US technique

* Compressibility
Apply firm & direct pressure in transverse scan Probe perpendicular to vein Normal compressibility
Complete collapse of vein

Adequate pressure
just enough to deform correspondent arteries

* DVT features
Acute DVT:
Fresh clots may not be visible, depending on echo
Only complete compressibility rule out DVT Avoid excessive compression to prevent dislodgement of the clot risk of PE !

Chronic DVT:
Aging thrombi recannulizec entrally & bl. flow possible & near-complete collapse occur! Thickened venous wall Longitudinal scan w/ color flow doppler : helpful

* 72/F Lt leg edema

DUIH case

SFA SFV

SFA

SFV

SFA

SFA SFV

SFV

Treatment of DVT
* Conventional anticoagulation therapy
Heparin (LMWH) and warfarin

* Systemic thrombolysis * Surgical treatment

Thrombectomy or/with arteriovenous fistula bypass operation

* Interventional management of DVT

Catheter-directed thrombolysis Mechanical thrombectomy:
Pigtail catheter fragmentation/Arrow-Trerotola PTD/Aspiration thrombectomy

Stent insertion for stenosis or occlusion IVC filter insertion and removal Combination therapy

Treatment of DVT

* Conventional anticoagulation
Preventing recurrent VTE, lowest bleeding cx
But < 20% of pts : evidence of early clot lysis in venogram Only 24% of iliofemoral DVT : patent at 1 year

* Clot burden usually too large for bodies

intrinsic lytic system to dissolve

Cannot eliminate risk of post-thrombotic syndrome
Venous obstruction & valvular insufficiency Ambulatory venous hypertension Patients w/ DVT 2/3 : some PTS, 7-23% : severe PTS, 4-6% :ulcer

Treatment of DVT

* Aim of any intervention

Directed at immediate and successful elimination of thrombus
Reducing the risk of fatal complications(PE) Increase likelihood of preservation of valve fx.

Indications for interventional therapy

Contraindication of intervention
* ContraIx to anticoagulation, contrast media, thrombolytic agents * Isolated distal thrombus
Focal popliteal/femoral thrombosis & without complete occlusion & with ascending flow

Catheter-directed thrombolysis (CDT)

* Local high-dose delivery of thrombolytic agents directly into venous thrombus
w/ use of variety of infusion catheters or wires & from various approach

* Advantages:

More rapid lysis of thrombus thrombus resolution Symptomatic relief Higher dose within thrombus w/ lower systemic dose Invasive Bleeding risk associated with lytic therapy ICU monitoring

* Disadvantages

Multi-side hole infusion catheter

Mechanical thrombectomy
* Mechanical Thrombectomy w/ or w/o local thrombolysis for removal of venous thrombus * Advantages
Rapid elimination of DVT, restore flow Lower lytic dose, shorter infusion time

* Disadvantages
Only acute DVT(4-5days) Limitation for too much DVT in LE Iatrogenic PE, injury to valve

Mechanical thrombectomy
* Mechanical Thrombectomy w/ or w/o local thrombolysis for removal of v. thrombus
Percutaneous aspiration thrombectomy : most commonly used Arrow precutaneous thrombectomy device Oasis thrombectomy catheter

Aspiration catheter

Arrow-Trerotola PTD
Oasis thrombectomy catheter

Endovascular stent
* Indication
Iliac vein compression syndrom (May-Thurner syndrome) Focal stenosis at iliac vein Diffuse stenosis with chronic DVT Retractable residual thrombus (stent graft)

* Stents
12-16 mm diameter Variable length, multiple stents Dilatation with 10-14 mm balloon

DUIH case

* 61/F Lt leg swelling

DUIH case

DUIH case * 61/F Lt leg swelling S/P aspiration thrombectomy Overnight UK thrombolysis for residual thrombus

* 61/F Lt leg swelling f/u venography

DUIH case

Stent insertion

* 61/F Lt leg swelling f/u venography

DUIH case

Stent insertion & balloon dilatation

* 61/F Lt leg swelling f/u venography

DUIH case

Stent insertion

* 61/F Lt leg swelling f/u venography

DUIH case