• Virchow's triad: Stasis, vascular injury, hypercoagulability
-Stasis: Venous insufficiency, heart failure, prolonged bed rest/plane travel
-Endothelial injury: Direct trauma, chemotherapy infusion, previous DVT, phlebitis, operative trauma all increase release of tissue factor increasing thrombin and decreasing fibrinolysis
-Hypercoagulability: Malignancy, protein C or S deficiency, disseminated intravascular coagulation (DIC), liver failure, elevated homocysteine, factor V Leiden, prothrombin gene variant, paroxysmal nocturnal hemoglobinuria
• Important risk factors
• Other risks
• Most common in calf veins, may arise in femoral or iliac
• 25% calf DVT progress proximally
• Proximal DVT (femoral or iliac)
-Chronic venous insufficiency, 25%
-Fatal pulmonary embolism (PE), 10%
• Phlegmasia cerulea dolens caused by iliofemoral venous thrombosis, which is characterized by cyanosis of limb from venous outflow obstruction; potentially limb-threatening
• In phlegmasia alba dolens, leg is pulseless, pale, cool; potentially limb-threatening
• Affects 500,000 persons in United States each year
• Up to 21% mortality in elderly
• 20-30% of new DVT have occult malignancy (lung, pancreas, prostate, breast, ovary most common)
• Surgery increases risk 21-fold
• Complication rates
• 50% are asymptomatic
• Thigh or calf pain with or without edema
• Extensive DVT
• Low-grade fever, tachycardia
• 50% have positive Homans sign (calf pain with ankle dorsiflexion)
• Acute PE
• Local muscle strain
• Achilles tendon rupture
• Baker cyst obstructing popliteal vein
• Retroperitoneal mass (obstructing iliac vein)
• Congestive heart failure (CHF), liver, kidney failure, inferior vena cava (IVC) obstruction (bilateral edema)
• Primary treatment
• Decreases recurrence and PE risk by 80%
• Limits propagation of clot (no effect on clot lysis)
• Iliofemoral thrombosis
• IVC filter is contraindication to anticoagulation
• Potentiates antithrombin III, inhibits thrombin
• Partial thromboplastin time (PTT) goal of 2 times normal
• Effective heparinization within 24 hrs decreases risk of DVT recurrence
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