Ver el código de «Deep venous thrombosis»

==Background==
{{Venous thromboembolism types}}

{{Venous system anatomy leg}}

==Clinical Features==
[[File:Deep vein thrombosis of the right leg.jpg|thumbnail|DVT of right leg]]
[[File:DVT.jpeg|thumbnail|Large [[DVT]] of left leg]]
*Leg swelling with circumference >3cm more than unaffected side
*Tenderness over calf muscle
*Homan's sign - pain during dorsiflexion of foot (SN 60-96% and SP 20-72%)<ref>Anand SS, et al. Does this patient have deep vein thrombosis? JAMA. 1998; 279(14):1094-9.</ref>

==Differential Diagnosis==
*[[Acute arterial ischemia|Arterial thrombosis]]
*Arteritis
*[[Arthritis]]
*[[Buerger disease]]
*[[Cellulitis]]
*[[Compartment syndrome]]
*[[Complex regional pain syndrome]]
*[[Fractures (main)|Fracture]]
*[[Gout and Pseudogout|Gout]]
*[[Lymphangitis]]
*Myositis
*[[Necrotizing fasciitis]]
*Nerve entrapment
*[[Neuropathy]]
*[[Osteomyelitis]]
*[[Paget-Schroetter syndrome]]
*Sciatica
*[[Septic Arthritis (General)|Septic Joint]]
*Tendonitis

{{Calf pain DDX}}
{{Unilateral leg swelling DDX}}

==Evaluation==
[[File:DVT-clinical-algorithm.jpg|thumbnail|ACEP DVT Evaluation Algorithm]]
[[File:DVT in the Femoral Vein.png|thumb|DVT of the femoral vein on [[DVT ultrasound]]]]
[[File:Deep vein thrombosis distally to the great saphenous vein, labeled.jpg|thumb|DVT of the common femoral vein on [[DVT ultrasound]].]]
[[ File:Iliac vein deep vein thrombosis.jpg|thumb|Iliac vein vein thrombosis, which constitutes a DVT in the pelvis.]]
===Lower Extremity===
*Clinical exam
*Risk stratification for further testing indicated using (e.g., see Modified Wells Score below)
**Consider [[D-dimer]]
**Consider [[DVT ultrasound]]

{{Modified Wells Score}}

===Upper Extremity===
''Requires [[DVT ultrasound|ultrasound]] for diagnosis.  Cannot be ruled out with d-dimer.<ref>Kucher N. Clinical practice Deep-vein thrombosis of the upper extremities. N Engl J Med. 2011;364:861–869.</ref>''
*Generally involves axillary or subclavian veins
*Primary upper extremity DVT typically presents in young healthy individuals
*Secondary upper extremity DVT often due to indwelling catheters
*Obtain a chest x-ray to rule out bony abnormalities that may be causing venous obstruction

==Management==
''The distinction between distal and proximal relates to veins below and above the knee respectively.<ref>Gualtiero P. How I treat isolated distal deep vein thrombosis (IDDVT). Blood 2014 123:1802-1809; doi: https://doi.org/10.1182/blood-2013-10-512616</ref> Patients with '''superficial venous thromboses such as the long saphenous and short saphenous are at risk of developing a DV'''T, especially in patients who have a history of prior [[DVT]] although management with anticoagulation is controversial.<ref>Litzendorf ME. Satiani B. Superficial Venous thrombosis:disease progression and evolving treatment approaches. Vasc Health Risk Manag. 2011(7). 569-575</ref>''
===Proximal DVT===
''Proximal veins are the '''external iliac''', '''common femoral''', '''greater saphenous''', '''profound (deep) femoral''', '''(superficial) femoral vein''', '''popliteal vein'''''
*If NO phlegmasia cerulea dolens:
**Anticoagulate with [[apixaban]], [[rivaroxaban]], or [[heparin]]/[[coumadin]] x 3 months
*If phlegmasia cerulea dolens:
**Consider thrombolytics +/- thrombectomy 
**Anticoagulate with [[apixaban]], [[rivaroxaban]], or [[heparin]]/[[coumadin]] x 3 months
*If anticoagulation contraindicated:
**[[IVC filter]]

====Mechanical Thrombectomy====
Consider pharmaco-mechanical (IR) management of proximal DVTs with the following charateristics:
*Objectively diagnosed (i.e., CT or US) 
*Acute (≤14 days)
*Symptomatic (at least one):
**rVCSS Pain Score ≥2
**New edema of calf or thigh (CEAP ≥3)
**Limited mobility or bed bound due to pain / swelling
**Impairment of the tissue perfusion (phlegmasia)

===Distal DVT===
''Distal veins are the '''anterior tibial''', '''posterior tibial''', '''peroneal''', '''gastrocnemius, soleus.'''''
*Symptomatic 
**Anticoagulate with [[apixaban]], [[rivaroxaban]], or [[heparin]]/[[coumadin]] x 3 months
*Asymptomatic with extension of thrombus toward proximal veins
**Anticoagulate with [[apixaban]], [[rivaroxaban]], or [[heparin]]/[[coumadin]] x 3 months
*Asymptomatic without extension
**Discharge with compressive U/S q2 weeks
*2020 review from JAMA<ref>Diagnosis and Treatment of Lower Extremity Venous Thromboembolism: A Review.  JAMA. 2020 Nov 3;324(17):1765-1776. doi: https://doi.org/10.1001/jama.2020.17272</ref> recommend treat calf DVT if "severe symptoms or risk factors for pulmonary embolism or extension to proximal veins (such as hospitalization, history of VTE, and cancer)."

===VTE in Pregnancy<ref>DʼAlton ME et al. National Partnership for Maternal Safety: Consensus bundle on venous thromboembolism. Obstet Gynecol 2016 Oct; 128:688.</ref>===
*Therapeutic [[Enoxaparin|LMWH]] or [[Unfractionated_heparin|unfractionated heparin]] anticoagulation dose in:
**Antepartum outpatient with multiple prior VTEs or any VTE with high-risk thrombophilia until ''6 weeks postpartum''
**Postpartum inpatient with prior unprovoked, estrogen-provoked VTE, or low-risk thrombophilia ''for duration of admission''
*Lower prophylactic anticoagulation dose in:
**Antepartum outpatient with prior unprovoked, estrogen-provoked VTE, or low-risk thrombophilia until''6 weeks postpartum''
**Patients admitted > 72 hrs, not at high risk for bleeding or imminent delivery
**Resume 12 hours after C-section and removal of epidural / spinal needle in indicated patients
*Halt anticoagulation if imminent delivery, C-section, epidural / spinal needle

===Recurrent DVT on Therapeutic Anticoagulation===
*Admit patients for vascular surgery and hematologist consult
*Consider Greenfield IVC filter placement
*Typically start heparin for additional anticoagulation

===Upper extremity DVT===
*If secondary to catheter, do not necessarily have to remove <ref> Kovacs MJ et al. A pilot study of central venous catheter survival in cancer patients using low-molecular-weight heparin (dalteparin) and warfarin without catheter removal for the treatment of upper extremity deep vein thrombosis (the catheter study) JTH. 2007;5:1650–1653. </ref>
*Anticoagulation as per lower extremity DVTs.
*Consider admission for catheter directed thrombolysis or mechanical thrombectomy, especially with any of the following characteristics<ref>Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016;149:315-52.</ref>
**Severe symptoms
**Thrombus extending from subclavian to axillary vein
**Other features that suggest success for thrombolysis and decrease risk:
***Symptoms <14 days
***Life expectancy >1 yr
***Low risk for bleeding

==Anticoagulation Options==
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Medication'''
| align="center" style="background:#f0f0f0;"|'''[[Warfarin]] (Coumadin)'''
| align="center" style="background:#f0f0f0;"|'''[[Rivaroxaban]] (Xarelto)'''
| align="center" style="background:#f0f0f0;"|'''[[Apixaban]] (Eliquis)'''
| align="center" style="background:#f0f0f0;"|'''[[Dabigatran]] (Pradaxa)'''
|-
| Standard Dosing||
*[[Enoxaparin]] 1mg/kg q12h x 4-5 days 
*[[Warfarin]] 
**Starting dose of 5mg/day 
**Give 7d supply with first dose in ED
||
*15mg PO BID x 21 days
**Then 20mg PO daily (duration depending on risk factors) 
||
*10mg PO BID x 7 days
**Then 5mg PO BID daily (duration depending on risk factors) 
||
*[[Enoxaparin]] 1mg/kg q12h x 4-5 days 
*Pradaxa 150mg BID <ref> https://pubmed.ncbi.nlm.nih.gov/19966341/ </ref>
|-
| Renal Dosing||
*[[Unfractionated Heparin]] 80 units/kg bolus
**Then 18 units/kg/hour 
**Check PTT after 6hr; adjust infusion to maintain PTT at 1.5-2.5x control 
*[[Warfarin]] as above
||
*Check creatinine on all patients prior to initiation 
*CrCl <30 avoid use
||
*No dosage adjustments necessary for renal impairment
**However, CrCl <25 mL/minute were excluded from clinical trials
||
*CrCl<50 avoid use
|}

===Contraindications to anticoagulation===
*Active hemorrhage
*Platelets <50
*History of [[intracerebral hemorrhage]]

==Disposition==
===Discharge===
Consider if all of the following are present:
*Ambulatory
*Hemodynamically stable
*Low risk of bleeding in patient
*Absence of renal failure
*Able to administer anticoagulation with appropriate monitoring 
*Able to arrange for 2-3 day follow-up

===Admit===
For any of the following:
*Ileofemoral DVT that is a candidate for thrombectomy (should have the following):<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646749/</ref>
**Acute iliofemoral DVT (symptom duration <21 days)
**Low risk of bleeding
**Good functional status and reasonable life expectancy
*[[Phlegmasia cerulea dolens]]
*High risk of bleeding on anticoagulation
*Significant comorbidities
*Symptoms of concurrent [[PE]]
*Recent (within 2 weeks) stroke or transient ischemic attack
*Severe renal dysfunction (GFR < 30)
*History of heparin sensitivity or [[Heparin-Induced Thrombocytopenia]]
*Weight > 150kg
*Upper extremity DVT, if indicated for thrombolysis vs outpatient for anticoagulation alone if low risk

==See Also==
*[[Anticoagulants]]
*[[Pulmonary embolism]]
*[[DVT ultrasound]]
*[[Paget-Schroetter syndrome]]

==External Links==
*[http://www.mdcalc.com/wells-criteria-for-dvt/ MDCalc - Wells' Criteria for DVT]
*[https://rebelem.com/tag/deep-vein-thrombosis/ REBEL EM - Should I Stay or Should I Go: Outpatient Treatment of Venous Thromboembolism]
*[https://coreem.net/core/deep-venous-thrombosis-dvt/ CORE EM - Deep Venous Thrombosis (DVT)]

==References==
<references/>

[[Category:Cardiology]]
[[Category:Vascular]]