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Venous Ultrasound
Published in John McCafferty, James M Forsyth, Point of Care Ultrasound Made Easy, 2020
If the proximal deep veins are obstructed, this can present with a very swollen thigh as well as the calf (i.e., an ileofemoral DVT). Phlegmasia alba dolens is the swollen ‘white’ painful limb that is found in patients with ileofemoral DVT. These patients generally have a more limited occlusion of the iliac veins. Phlegmasia cerulea dolens is the swollen ‘blue’ painful limb that is seen in patients with a more significant ileofemoral DVT with more extensive thrombosis. In these patients, the venous hypertension is more pronounced with elevated compartment pressures leading to a greater degree of pain and discomfort. The blue cyanotic discolouration is caused by a stagnation of venous blood in the dermal and subdermal venous plexuses. At the most severe end of the spectrum is venous gangrene, which represents soft tissue necrosis in a limb with a large burden proximal DVT. This presentation usually represents a progression from phlegmasia alba dolens through phlegmasia cerulea dolens. The venous gangrene itself ultimately results from small vein and microvascular thrombosis. Venous gangrene in these contexts is often associated with malignancy and other serious conditions like heparin-induced thrombocytopenia, disseminated intravascular coagulation, acute liver dysfunction, and sepsis. Ileofemoral DVT should therefore be taken seriously and early consultation with vascular surgery is recommended.
Pharmacologic and pharmacomechanical thrombolysis for acute deep vein thrombosis
Published in Sachinder Singh Hans, Alexander D Shepard, Mitchell R Weaver, Paul G Bove, Graham W Long, Endovascular and Open Vascular Reconstruction, 2017
There are no established criteria for which patients benefit most from CDT or pharmacomechanical CDT. Patients with limb-threatening phlegmasia cerulea dolens or young patients with significant symptoms from a proximal deep vein thrombosis (DVT) should be considered if they are not at an increased risk for bleeding complications. Additionally, involvement of the common femoral (CFV) or iliac veins should point toward endovascular therapy, because this level of involvement is associated with a much higher risk of PTS and recurrent DVT.4 Otherwise, patient selection for intervention occurs on a case-by-case basis, with the clinical picture, concurrent medical conditions, individual risk of bleeding, patient desire, and ability to tolerate this procedure being the determining factors.
The clinical presentation and natural history of acute deep venous thrombosis
Published in Peter Gloviczki, Michael C. Dalsing, Bo Eklöf, Fedor Lurie, Thomas W. Wakefield, Monika L. Gloviczki, Handbook of Venous and Lymphatic Disorders, 2017
Symptoms do tend to be more severe as thrombosis extends more proximally. When present, signs and symptoms of acute DVT may include pain, edema, erythema, tenderness, fever, prominent superficial veins, pain with passive dorsiflexion of the foot (Homan’s sign), and peripheral cyanosis. Although potentially associated with concurrent DVT, a palpable cord is more suggestive of superficial venous thrombosis. However, up to 50% of patients with an acute DVT may lack specific signs and symptoms.4,5 Post-operative patients are, in particular, more likely to have small, asymptomatic, distal, non-occlusive thrombi. Phlegmasia cerulea dolens, characterized by the triad of massive swelling, cyanosis, and pain,6 is the most severe form of acute DVT and results from near-complete thrombosis of an extremity’s venous outflow. In advanced cases, it is marked by severe venous hypertension with collateral and microvascular thrombosis, leading to venous gangrene. Venous gangrene has been particularly associated with warfarin-mediated protein C depletion in patients with cancer or heparin-induced thrombocytopenia.7,8
A review of upper extremity deep vein thrombosis
Published in Postgraduate Medicine, 2021
Oneib Khan, Ashley Marmaro, David A Cohen
Thrombolytic therapy has been considered for the treatment of UEDVT. It is never used as a substitute for anticoagulation but rather an adjunct to it. Based on trials in LEDVT, thrombolytic therapy may offer a reduction in rates of moderate-to-severe PTS; however, it is debatably overshadowed by the increase in major bleeding [59,60]. There is a dearth of data regarding outcomes for thrombolysis in UEDVT. Small studies totaling fewer than 50 patients have shown increased recanalization (1 vs 4 p = 0.04) and symptom resolution rates (4 vs 8 p = 0.04) for patients that underwent thrombolysis and anticoagulation compared to anticoagulation alone [61]. Bleeding outcomes are also limited; there was one retrospective review of 95 patients in which 7/33 (21%) undergoing thrombolytic therapy had significant peri-intervention bleeding [62]. CHEST guidelines recommend anticoagulation alone over anticoagulation with thrombolysis, and the decision to use or avoid thrombolysis does not affect the approach to anticoagulation [38]. At this time, the only clear indication for thrombolysis is for phlegmasia cerulea dolens to reduce the risk of venous gangrene. Beyond that, the decision to pursue thrombolysis should be done via a multidisciplinary approach on a case by case basis.
Prevention, treatment, and risk factors of deep vein thrombosis in critically ill patients in Zhejiang province, China: a multicenter, prospective, observational study
Published in Annals of Medicine, 2021
Li Li, Jia Zhou, Liquan Huang, Junhai Zhen, Lina Yao, Lingen Xu, Weimin Zhang, Gensheng Zhang, Qijiang Chen, Bihuan Cheng, Shijin Gong, Guolong Cai, Ronglin Jiang, Jing Yan
Deep vein thrombosis (DVT) is caused by a blood clot obstructing blood flow in the deep venous system, most commonly occurring in the lower limbs [1]. It can be provoked by factors, such as recent surgery or trauma, hospitalisation with prolonged bed rest, or the use of oral contraceptives [1]. An unprovoked DVT may be idiopathic or inherited or from acquired hypercoagulable states, such as cancer and pregnancy [1]. The estimated annual worldwide incidence of venous thromboembolism (VTE) is 10 million [1–3]. DVT is observed in about 0.51% of hospitalised patients [4], 0.8%–8% of patients with cancer [5–7], 0.8%–9.6% of patients with surgery [8–10], and 5%–31% of intensive care unit (ICU) patients [11,12], and the incidence increases with age [1–3]. A study based on a large healthcare database in China revealed an annual incidence of DVT of 30.0 per 100,000 populations [13]. Pulmonary embolism, post-thrombotic syndrome, phlegmasia cerulea dolens, phlegmasia alba dolens, and paradoxical embolism leading to cryptogenic embolic stroke are possible complications of DVT [14–17]. In addition, DVT is associated with an increased risk of mortality [18–20].
Current approaches in the treatment of catheter-related deep venous thrombosis in children
Published in Expert Review of Hematology, 2020
Julie Jaffray, Neil Goldenberg
In patients without contraindications to anticoagulation, anticoagulant therapy is typically initiated to reduce the risk of local DVT progression, the development of new non-contiguous DVT, or PE and arterial ischemic stroke, in the case of ‘paradoxical embolism’ to the cerebral arteries via a known or occult intracardiac shunting lesion such as a patent foramen ovale or atrial septal defect. These latter risks are often collectively referred to as ‘recurrent VTE.’ Conventional anticoagulation does not directly induce thrombolysis; it is thought that attenuation of thrombin generation via anticoagulation instead assists the fibrinolytic activity of the patient’s plasma toward gradual clot breakdown. A pharmacological fibrinolytic agent such as tissue plasminogen activator (tPA) can be locally administered in select patients for more aggressive thrombolysis, although the risk of bleeding complications must also be considered; thrombolysis is typically reserved for patients with low bleeding risk who either have phlegmasia cerulea dolens or very high PTS risk (e.g. completely occlusive ipsilateral recurrence of proximal DVT). A detailed discussion of thrombolytic therapy modalities and evidence in pediatric DVT treatment is beyond the scope of this review; the reader is instead referred to a previously published narrative review focused on that topic [59].