Deep Vein Thrombosis (DVT)

Introduction and Facts

Deep vein thrombosis is known as deep vein thrombosis (DVT). Thrombus in the deep venous system is actually harmless, can be dangerous and can even cause death if part of the thrombus is released, then follows the bloodstream and clogs arteries in the lungs (pulmonary embolism).

The incidence of DVT in Europe and the United States is approximately 50 per 100,000 population/year. The incidence of DVT increases with age, around 1 per 10,000 – 20,000 population under 15 years old to 1 per 1000 population over 70 years old. The incidence of DVT in Asian and Hispanic races is reported to be lower than in Caucasian, African-Latin American, and Asia Pacific races. There was no significant difference in incidence between men and women.

Pathophysiology

Venous thrombosis usually consists of fibrin, red blood cells, and some components of platelets and leukocytes. There are three things that play a role in the process of thrombosis (Virchow's Triad):

1. Venous stasis. Venous blood flow tends to be slow, even stasis, especially in areas that have been immobilized for a long time. Venous stasis is a predisposing factor for local thrombosis, because it can interfere with the clearance mechanism of blood clotting factor activity, thereby facilitating the formation of thrombosis.

2. Damage to blood vessels. Damage to blood vessels can play a role in the process of formation of venous thrombosis, through:

- Direct trauma resulting in clotting factors

- Endothelial cell activation by cytokines released as a result of tissue damage and inflammatory processes.

3. Changes in blood clotting power. Under normal circumstances there is a balance between the blood coagulation system and the fibrinolytic system. Thrombotic tendencies occur when blood clotting activity is increased or fibrinolytic activity is decreased. DVT often occurs in cases of increased blood clotting activity, such as in hypercoagulability, anti-thrombin III deficiency, protein-C deficiency, protein S deficiency, and plasminogen abnormalities.

Clinical Symptoms and Complications

Complaints and symptoms of deep vein thrombosis can include:

1. Pain. The intensity of pain does not depend on the size and extent of the thrombosis. Pain will be reduced if the patient lies down, especially if the position of the leg is elevated.

2. Swelling. The emergence of edema can be caused by proximal venous occlusion and inflammation of the perivascular tissue. If it is caused by a blockage, the swelling is located under the blockage and is painless, whereas if it is caused by perivascular inflammation, the swelling occurs in the area of ​​thrombosis and is usually accompanied by pain. Swelling increases with walking and will decrease when resting with the feet slightly elevated.

3. Changes in skin color. Skin discoloration is non-specific and less common in deep vein thrombosis than in arterial thrombosis, occurring in only 17% - 20% of cases. The skin may turn pale and sometimes purple. Changes in color to pale and cold to the touch is a sign of large venous obstruction along with arterial spasm, called phlegmasia alba dolens.

Diagnosis

1. History and Physical Examination. The history and physical examination are very important in the approach of a patient with suspected thrombosis. Previous medical history is important because it can identify risk factors and previous history of thrombosis. Having a family history of thrombosis is also important.

2. Laboratory. Laboratory examination revealed an increase in D-dimer levels and a decrease in antithrombin (AT). D-dimer is a product of fibrin degradation. D-dimer examination can be done by ELISA or latex agglutination assay.

3. Radiological. Radiological examination is important for diagnosing DVT. Several types of radiological examinations that can be used to establish the diagnosis of DVT, namely: venography, Impedance Flestimography, Ultrasonography (USG) Doppler.

Management and Care

Only carried out in cases where the diagnosis has been clearly established considering that drugs can cause serious side effects. The goals of treatment for acute phase DVT are:

1. Stops the increase of thrombus

2. Limiting progressive leg swelling

3. To lyse and remove blood clots and prevent venous dysfunction or the occurrence of post-thrombotic syndrome

4. Prevent the occurrence of embolism

a. Non-pharmacological. Non-pharmacological management is mainly aimed at reducing morbidity in acute attacks and reducing the incidence of postthrombotic syndrome which is usually characterized by pain, stiffness, edema, paresthesias, erythema, and edema. To reduce the complaints and symptoms of venous thrombosis, patients are advised to rest in bed (bedrest), elevate the position of the legs, and put on compression stockings with a pressure of approximately 40 mmHg.

b. Pharmacologist. The extent of the process of thrombosis and pulmonary embolism can be prevented by anticoagulants and fibrinolytics.

  1. Unfractionated Heparin. Unfractionated heparin therapy is based on body weight and the dose is titrated according to the Activated Partial Thromboplastin Time (APTT) value. The desired APTT value is 1.5-2.5 control.

   2. Low-Molecular-Weight Heparin (LMWH). Compared with unfractionated heparin, LMWH is more advantageous because of its longer biological half-life, it can be administered subcutaneously once or twice daily, the dosage is fixed and does not require laboratory monitoring. In DVT patients, subcutaneous heparin is no less effective than continuous infusion of unfractionated heparin

  3. Warfarin. Warfarin is the drug of choice for acute anticoagulation. Warfarin is given immediately after the diagnosis of DVT is established, but its action may take a week or more. Therefore, LMWH is given concurrently as a concomitant therapy until warfarin reaches its therapeutic dose.

  4. Thrombolytic therapy. Unlike anticoagulants, thrombolytic drugs cause direct lysis of the thrombus by increasing plasmin product through plasminogen activation. The FDA-recommended thrombolytic drugs include streptokinase, recombinant tissue plasminogen activator (rt-PA), and urokinase.

c. Thrombectomy. Open surgical thrombectomy is recommended for DVT who has criteria including acute iliofemoral DVT, but there are contraindications to thrombolytic or thrombolytic or failed mechanical thrombectomy, the lesion is inaccessible to the catheter, the thrombus is difficult to rupture, and anticoagulation is contraindicated.

Reference:

Jayanegara AP. Diagnosis dan tatalaksana deep vein thrombosis. CDK 2016:244:43(9):652-7