Title: Thrombophlebitis and Occlusive Arterial Disease
1Thrombophlebitis and Occlusive Arterial Disease
- October 6th, 2005
- George Filiadis D.O.
2Thrombophlebitis
- Formation of a venous clot depends on the
presence of of at least of one of Virchows triad
factors -venous stasis -injury to
vessel wall -hypercoagulable state
3Clinical risk factors for deep vein thrombosis
- Trauma, travel
- Hypercoagulable, hormone replacement
- Recreational drugs(IV drugs)
- Old (age gt60y)
- Malignancy
- Birth control, blood group A
- Obesity, obstetrics
- Surgery, smoking
- Immobilization
- Sickness
4Pathophysiology
- Most common cause of hereditary hemophilia is
factor V Leiden - See Table 59.2 for other hypercoagulable states
- Thrombi usually form at the venous cusps of deep
veins where altered or static blood flow causes
clot formation - Alternatively, clots form from intimal defects
- Clots are composed from fibrin, red cells and
platelets and cause partial/complete obstruction
of vein
5Pathophysiology
- Postphlebitic syndrome (PPS) may develop after
the resolution of a DVT - PPS is due valvular incompetence, persistent
outflow obstruction and abnormal microcirculation.
6Superficial Thrombophlebitis
- Thrombosis can occur in any superficial vein
primarily the saphenous vein and its tributaries - Local pain, redness, and tenderness are
characteristic findings. - Mild cases can be treated with warm compresses,
analgesia and elastic supports - Severe cases can be debilitating and should be
managed by bed rest, elevation of extremity,
support stockings, and analgesia. - Antibiotics and anticoagulants are useful in
septic thrombophlebitis
7Superficial Thrombophlebitis
- Incidence of DVT from extension of a superficial
clot is 3. - Most clots in great saphenous vein will extend
into a deep vein system in a week or so thus a
follow-up US is guaranteed - Definite treatment is ligation and excision of
affected vein.
8Deep Vein Thrombosis
- Clinical exam is unreliable for detection or
exclusion of a DVT - Pain, redness, swelling, and warmth are present
in less than half the patients with confirmed
DVT. - Pain in calf with dorsiflexion of ankle with the
leg straight (Homans sign) is unreliable - See table 59.3 for predictors of deep vein
thrombosis
9Deep Vein Thrombosis
- Symptomatic DVT will be in popliteal or more
proximal veins more than 80 - Nonextending calf DVT rarely cause PE
- Uncommon presentations of DVT include phlegmasia
cerulea dollens and phlegmasia alba dollens - In phlegmasia cerulea dollens, patients present
with extensive swollen and cyanotic leg due to
massive ileofemoral thrombosis which can lead to
venous gangrene.
10Deep Vein Thrombosis
- In phlegmasia alba dolens, the leg is white due
to arterial spasm secondary to massive
iliofemoral thrombosis, often mistaken for
arterial occlusion. - PPS can be difficult to differentiate from
recurrent DVT due to pain, swelling and
ulceration of the skin. - Up to to one third of the patients with DVT can
develop PPS.
11Deep Vein Thrombosis-Diagnosis
- All patients with any signs or symptoms
suggestive DVT should undergo an objective
diagnostic evaluation - Venography was the historical gold standard for
detection of DVT with 100 sensitivity and
specificity but it is invasive and can cause
contrast-related reactions, phlebitis and DVT
(3).
12Deep Vein Thrombosis-Diagnosis
- Choice of test to identify DVT is ultrasound
- Ultrasound has 97 and 94 sensitivity and
specificity respectively for detecting proximal
DVT - Ultrasound is less sensitive for pelvic DVT and
has sensitivity of 73 for a calf DVT. - Impedance plethysmography is portable and
inexpensive but less sensitive than US - IP measures changes in electrical resistance in
response to changes in calf volume due to
obstruction
13Deep vein thrombosis-Diagnosis
- Radioisotopes have been used to diagnose DVT but
are not particularly useful in ED - MRI is being used with increased frequency and
can detect a filling defect in entire extremity
(including calf and pelvic veins) - D-Dimer fragments which are degradation products
of fibrin can be used to as an indicator for the
presence or absence of DVT or PE. - The ELISA based D-Dimer has sensitivity 97 and
specificity 35 -
14Deep Vein Thrombosis-Diagnosis
- When D-Dimer is less than 500ng/ml, the
likelihood of DVT is less than 1. - The latex agglutination assay D-Dimer is less
sensitive than the ELISA essay. - Sepsis, surgery, trauma, hemorrhage, pregnancy,
cardiovascular diseases, collagen vascular
disease, liver disease, cancer are associated
with elevated d-dimer value.
15Clinical Approach to Establishing the Diagnosis
16Treatment
- Bed rest, leg elevation and elastic stockings are
of unproven benefit in the management of DVT. - Aggressive anticoagulation will prevent extension
of the clot. - Early ambulation after adequate anticoagulation
is a safe approach - Primary objective of treating DVT is the
prevention of pulmonary embolus
17Treatment
- Patients with negative ultrasound can safely have
a repeat ultrasound in a week without
anticoagulation - Risk of PE in these patients is near 0 and risk
of forming a DVT is 1. - Anticoagulation is recommended for patients with
calf DVT who had PE/DVT, immobile, have
hypercoagulable state
18Treatment
- Patients with proximal DVT require
anticoagulation - Preferred treatment is LMWH over UFH because of
the ease of administration, more predictable
anticoagulant effect, lack of need to monitor the
anticoagulation effect, lower incidence of major
bleeding and HIT - LMWH has a preferentially inhibitory effect on
factor Xa.
19Treatment
- Because of LMWH is cleared by the kidneys, it
should be avoided in outpatients with Cr gt2.03 - One need not to wait for the creatinine result
before initiating LMWH therapy. - The ability to discharge patients from the ED
after initial dose of LMWH is cost-effective,
safe, practical and acceptable practice as long
as there is a secured 24 hr follow up with PCP.
20Treatment
- Indications for admission include inability to
ambulate, poor social support, unreliable
follow-up, difficulty with education with drug
administration, need for lysis or invasive
therapy, and an alternative serious diagnosis
under investigation or that requires
treatment(arterial ischemia, cellulitis, pelvic
mass)
21Treatment
- If LMWH is contraindicated, use UFH as 80
units/kg bolus and then 18 units/kg/hr - Serious bleeding from LMWH cannot be completely
reversed with protamine which has been associated
with hypotension and anaphylactoid reactions. - If a patient has contraindication to heparin like
in pt with HIT, you can use a thrombin inhibitor
like lepirudin
22Treatment
- In pregnant pt who cannot have heparin, danaproid
should be used. - It is acceptable to start coumadin and LMWH
simultaneously. - Warfarin is contraindicated in pregnancy, active
bleeding, recent major surgery (thoracoabdominal,
nervous system, spine, eye) - LMWH does not interfere with the work up of a
possible hypercoagulable state compared with UFH.
23Treatment
- Initial hematological testing at follow-up
includes factor V leiden, prothrombin molecular
tests, screening for antiphospholipid
anticoagulants and a fasting homocysteine level. - Upon completion of the anticoagulation , further
testing includes antithrombin III, protein C,
protein S, and factor VIII level
24Treatment
- Thrombolysis for DVT is indicated for extensive
iliofemoral thrombosis and upper extremity DVT in
patients with low risk for bleeding. - IVC filter is indicated for when anticoagulation
therapy is contraindicated, there is embolization
of DVT after 1-2 weeks of anticoagulation
25Treatment
- Thrombectomy is only indicated with ischemic leg
secondary to a massive venous clot like in
phlegmasia cerulea dolens. - In ED , pt adequately anticoagulated who present
with new thrombus or propagation should receive
LMWH - If the fail LMWH or there is a free-floating
thrombus an IVC should emergently inserted.
26Pelvic Vein Thrombosis
- Usually its an extension of a clot from the
femoral vein. - An isolated pelvic vein thrombosis is rare and
can be a complication in the postpartum period,
after pelvic surgery or trauma. - Septic pelvic vein thrombophlebitis is a
life-threatening condition after post-partum
endometritis and is usually diagnosed with CT or
MRI.
27Axillary and Subclavian Vein thrombosis
- 2-4 of DVTs occur in axillary or subclavian vein
- Risks include recent central venous catheters or
pacemakers, IV drug use, malignancy,
hypercoagulable states and excessive or unusual
exercise, chronic compression(cervical rib,
scalene or web) - PE occurs in 5-10 of cases involving axillary or
subclavian DVT - Treatment includes anticoagulation alone or
preceded by thrombolysis.
28OCCLUSIVE ARTERIAL DISEASE
- Acute limb ischemia secondary to thrombosis or
embolus is true emergency. - Mortality is 25 and risk of amputation is 20.
- 11-27of elderly have peripheral arterial disease
- Smoking, diabetes, hyperlipidemia, hypertension
and homocysteinemia are significant risk factors - At least half of the patients with coronary or
cerebrovascular disease have PVD
29Pathophysiology
- Acute limb ischemia leads to cell death and
irreversible tissue damage. - After prolonged arterial obstruction, reperfusion
may not be fully attainable due to distal edema
and thrombi forming in the microcirculation. - Peripheral nerves and skeletal muscle are very
sensitive to ischemia and irreversible damage can
occur within 6 h of anoxia - Non-embolic ischemia is due to atherosclerosis of
the vessels
30Pathophysiology
- Progression of ischemic injury can occur through
several mechanisms i)propagation of clot to
include collateral vessels ii)ischemia-rela
ted distal edema leading to high compartment
pressures iii)fragmentation of clot in the
microcirculation iv)edema of the
microvasculature cells
31Etiology
- Thrombotic occlusion is significantly more common
cause of acute limb ischemia than is embolism. - Emboli originate from the heart in 80-90 with
atrial fibrillation being the cause in two thirds
of all peripheral emboli. - Mural thrombus in the ventricle after recent
myocardial infarction is the second most common
cause.
32Etiology
- Other causes of emboli include atrial myxomas,
vegetations from valve leaflets, and parts of
prosthetic devices such as mechanical valves. - Noncardiac causes include thrombi from aneurysms
and atheromatous plaques. - Iatrogenic embolization can happen during
angiograhic procedures of the aorta and larger
vessels
33Etiology
- Thrombosis unrelated to atherosclerotic disease
can occur at an area of vessel injury during
invasive studies. - Peripheral arterial supply can be obstructed by
vasospastic or inflammatory conditions like
Raynaud disease and Thromboangitiis obliterans
(young smokers) - Limb ischemia can also seen with central causes
like thoracic aortic dissection and Takayasu
arteritis.
34Etiology
- Low cardiac output states like cardiogenic or
hypovolemic shock may also present with limb
ischemia - Cardiac tamponade, ischemic cardiomyopathy,
valvular heart disease can impair left ventricle
function and lead to leg ischemia in patients
with existing peripheral vascular disease.
35Clinical features
- 6 Pspain, pallor, polar (for cold),
pulselessness, paresthesias, and paralysis. - Despite the belief that the limb salvage is
possible within 4-6h, tissue loss can occur with
significantly shorter occlusion times. - Chronic peripheral arterial insufficiency is
characterized by intermittent claudication with
activity that is relieved at rest. - Shiny, hyperpigmented skin with hair loss and
ulceration, thickenend nails, poor pulses are
hallmarks of chronic disease
36Diagnosis
- Clinical evaluation is the most useful diagnostic
tool. - Capillary refill is not reliable alone
- A hand held Doppler can detect the presence or
absence of a pulse. - If a pulse is detected, then the ankle-brachial
index (ABI) and segmental leg pressures should be
checked - An ABIlt0.5 indicates acute arterial obstruction
- If time permits, do a duplex ultrasound
37Treatment
- Goals of therapy include restoration of blood
flow, preservation of limb and life, and
prevention of recurrent thrombosis - Current practice includes UFH to prevent clot
extension, venous thrombosis, the appearance of
thrombi distal to the obstruction, and
reocclusion. - Fluid resuscitation and treatment of heart
failure and dysrhythmias are sometimes necessary
to improve limb perfusion. - Definite treatment includes surgery or
thrombolysis
38Upper Extremity Ischemia
- Upper extremity arterial occlusion is less
common. - There is a well-developed collateral circulation
around the shoulder and elbow, thus arterial
occlusion is better tolerated. - Usual causes are vasospasm, arteritis, trauma,
hypercoagulable state, plaque rupture, thoracic
outlet syndrome, aneurysms. - Treatment includes heparinization and surgical
thrombectomy.
39Aneurysms of the extremity
- Incidence of aneurysms in lower extremities
appears to be increasing due to the aging
population. - Femoral and popliteal aneurysms are the most
common. - Symptoms include local pain, limb edema, and
ischemic complications - For femoral aneurysms (majority are false), US,
CT or MRI can confirm the diagnosis
40Aneurysms of the extremity
- In patients with popliteal aneurysm there is 37
chance of abdominal aortic aneurysm and 50
chance of coexisting popliteal aneurysm on the
contralateral leg. - Subclavian artery aneurysms can produce central
neurologic findings or upper extremity iscemia
and are due to atherosclerosis, trauma, thoracic
outlet obstruction, syphilis or cystic medial
necrosis.
41Questions
- 1.Regarding superficial thrombophlebitis, all of
the following are correct except - A)treatment includes bedrest, elevation, support
stockings, and analgesia. - B)antibiotics and anticoagulants are of no proven
benefit. - C)incidence of DVT from superficial thrombus is
30 - D)all of the IV drug users with superficial DVT
should receive antibiotics
42Questions
- 2.T/F Calf DVT usually extend proximally and are
a common case of PE - 3.T/F Occlusive arterial disease is usually due
to a thrombosis event rather than embolic - 4. T/F Pt with political aneurysm frequently have
abdominal aortic aneurysm and contra lateral
political aneurysm.
43Questions
- 5.Which of the following statements is true
- A)Diagnosis of a DVT can be based on clinical
exam - B)Test of choice for diagnosis of DVT is
ultrasound. - C)Venography is the gold standard diagnostic
modality given its low complications rate - D)Ultrasound has higher sensitivity for detecting
calf DVT than proximal DVT - Answers 1)c, 2)F, 3)T, 4)T, 5)B