Deep Venous Thrombosis and its Complications M A
Deep Venous Thrombosis and its Complications M. A. Kubtan M. D-F. R. C. S. (U. K) Dept of General Surgery Al Mouasat University Hospital Damascus MAK 1
The Role of Clotting In the blood vascular system the clotting mechanism guards against the danger of haemorrhage MAK 2
Thrombosis Is the formation of a solid mass ( Thrombus ) in the circulation from the constituents of streaming blood MAK 3
Causes of Phlebothrombosis Ø Changes in the vessel Wall. Ø Changes in the Blood flow. Ø Changes in the composition of the Blood. MAK 4
Changes in the Vessel Wall Ø Pressure on the veins by the heavy calf tissues when the patient is immobilised in bed. Ø Local hypoxia due to pressure on the vessles associated with immobility. Ø Direct trauma by a fracture edges. Ø Ill applied tourniquets and plaster of Paris. MAK 5
The Blood Flow Ø Stasis (The usual cause of venous thrombosis) Ø Increased viscosity of blood Ø In polycythaemia Vera Ø Dehydration Ø Eddy Current MAK 6
The Composition of Blood Ø Platelets ( Thrombocytosis ). Ø Clotting Factors. MAK 7
Platelets Thrombocytosis Transient ( after Parturition, Trauma, Sever Haemorrhage, and after Splenectomy ). Persistent ( Polycythaemia Vera ). MAK 8
Platelets Function Ø Platelet Aggregation. Ø Platelet Adhesiveness. MAK 9
The Role of Clotting Mechanism The Clotting Time Is shortened after Ø Sever Haemorrhage. Ø Trauma. Ø Sever Infections ( Typhoid Fever ). Ø Administration of Corticosteroids. Ø Oral Contraceptive. Ø Lipaemia shortens the clotting time and inhibits fibrinolysis. MAK 10
Venous Thrombosis Ø Thrombophlebitis . Ø Phlebothrombosis. MAK 11
Thrombophlebitis is a condition in which there is both inflammation and a blood clot in a vein. Thrombophlebitis can occur in either superficial or deep veins. MAK 12
Phlebothrombosis Ø Ø Ø It is essentially due to Stasis. It may be caused by local injury to the venous endothelium. There is no obvious local infective element. It is common postoperative compliction Frequently encountered in Heart disease. MAK 13
A DVT is a condition where in a blood , clot (thrombus) forms in a vein of the deep system. MAK 14
Pathogenesis of Phlebothrombosis 1. 2. 3. 4. 5. Primary platelet Thrombus. The Coralline Thrombus. Occluding Thrombus. Consecutive Clot. Propagated Clot. MAK 15
Primary Platelet Thrombosis ﺧﺜﺮﺓ ﺍﻟﺼﻔﻴﺤﺎﺕ ﺍﻟﺒﺪﺋﻴﺔ ﺍﻟﺸﺎﺣﺒﺔ Ø Ø Ø Platelet adhere to the vein wall and aggregate to form a pale thrombus. This allows clotting factors to accumulate in the area. Promote an increase in the fibrin element. MAK 16
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Coralline Thrombus ﺍﻟﺨﺜﺮﺓ ﺍﻟﻤﺮﺟﺎﻧﻴﺔ ﺍﻟﻠﻮﻥ A mixed thrombus Ø Ø Ø Due to fibrin deposition on the primary platelet thrombus. Leads to further platelet deposition Consist of alternate layers of fused platelets and fibrin with entrapped blood cells. They are bent in the direction of blood flow. Ripple appearance (Line of Zahn ). MAK 18
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Occluding Thrombs ﺍﻟﺨﺜﺮﺓ ﺍﻟﺴﺎﺩﺓ Ø The growth of coralline thrombus progressively occludes the vein. Ø Composed of blood clot with smaller platelet element. Ø It is red. MAK 20
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Consecutive Clot ﺍﻟﺨﺜﺮﺓ ﺍﻟﻤﺘﻌﺎﻗﺒﺔ Ø Ø Ø Once the vein is occluded The stationary column of blood undergoes coagulation forming a Consecutive clot. When consecutive clot extend to the next venous tributary it may become endothelialised , or there is the development of more thrombus or clot. MAK 22
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Propagated Clot ﺍﻟﺨﺜﺮﺓ ﺍﻟﻤﺘﻤﺎﺩﻳﺔ Ø Ø When clot reaches to the entrance of venous tributary , it may lead to formation of another consecutive clot. Stagnation of column of blood above the consecutive clot may produce propagated clot en mass. MAK 24
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A thrombosis in a deep vein is a much more serious problem than one in a superficial vein. The reason for this is that a piece of the clot in DVT may break off and travel through the deep veins back to the heart, and eventually be pumped by the heart into the arteries of the lung. MAK 30
DVTs can occur anywhere in the body but are most frequently found in the deep veins of the legs, thighs, and pelvis. MAK 31
DVT is a common condition that affects almost 2 million Americans each year. Among patients with DVT, pulmonary embolism will occur in 30%. Pulmonary embolism causes 600, 000 deaths each year. MAK 32
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What Are The Symptoms of a DVT In the affected leg Ø swelling Ø Pain Ø no symptoms at all unless the clot dislodges MAK 34
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Common Sites Affected by Thrombosis Ø Deep Veins of the Calf. Ø It may extend to PTV or the POPV. Ø At the beginning of Femoral Vein. Ø Commonly in Lt CIV due to pressure from the Rt CIA. Ø Following Pelvic Operation. MAK 36
Plsmatic D-dimers Ø Ø Ø Fibrin is the main constituent of a thrombus. Its formation is rapidly followed by activation of fibrionlytic system leading to lysis of fibrin clot. Dissolution of stabilized fibrin releases specific breakdown products D-dimers (DD). MAK 37
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DD assay as a useful first stage diagnostic tool Ø Ø Ø Negative result can rule out thromboembolic event. False positive ( Specificity 40% ). Test used 1. ELISA (Enzyme-linked immunosorbant assays ). 2. Latex tests less sensitive. MAK 39
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Venography MAK 41
MR MAK 42
Special Clinical Types Ø Phlegmasia alba dolens. Ø Phlegmasia Coerulea dolens. Ø Trousseu, s Syndrome. Ø Pregnancy-related thrombosis. MAK 43
Iliac Femoral Vein Thrombosis MAK 44
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Isotope Scan MAK 48
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Ø Local Causes i ) lack of Muscular Activity. ii ) Incompetent Valves. iii ) Pressure from outside ( Tumours, Ascites , Plasters and Bandages. ) MAK 50
Predisposing Factors. 1 Fatal complication of D. V. T. 2. Secondary to non surgical disorders. Ø Congestive Heart Failure. Ø Cerebrovascular Accidents. Ø Chronic Pulmonary Diseases. Ø Systemic Infection. Ø Disseminated Carcinomatosis. Ø Miscellaneous. MAK 51
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Size An emboli prove fatal if it measures 1. 5 cm in diameter and 50 cm or more in length. MAK 54
Areas are commonly affected Rt pulmonary artery is more commonly affected than the left. Ø Lower lobes are more commonly affected than the upper lobes. Ø MAK 55
Origin of PE originated from iliac and femoral veins. Ø 20% originated from I. V. C. , Subclavien, Axillary, Internal jagular, Cavernous Sinuses of the Brain, and Cardiac Tumors arising in the Rt Atrium or Rt Ventricle. Ø 80% MAK 56
Prevention of PE Preventing the occurrence of D. V. T. Ø Early ambulation. Ø Elevation of lower extremities. Ø Elastic stockings. Ø Mechanical compression. Ø Anti platelets agents (Aspirin, Dipyridamol). Ø S/C LMWH Ø Insertion of stainless steel Umbrella ( Greenfield). MAK 57
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Complications of Umbrella ØMigration. ØProtrusion of struts through the Ø caval wall. ØFormation of thrombus. ØMisplacement of the umbrella. ØRetroperitoneal haemorhage. ØPerforation of duodenum and Ø ureter. MAK 60
The Massage As a precaution installation of the Greenfield umbrella should be the treatment of choice to combat the risk of fatal pulmonary embolus whenever possible MAK 61
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