1. Modern Management of
Deep Vein Thrombosis
Dr. Sharfuddin Chowdhury
Department of Surgery
Groote Schuur Hospital and University of Cape Town

2. Introduction
• Deep Vein Thrombosis (DVT) refers to the formation of clot in the
deep veins of the extremities or pelvis due to a disordered balance
between the thrombotic and fibrinolytic systems.
• There are three possible sequele following a DVT:
 Acute Pulmonary Thrombo-Embolism (PTE)
 Complicated DVT (Phlegmasia; venous gangrene)
 The Post-Thrombotic Syndrome (PTS) .

3. Epidemiology
• Worldwide 70-113 cases per 100,000 per year
• No conclusive gender difference, however recurrence is
M>F
• Equally frequent among Whites and Blacks.
• More common during winter months by 10% - 15%
compared to summer months.

4. Epidemiology
• Prevalence of DVT in hospitalized patient groups
Spinal cord injury 60-80%
Major trauma 40-80%
Hip/Knee arthoplasty or hip fracture surgery 40-60%
Critical care 10-80%
Stroke 20-50%
General surgery 15-40%
Major gynaecological surgery 15-40%
Neurosurgery 15-40%
Major urologic surgery 15-40%
Medical patients 10-20%

5. Classification
• Acute (< 2 weeks)
• Recurrent DVT
• Anatomical
Bilateral
Ilio-femoral (L) ilio-femoral
Multi segmental
Profunda femoris vein
Femoro-popliteal
Proximal
Knee
Distal

6. Clinical Presentation
Acute DVT may present as
Asymptomatic
Symptomatic
Complicated Phlegmasia Caerulea dolens (PCD)
Alba dolens (PAD)
PTE
Symptoms:
Pain- exacerbated by ambulation, relieved by rest
Swelling- below knee (distal DVT), Up to groin (proximal DVT)
Erythema

7. Diagnosis of DVT

8. Diagnosis of DVT
• Pre-test probability:
A meta analysis involving more than 5000 patients with suspected DVT from 12
clinical trials and systematic reviews showed that the combination of normal D-
dimer and low clinical probability for DVT safely rules out the diagnosis of DVT.
Level of Evidence: High (1A)
Modified Wells Score Score
Modified Wells Score
Paresis, Paralysis or recent leg plaster immobilization 1
Active cancer (on going chemotherapy or within 6 months or palliative treatment) 1
Recent immobilization/ bed rest (> 3 days) or recent surgery (within 4 weeks) 1
calf circumference > 3 cm on affected side compared with normal side 1
Localized tenderness along the deep venous system distribution 1
Entire leg swollen 1
Pitting oedema of only the symptomatic leg 1
Collateral superficial veins (non-varicose) 1
Prior history of DVT 1
Alternative diagnosis at least as likely as DVT (ruptured Baker’s cyst,RA,Cellulitis -2
etc.)
Score 0= Low risk, 1-2=Moderate risk, 3 or above = High risk

9. D-Dimer
 D-dimer is a specific degradation product of cross-linked
fibrin.
 Sensitive but non specific marker
 False-positive D-dimers occur in patients with
o Recent (within 10 days) surgery or trauma,
o Recent myocardial infarction or stroke,
o Acute infection,
o Disseminated intravascular coagulation,
o Pregnancy or recent delivery,
o Active collagen vascular disease, or metastatic cancer

10. Imaging
Imaging Advantages Disadvantages
Modality
Compression Sensitivity 97-100% and specificity of Difficult to perform in patients with
Ultrasound 98-99% for proximal DVT morbid obesity, severe oedema, casts
or other immobilization devices
Non invasive, repeatable and widely
available Decrease ability to visualize the
Popliteal fossa in cases of distal DVT
Higher sensitivity in detecting distal
thrombosis Operator dependent
CT Non invasive Limited data
Venography Can diagnose Pelvic DVT
Concurrently exclude PE
MRV Highly accurate Expensive
Safe during Pregnancy Not readily available
Non-invasive
Contrast “Gold Standard” Invasive
Venography Sensitivity approaches 100% Requires specialized equipment
Easily interpretable Rare but serious side effects

11. Imaging
Imaging Advantages Disadvantages
Modality
Compression Sensitivity 97-100% and specificity of Difficult to perform in patients with
Ultrasound 98-99% for proximal DVT morbid obesity, severe oedema, casts
or other immobilization devices
Non invasive, repeatable and widely
available Decrease ability to visualize the
Popliteal fossa in cases of distal DVT
Higher sensitivity in detecting distal
thrombosis Operator dependent
CT Non invasive Limited data
Venography Can diagnose Pelvic DVT
Concurrently exclude PE
MRV Highly accurate Expensive
Safe during Pregnancy Not readily available
Non-invasive
Contrast “Gold Standard” Invasive
Venography Sensitivity approaches 100% Requires specialized equipment
Easily interpretable Rare but serious side effects

12. Imaging
Imaging Advantages Disadvantages
Modality
Compression Sensitivity 97-100% and specificity of Difficult to perform in patients with
Ultrasound 98-99% for proximal DVT morbid obesity, severe oedema, casts
or other immobilization devices
Non invasive, repeatable and widely
available Decrease ability to visualize the
Popliteal fossa in cases of distal DVT
Higher sensitivity in detecting distal
thrombosis Operator dependent
CT Non invasive Limited data
Venography Can diagnose Pelvic DVT
Concurrently exclude PE
MRV Highly accurate Expensive
Safe during Pregnancy Not readily available
Non-invasive
Contrast “Gold Standard” Invasive
Venography Sensitivity approaches 100% Requires specialized equipment
Easily interpretable Rare but serious side effects

13. Imaging
Imaging Advantages Disadvantages
Modality
Compression Sensitivity 97-100% and specificity of Difficult to perform in patients with
Ultrasound 98-99% for proximal DVT morbid obesity, severe oedema, casts
or other immobilization devices
Non invasive, repeatable and widely
available Decrease ability to visualize the
Popliteal fossa in cases of distal DVT
Higher sensitivity in detecting distal
thrombosis Operator dependent
CT Non invasive Limited data
Venography Can diagnose Pelvic DVT
Concurrently exclude PE
MRV Highly accurate Expensive
Safe during Pregnancy Not readily available
Non-invasive
Contrast “Gold Standard” Invasive
Venography Sensitivity approaches 100% Requires specialized equipment
Easily interpretable Rare but serious side effects

14. Diagnostic Algorithms
SUSPECTED DVT
Pre-test clinical probability
Low / moderate probability
D-Dimer assay
Negative Positive/Equivocal
No Treatment Venous US
Negative Positive Equivocal
No Treatment Treatment MRI/CV
Negative Positive
No Treatment Treatment

15. Diagnostic Algorithms
SUSPECTED DVT
Pre-test clinical probability
High probability
Compression US
Negative Positive Equivocal
Serial US 5-7 days
Negative Positive
No Treatment Treatment Treatment MRI/CTV
Negative Positive
No Treatment Treatment

16. Prevention / Prophylaxis

17. Prevention / Prophylaxis

18. Factor Xa inhibitors
• Fondaparinux • Rivaroxaban
• Synthetic analogue of • Direct, selective and
antithrombin-binding reversible inhibitors of Xa.
pentasaccharide • Orally with acceptable
sequence. safety profile.
• Doesn’t cause • No monitoring needed.
Thrombocytopenia, • Non-valvular Afib. Ortho
Osteoporosis. VTE Proph.
• Dosing • Dose: 10 mg OD
2.5mg od for prophylactic VTE
7.5mg od for established VTE
5mg <50kg,10mg >100kg

19. Direct thrombin inhibitors
• Hirudin • Dabigatran
• Heparin and LMWH are • Oral DTI
indirect inhibitors of
thrombin. • Indications:
AF,
• DTI do not require a
Ortho VTE Prophylaxis
plasma cofactor. Bind
directly to thrombin and
block its interaction with • Dose: 150-200mg od
its substrates.
• Monitoring not needed.
• Use: HIT , PCI

20. Grades of Recommendation
Grade Description of 2012 ACCP grade
1A Strong recommendation, high-quality evidence
1B Strong recommendation, moderate-quality evidence
1C Strong recommendation, low- or very-low-quality evidence
2A Weak recommendation, high-quality evidence
2B Weak recommendation, moderate-quality evidence
2C Weak recommendation, low- or very-low-quality evidence

21. Prophylaxis (ACCP Guidelines 2012)
• Recommended Prophylaxis in surgical patients according to the estimated
level of risks (ACCP Guidelines 2012)
A. GENERAL AND ABDOMINO PELVIC SURGERY
Risk level Prophylaxis
Very low risk Early mobilization
Low risk IPC (2C)
Moderate risk LMWH, LDUH (2B) or IPC (2C)
High risk LMWH / LDUH (1B) and IPC / ES (2C)
Cancer surgery- LMWH 4 weeks (1B)
IPC until risk of bleeding diminishes and LMWH /
LDUH may be initiated

22. Prophylaxis (ACCP Guidelines 2012)
• Major Trauma:
Traumatic brain injury, acute spinal injury: UH, LMWH or IPC
High risk: IPC and UH / LMWH
(When not contraindicated by lower extremity injury)
• Orthopaedic Surgery:
Major Surgery (THA / TKA / HFS):
> In hospital dual prophylaxis with antithrombotic agent (1B) and IPC (2C)
> extended thromboprophylaxis in out patient period for up to 35 days (2B)
> In case of increased risk of bleeding – IPC
> Patients declining or uncooperative with injections: Apixaban, Dabigatran,
Rivaroxiban, or dose adjusted VKA
 IVC Filter should not be used for primary VTE prevention (2C)
 Periodic surveillance with venous compression ultrasound should
not be performed (2C)

23. Management of DVT
Key recommendations according to ACCP Guidelines 2012
Distal DVT :
A. No, mild or moderate symptoms and no risk for clot extension:
No anticoagulation
Serial doppler US over next 2 weeks to exclude clot extension (2C)
B. Severe Symptoms:
Anticoagulation 3 months (2C)
Proximal DVT:
> Anticoagulation 3 months (1B)
Enoxaparin(bd) (2B) or Dalteparin/Tinzaparin/Fondaparinux (od) (2C)
Followed by Warfarin rather than Dabigatran or Rivaroxaban
> No routine use of thrombolytics or thrombectomy (2C)
> Treat as an outpatient, if feasible

24. Management of DVT
• Incidentally discovered (Asymptomatic DVT)
> Leg, pelvic or vena cava thrombosis – Anticoagulation
3 months(2B)
> Abdominal (portal, splenic, mesenteric or hepatic vein)
thrombosis-no anticoagulation (2C)
• Cancer associated DVT:
> Anticoagulation at least 3 months, preferably long term
unless bleeding risk is very high (1B)
> LMWH is the preferred treatment, rather than Warfarin
(2B)

25. Management of DVT
• Arm DVT:
> Axillary or more proximal veins- anticoagulation alone 3
months (1B) rather than thrombolysis (2C)
> DVT associated with central venous catheter:
Do not remove functional catheter and anticoagulate (2C)
if catheter is removed continue anticoagulation 3 months
thereafter.
• Superficial thrombophlebitis:
Superficial thrombophlebitis of leg of at least 5 cm length-
Prophylactic dose of Fondaparinux or LMWH for 45 days
(2B).

26. Management of DVT
•Vena cava filter (=IVC filter):
> should only be placed in the patient with acute DVT
where anticoagulation is contraindicated (1B)
> a permanent IVC filter, of itself, is not an indication for
extended anticoagulation.
•Compression stockings:
at least 2 years to prevent or minimize PTS (2C)
If at 2 years patient has bothersome symptoms of PTS
(Pain, swelling), continue to wear for symptoms relief

27. IVC Filters
• Indications:
– Absolute contraindication to therapeutic
anticoagulation
– Failure of anticoagulation
• Relative Indications:
– recurrent VTE on anticoagulation,
– Recurrent PE with pulmonary hypertension,
– Extensive free-floating ilio-femoral thrombus, and
– Post-thrombolysis of ilio-caval thrombus.

28. IVC Filters- Classification
– Temporary filters are attached to a catheter that
exits the skin
– Retrievable filters are similar in design to permanent
filters but are designed to be removed.

29. IVC Filters – Different Types
A. Stainless steel
Greenfield filter
B. Modified hook titanium
Greenfield filter
C. Bird’s nest filter
D. Simon Nitinol filter
E. Vena tech filter

30. Filter Placement & Location
• Angiographic imaging of the IVC: characterise
IVC anatomy, exclude the presence of IVC
thrombus.
• Inserted percutaneously via the femoral or
jugular approach under fluoroscopy guidance.
INFRARENAL
90% of clinically significant PE originates
from the lower extremity or pelvic veins, optimally
immediately below the renal veins to minimize
dead space if filter becomes thrombosed or IVC
thrombus to form.

31. Filter Placement-Location
Suprarenal placement:
Duplicated IVC
Large volume of thrombus
within the infrarenal IVC
Extrinsic compression (!
Pregnancy/Young females)

32. Filter Placement-Location
Bilateral Iliac Vein:
Megacava
Duplicated IVC
Retroaortic left renal vein
component that drains into the
IVC close to the iliac venous
confluence

33. Complications of IVC Filters
Recurrent PE 2-5%
Fatal PE 0.7%
Venous Access site thrombosis 2-28%
Filter migration 3-69%
IVC wall penetration 9-24%
IVC obstruction 6-30%
Filter fracture 1%
– Christopher J. Kwolek MD, Division of vascular and endo vascular surgery, Massachuatts General Hospital,

34. Anticoagulation after Filter Placement
 Whether concomitant anticoagulation therapy should
be utilized following filter placement is unknown.
 Patients with IVC filters are at risk for
– IVC thrombosis,
– insertion site thrombosis and
– recurrence of the initial thromboembolic event
 ACCP Guidelines suggest the use of conventional
anticoagulation therapy if the risk of bleeding
resolves. (2B)

35. IVC Filter-Retrieval
Success depends on:
• filter dwell time
• amount of hook/strut/leg
penetration and endothelialization
• accessibility of the retrieval hook
Turba et al report a 95% success
rate for the GT Filter even with
filters in place for more than 6
months. (Feb 2010 Endovascular today)

36. Methods of Thrombus Removal

37. Early Thrombus Removal
-Ilio-femoral DVT
• 2008 Guidelines- In favour of CDT (2B)
• 2012 Guidelines- Against CDT (2C)
BUT-
 DVT causes severe leg pain and
swelling
 With anticoagulation, the period before
improvement varies
 Difficulty ambulating and returning to
full activity impair QOL

38. • Patient with ileo-femoral DVT (CFV and/or Iliac vein)
develop PTS 60% of the time
Author / year Journal N 2year PTS
Prandoni 1996 Ann Intern Med 355 23%
Brandjes 1997 Lancet 96 23%
Prandoni 2004 Ann Intern Med 90 25%
Partsch 2004 Int J Angiol 37 46%
Van Dongen 2005 J Thromb Haemost 244 30%
Kahn 2008 Ann Intern Med 387 60%
Enden 2012 Lancet 99 56%

39. • Does immediate clot removal speed symptom relief, save
valves, preserve patency and prevent PTS?
Single- Centre RCTs Multicentre RCT - CaVenT Study
 A 35-patient RCT found CDT with  189 patients with femoral, common
streptokinase to provide better 6- femoral, or iliac DVT: CDT + AC/comp
month venous patency (72% vs 12%, p vs AC/comp alone
< 0.01) and less valvular reflux (11%
vs 41%, p = 0.042) – Enden T et al. Lancet 2012; 379:31-38
– Elsharawy M et al. Eur J Vasc Endovasc Surg
2-year PTS was significantly reduced
2002.
with use of CDT (41.1% versus 55.6%
 A 183-patient RCT found CDT-PCDT to Control, p = 0.047)
reduce 6-month PTS (3.4% vs 27.2%, p
Limitations: sample size, used CDT (not PCDT)
< 0.001) and recurrent VTE (2.3%
versus 14.8%, p = 0.003)
– Sharifi M et al. Cathet Cardiovasc Interv
2010.

40. A multicentre randomized trial on Acute venous Thrombosis :
Thrombus Removal with Adjunctive Catheter directed Thrombolysis
(ATTRACT) trial sponsored by The National Heart Lung and Blood
Institute (NHLBI),U.S.
As of:: July 3, 2012, 312 Patients have been enrolled

41. Catheter Directed Thrombolysis (CDT)
• Indications:
Acute ilio-femoral DVT
Multi level DVT
Massive DVT (Phlegmasia)
< 10 days old
• Contraindications:
Absolute Strong Relative Other Relative
Active bleeding / DIC Recent Major Surgery Renal failure
Recent CVA / TIA Major Trauma(<10 days) Severe hepatic dysfunction
Neurosurgery or Eye surgery (<3 months) Bacterial endocarditis
Intracranial Trauma Major GIT bleed (<3 mo) Diabetic haemorrhagic
(<3 months) Uncontrolled HPT(>180) Retinopathy
Recent delivery (<10 d) Pregnancy or lactation
ICSOL or seizure disorder
Recent CPR (< 10 d)

42. CDT- Procedure
• In cath lab
• Under Local Anaesthesia
• Straight flush angio-cath with multiple sideholes
• The catheter tip is placed into the clot
• Initial lysis with rt PA 10mg diluted in 200ml NS
• Followed by rt PA infusion 1mg/hr(40 mg in 1L NS @ 25ml/hr)for 24hrs.
• In addition Heparin infusion 500 U/hr to prevent catheter thrombosis
• Monitor APTT (Therapeutic 2.5 X control) & Fibrinogen level 6hrly
• Stop infusion if Fibrinogen levels < 2mg/dl
• Ascending phlebogram before removal of catheter
• Commence full anticoagulation & Warfarin after thrombus clearance

43. Angio Jet / Pulse Power Spray
• The Angio Jet catheter system is comprised of a single –
use catheter, single use pump set and a drive unit
• Small pulses of high dose lytic agent delivered through a
multi-side hole catheter with a guide wire occluding the end
hole.
• Jets create a localized low pressure zone at the catheter tip
macerating thrombus and redirecting flow and debris into
outflow channels directed behind the catheter tip for
aspiration and removal.
• Success in thrombus removal, restoration of venous
patency, and preservation of valvular function and low
haemorrhagic complications has been demonstrated.
Example and principle of Angio Jet Power-Pulse
spray for DVT (Courtesy of Possis Medical, Inc.,
• Expensive Minneapolis, MN.)

44. Trellis-8 Infusion System
• The double balloon catheter is inserted into the
thrombosed venous segment with the proximal
balloon positioned at the upper edge of the thrombus.
• Balloons are inflated and rtPA is infused into the
thrombosed segment isolated by the balloons.
• The intervening catheter spins at 1500 rpm for 15-20
mins.
• The liquefied and fragmented thrombus is aspirated.
Example of Trellis-8
infusion catheter for DVT.
(Courtesy of Bacchus
• Success evaluated by repeats segmental Vascular, Inc., Santa Clara,
CA.)
phlebography

45. Ultrasound Accelerated Thrombolysis
• In combination with CDT
• Does not directly macerate the clot
• Create micro streams, increase
thrombus permeability results in
augmented lytic dispersion within the
thrombus.
• Parikh et al reported their initial
experience with EKOS Endo wave
system accelerated thrombolysis in
53 patients. Complete lysis
(>90%)was observed in 70%, overall
in 91%, median infusion time was 22
Example and principle of the EKOS
hours, treatment time and the dose of
ultrasound facilitated thrombolysis
lytic agents were reduced. (Courtesy of EKOS Corp., Bothell, WA.)
J Vasc Interv Radiol 2008 19:521-528

46. Adjunctive Venoplasty and Stenting
• Adequate treatment of anatomic
compression, stenosis, or persistent small
thrombus after CDT or PMT requires
angioplasty and stenting.
• May Thurner syndrome (compression of
left CIV by right CIA against L5) is the most
common anatomic variant.
• With anti coagulation alone, untreated iliac
vein obstruction prevents vessel
recanalization in 70-80% of patients and Venogram 6 weeks following EKOS
clot propagation may continue up to 40%. and AngioJet with stent in left
common iliac vein. Vein is widely
patent without thrombus in filter
which was removed

47. Venous Thrombectomy
• Venous Thrombectomy is
falling out of favour.
• For pts. with CI to
pharmacological thrombolysis
or
• Those in whom other
modalities have failed in the
setting of PCD
• Under GA, Groin exposure,
Venotomy, venous balloon
catheter to extract thrombus.
.

48. Conclusion
• Acute DVT should be viewed as a chronic disease due to
substantial long-term patient disability.
• Anticoagulation remains the cornerstone of prevention and
treatment of DVT.
• Newer anti coagulants may simplify therapeutic paradigms
and are expected to improve overall clinical outcome.
• IVC filters should not be used routinely to prevent PE.
• Most ACCP recommendations are weak 2B/C.
• Catheter-based endovascular therapies offer the potential to
preserve life and limb.
• ATTRACT trial results awaited.

49. THANKYOU.