Deep Vein Thrombosis

[CaptainSSO]

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Could someone clarify the particulars of DVT for me? It's just the formation of a single blood clot? Does it stick to the side of a vein or something? I guess I just don't understand why there is such an extensive treatment for it, like compression stockings and anticoagulants, and isn't just surgically removed. Sorry if this isn't the right place for this, I just didn't really know where else to ask.

 

[IMDoc607]

Could someone clarify the particulars of DVT for me? It's just the formation of a single blood clot? Does it stick to the side of a vein or something? I guess I just don't understand why there is such an extensive treatment for it, like compression stockings and anticoagulants, and isn't just surgically removed. Sorry if this isn't the right place for this, I just didn't really know where else to ask.

It is exactly what it says it is. It is a clot in the deep veins. There is an extensive treatment for it because it can be deadly. When you are on rotations, you will see that there is pretty much always DVT prophylaxis. The kind of prophylaxis depends on the patient. You also need to be careful with medications. You can't just start warfarin because you can get skin necrosis because in the coagulation cascade factor 7 has the longest half life. Therefore you must bridge over to coumadin from Heparin till the INR is around 2-3. You also have a choice between Lovenox and Heparin. Depending on their renal function I see lovenox given most frequently.

 

[ZagDoc]

Don't think of veins as solid pipes. Veins are floppy, dynamic. So when there's something "stuck" in it, it tends to stay still by virtue of the elasticity of the wall around it (I think of it like a brick in a sock). It irritates the walls of the vein, inducing inflammatory responses around the clot (which is why you can get pain and erythema arounda DVT). The coagulation and anti-coagulation cascades are dynamic processes, and blood continues to flow around the clot. Think of a glacier in the ocean. There's water flowing around it, eroding away. Heat melts the glacier, frost solidifies it. Occasionally chunks of the glacier can break off and travel away in the water. This is why DVTs can "grow" up into the iliacs and vena cava. It's why chunks can break off and throw a PE.

Part of the reason DVT prophylaxis is such a big deal is political ("never events" and the like). But part of it is that PE can be such a sudden, irreversibly deadly event. I've seen a patient die of a PE in-house... they have that look of "impending doom", eyes wide, gasping for air. It's something you'll never forget.

Don't know of the correct answer in regards your to question about surgically removing it, but my suspicion is that it's been studied and its a risk/reward issue. By disturbing the clot, you risk throwing an embolus downstream, most clots form in the DEEP veins (by virtue of the name) so it's not an easily accessible site, post-op complications, etc.

 

[username456789]

Could someone clarify the particulars of DVT for me? It's just the formation of a single blood clot? Does it stick to the side of a vein or something? I guess I just don't understand why there is such an extensive treatment for it, like compression stockings and anticoagulants, and isn't just surgically removed. Sorry if this isn't the right place for this, I just didn't really know where else to ask.

It's common for them to form at/near/on the VALVES in the veins as well. And yes, the risk for them embolizing to the lungs is the main concern, as it can cause very acute complications (including death).

As Zag said, it seems a bit of overkill to operate on a patient you have identified as having a DVT, particularly since the drastically increase a patient's morbidity with any type of surgery (especially when accessing DEEP veins). You can usually get a patient anticoagulated fairly quickly with the medications available.

 

[Droopy Snoopy]

Don't forget that in that segment of the population with PFOs (10-25% depending on your source) an embolism originating from a DVT has the potential to hit your cerebrovascular structures as well. Dying from a PE is bad, but I would argue that living with a huge stroke or blindness might be worse. In a courtroom at least the jury is going to look from the rich doctor on the stand to the blind guy drooling on the plaintiff's table and take about 5 seconds to cripple your career.

Either way it's a significant and preventable cause of nosocomial M&M along with infection, GI ulceration, and skin breakdown. I would encourage you guys to get into the habit of making three things standard on every problem list and note: code status, discharge planning, and prophylaxis of those four issues. You'd be surprised how often we overworked residents and staff focus on the primary management and end up overlooking the so-called 'little' things that invariably keep a person in the hospital an extra day or ten.