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| {{Thrombosis}} | | {{Thrombosis}} |
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| {{CMG}} | | {{CMG}} |
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| | '''Associate Editors-in-Chief:''' [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org] |
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| ==[[Thrombosis overview|Overview]]== | | ==[[Thrombosis overview|Overview]]== |
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| ==Causes== | | ==[[Thrombosis etiology|Etiology]]== |
| Classically, thrombosis is caused by abnormalities in one or more of the following ([[Rudolf Virchow|Virchow]]'s triad):
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| * The composition of the blood (hypercoagulability)
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| * Quality of the vessel wall (endothelial cell injury)
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| * Nature of the blood flow (hemostasis)
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| The formation of a thrombus is usually caused by the top three causes, known as Virchow's triad. To elaborate, the pathogenesis includes: an injury to the vessel's wall (such as by trauma, infection, or turbulent flow at bifurcations); by the slowing or stagnation of blood flow past the point of injury (which may occur after long periods of sendentary behavior - for example, sitting on a long airplane flight; by a blood state of hypercoagulability (caused for example, by genetic deficiencies or autoimmune disorders).
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| High altitude has also been known to induce thrombosis [http://dx.doi.org/10.1371/journal.pmed.0040290][http://www.mounteverest.net/news.php?news=16349]. Occasionally, abnormalities in [[coagulation]] are to blame.
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| Intravascular [[coagulation]] follows, forming a structureless mass of [[red blood cell]]s, [[leukocyte]]s, and [[fibrin]].
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| | | ==[[Thrombosis classification|Classification]]== |
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| ==Classification== | |
| There are two broad forms of thrombosis, [[arterial thrombosis|arterial]] and [[venous thrombosis|venous]]. They are somewhat distinct in their underlying pathophysiology, but there is also a degree of overlap in the underlying pathophysiology.
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| You can read more about each of the conditions separately here:
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| {{main|Arterial thrombosis}} | | {{main|Arterial thrombosis}} |
| {{main|Venous thrombosis}} | | {{main|Venous thrombosis}} |
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| ==Locations at risk of arterial thrombosis== | | ==Site of Thrombosis== |
| *[[Carotid artery]]
| | {{Thrombosis possible site arterial|Arterial}} | {{Thrombosis possible site venous|Venous}} |
| *[[Coronary artery]]
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| *[[Intracerebral artery]]
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| *[[Mesenteric artery]]
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| *[[Peripheral artery]]
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| *[[Placental artery]]
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| *[[Pulmonary embolization]]
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| *[[Retinal artery]]
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| *[[Vertebral artery]]
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| ==Locations at risk of venous thrombosis==
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| *Bones (particularly hip and jaw)
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| *[[Brachial vein]]
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| *[[Budd-Chiari syndrome|hepatic vein thrombosis]] (Budd-Chiari syndrome)
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| *[[Cerebral venous sinus thrombosis]]
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| *[[Deep venous thrombosis]] (with or without [[pulmonary embolism]]; together classified as '''venous thromboembolism'''/VTE)
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| *[[Mesenteric vein]]
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| *[[Paget-Schroetter disease]] (upper extremity vein)
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| *[[Placental vein]]
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| *[[Portal vein thrombosis]]
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| *[[Pulmonary vein]]
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| *[[Renal vein thrombosis]]
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| *[[Retinal vein]]
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| *[[Superior vena cava syndrome]]
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| *[[Thoracic outlet syndrome]] (the cause of most [[Subclavian Vein]] Thrombosis unrelated to trauma)
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| ==Differential diagnosis of causes of arterial thrombosis==
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| *[[Abruptio placentae]]
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| *[[Arteritis]]
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| *[[Atherosclerosis]]
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| *[[Cancer]] (particularly [[pancreatic cancer]])
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| *Catheters (indwelling in the venous bloodstream)
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| *[[Cholesterol embolization]]
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| *[[Diabetes mellitus]]
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| *[[Eclampsia]]
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| *[[Embolization]] including [[cholesterol embolization]]
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| *Genetics
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| *[[Hyperlididemia]]
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| *[[Hypertension]]
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| *[[Pre-eclampsia]]
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| *[[Smoking]]
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| *[[Stent]]
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| *[[Thoracic outlet syndrome]]
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| *[[Vasculitis]]
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| ==Differential diagnosis of causes of venous thrombosis==
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| *[[Cancer]] (particularly [[pancreatic cancer]])
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| *Catheters (indwelling in the venous bloodstream)
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| *Estrogen replacement therapy
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| *Factor deficiency
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| *Fracture
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| *Hip surgery
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| *Knee surgery
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| *Oral contraceptives
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| *[[Pregnancy]]
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| *[[Protein C deficiency]]
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| *[[Protein S deficiency]]
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| *Steroids
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| *[[Superior vena cava syndrome]]
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| *Surgery (release of tissue factor, immobilization)
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| *[[Thoracic inlet syndrome]]
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| ==Complications of thrombosis including embolization==
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| If a bacterial infection is present at the site of thrombosis, the thrombus may break down, spreading particles of infected material throughout the [[circulatory system]] ([[pyemia]], [[septic embolus]]) and setting up metastatic abscesses wherever they come to rest. Without an infection, the thrombus may become detached and enter circulation as an [[embolus]], finally lodging in and completely obstructing a blood vessel (an [[infarction]]). The effects of an infarction depend on where it occurs.
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| Most thrombi, however, become [[Fibrinolysis|organized into fibrous tissue]], and the thrombosed vessel is gradually recanalized.
| | ==[[Thrombosis differential diagnosis|Differential diagnosis]]== |
| | {{Thrombosis differential diagnosis arterial|Arterial}} | {{Thrombosis differential diagnosis venous|Venous}} |
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| ==Diagnostic evaluation of underlying cause== | | ==[[Thrombosis complications|Complications]]== |
| '''cDNA-PCR assays for gene mutations and polymorphisms:'''
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| :*4G/5G [[polymorphism]] of the [[plasminogen activator inhibitor]]-1 gene (PAI-1)
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| :*[[Cystathionine beta synthetase]] (CBS) CBS T833C & G919A
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| :*[[Factor V Leiden]]
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| :*[[Glycoprotein IIIa]] A1/A2 (platelet glycoprotein)
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| :*[[Methylenetetrahydrofolate reductase]] (MTHFR) MTHFR C677T
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| :*[[Prothrombin]] G20210A
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| '''Serologic (blood) tests:'''
| | ==[[Thrombosis risk stratification|Risk Stratification]]== |
| :*[[Anticardiolipin antibodies]] (ACLA) IgG and IgM ACLA
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| :*[[Antithrombin III]]
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| :*[[Factor VIII]]
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| :*[[Homocysteine]]
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| :*[[Lupus anticoagulant]] (LA)
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| :*[[Proteins C]]
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| :*[[Protein S]]
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| '''Evaluation of hypofibrinolysis'''
| | ==[[Thrombosis risk prognosis|Prognosis]]== |
| :*4G/5G [[polymorphism]] of the [[plasminogen activator inhibitor]]-1 gene ([[PAI-1]])(requires cDNA-PCR assay for gene mutation)
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| :*[[Lipoprotein a]] [[Lp(a)]]
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| ==Prevention== | | ==[[Thrombosis diagnostic evaluation|Diagnostic evaluation]]== |
| Thrombosis and embolism can be partially prevented with anticoagulants in those deemed at risk. Generally, a risk-benefit analysis is required, as all anticoagulants lead to a small increase in the risk of major bleeding. In [[atrial fibrillation]], for instance, the risk of [[stroke]] (calculated on the basis of additional risk factors, such as advanced age and [[hypertension|high blood pressure]]) needs to outweigh the small but known risk of major bleeding associated with the use of [[warfarin]].<ref>{{NICE|36|Atrial fibrillation|June 2006}}</ref>
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| In people admitted to hospital, thrombosis is a major cause for complications and occasionally death. In the UK, for instance, the Parliamentary [[Health Select Committee]] heard in 2005 that the annual rate of death due to hospital-acquired thrombosis was 25,000.<ref name=Hunt>{{cite journal |author=Hunt BJ |title=Awareness and politics of venous thromboembolism in the United kingdom |journal=Arterioscler. Thromb. Vasc. Biol. |volume=28 |issue=3 |pages=398–9 |year=2008 |month=March |pmid=18296598 |doi=10.1161/ATVBAHA.108.162586 |url=http://atvb.ahajournals.org/cgi/content/full/28/3/398}}</ref> In patients admitted for surgery, graded [[compression stockings]] are widely used, and in severe illness, prolonged immobility and in all [[orthopedic surgery]], [[clinical practice guideline|professional guidelines]] recommend [[low molecular weight heparin]] administration, mechanical calf compression or (if all else is contraindicated and the patient has recently suffered deep vein thrombosis) the insertion of a [[Inferior vena cava filter|vena cava filter]].<ref>{{NICE|46|Venous thromboembolism (surgical)|April 2007}}</ref><ref name=ACCP>{{cite journal |author=Geerts WH, Pineo GF, Heit JA, ''et al'' |title=Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy |journal=Chest |volume=126 |issue=3 Suppl |pages=338S–400S |year=2004 |month=September |pmid=15383478 |doi=10.1378/chest.126.3_suppl.338S |url=http://www.chestjournal.org/cgi/content/full/126/3_suppl/338S}}</ref> In patients with medical rather than surgical illness, LMWH too is known to prevent thrombosis,<ref name=ACCP/><ref>{{cite journal |author=Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA |title=Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients |journal=Ann. Intern. Med. |volume=146 |issue=4 |pages=278–88 |year=2007 |month=February |pmid=17310052 |url=http://www.annals.org/cgi/reprint/146/4/278.pdf |format=PDF}}</ref> and in the United Kingdom the [[Chief Medical Officer (United Kingdom)|Chief Medical Officer]] has issued guidance to the effect that preventative measures should be used in medical patients, in anticipation of formal guidelines.<ref name=Hunt/>
| | ==[[Thrombosis prevention|Prevention]]== |
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| ==See also== | | ==See also== |
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