Deep vein thrombosis natural history, complications and prognosis: Difference between revisions
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| [[File:Siren.gif|30px|link=Deep vein thrombosis resident survival guide]]|| <br> || <br> | |||
| [[Deep vein thrombosis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] | |||
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'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' {{CZ}} [[User:Kashish Goel|Kashish Goel, M.D.]]; '''Assistant Editor(s)-In-Chief:''' [[User:Justine Cadet|Justine Cadet]] | '''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' {{CZ}} [[User:Kashish Goel|Kashish Goel, M.D.]]; '''Assistant Editor(s)-In-Chief:''' [[User:Justine Cadet|Justine Cadet]] | ||
{{Deep vein thrombosis}} | {{Deep vein thrombosis}} | ||
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==Natural History== | ==Natural History== | ||
* Many patients with a [[deep vein thrombosis]] (DVT) originating in the calf veins are asymptomatic until proximal vein involvement.<ref name="pmid12814982">{{cite journal |author=Kearon C |title=Natural history of venous thromboembolism |journal=[[Circulation]] |volume=107 |issue=23 Suppl 1 |pages=I22–30 |year=2003 |month=June |pmid=12814982 |doi=10.1161/01.CIR.0000078464.82671.78 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12814982 |issn=}}</ref> | * Many patients with a [[deep vein thrombosis]] (DVT) originating in the calf veins are asymptomatic until proximal vein involvement.<ref name="pmid12814982">{{cite journal |author=Kearon C |title=Natural history of venous thromboembolism |journal=[[Circulation]] |volume=107 |issue=23 Suppl 1 |pages=I22–30 |year=2003 |month=June |pmid=12814982 |doi=10.1161/01.CIR.0000078464.82671.78 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12814982 |issn=}}</ref> However, even assymptomatic DVTs are associated with increased risk of death<ref name="pmid30419597">{{cite journal| author=Kalayci A, Gibson CM, Chi G, Yee MK, Korjian S, Datta S et al.| title=Asymptomatic Deep Vein Thrombosis is Associated with an Increased Risk of Death: Insights from the APEX Trial. | journal=Thromb Haemost | year= 2018 | volume= 118 | issue= 12 | pages= 2046-2052 | pmid=30419597 | doi=10.1055/s-0038-1675606 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30419597 }} </ref>. | ||
* About half of all calf DVTs resolve spontaneously, without intervention.<ref name="pmid12814982">{{cite journal |author=Kearon C |title=Natural history of venous thromboembolism |journal=[[Circulation]] |volume=107 |issue=23 Suppl 1 |pages=I22–30 |year=2003 |month=June |pmid=12814982 |doi=10.1161/01.CIR.0000078464.82671.78 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12814982 |issn=}}</ref> | * About half of all calf DVTs resolve spontaneously, without intervention.<ref name="pmid12814982">{{cite journal |author=Kearon C |title=Natural history of venous thromboembolism |journal=[[Circulation]] |volume=107 |issue=23 Suppl 1 |pages=I22–30 |year=2003 |month=June |pmid=12814982 |doi=10.1161/01.CIR.0000078464.82671.78 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12814982 |issn=}}</ref> | ||
* One-sixth of all calf DVTs progress to involvement with the proximal veins.<ref name="pmid12814982">{{cite journal |author=Kearon C |title=Natural history of venous thromboembolism |journal=[[Circulation]] |volume=107 |issue=23 Suppl 1 |pages=I22–30 |year=2003 |month=June |pmid=12814982 |doi=10.1161/01.CIR.0000078464.82671.78 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12814982 |issn=}}</ref> | * One-sixth of all calf DVTs progress to involvement with the proximal veins.<ref name="pmid12814982">{{cite journal |author=Kearon C |title=Natural history of venous thromboembolism |journal=[[Circulation]] |volume=107 |issue=23 Suppl 1 |pages=I22–30 |year=2003 |month=June |pmid=12814982 |doi=10.1161/01.CIR.0000078464.82671.78 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12814982 |issn=}}</ref> | ||
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** Other research suggests that approximately one-fourth of all patients die within one year of venous thrombosis onset.<ref name="pmid12814982">{{cite journal |author=Kearon C |title=Natural history of venous thromboembolism |journal=[[Circulation]] |volume=107 |issue=23 Suppl 1 |pages=I22–30 |year=2003 |month=June |pmid=12814982 |doi=10.1161/01.CIR.0000078464.82671.78 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12814982 |issn=}}</ref> | ** Other research suggests that approximately one-fourth of all patients die within one year of venous thrombosis onset.<ref name="pmid12814982">{{cite journal |author=Kearon C |title=Natural history of venous thromboembolism |journal=[[Circulation]] |volume=107 |issue=23 Suppl 1 |pages=I22–30 |year=2003 |month=June |pmid=12814982 |doi=10.1161/01.CIR.0000078464.82671.78 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12814982 |issn=}}</ref> | ||
** Patients presenting with a venous thrombosis consistently have higher in-hospital mortality rates.<ref name="pmid12814982">{{cite journal |author=Kearon C |title=Natural history of venous thromboembolism |journal=[[Circulation]] |volume=107 |issue=23 Suppl 1 |pages=I22–30 |year=2003 |month=June |pmid=12814982 |doi=10.1161/01.CIR.0000078464.82671.78 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12814982 |issn=}}</ref> | ** Patients presenting with a venous thrombosis consistently have higher in-hospital mortality rates.<ref name="pmid12814982">{{cite journal |author=Kearon C |title=Natural history of venous thromboembolism |journal=[[Circulation]] |volume=107 |issue=23 Suppl 1 |pages=I22–30 |year=2003 |month=June |pmid=12814982 |doi=10.1161/01.CIR.0000078464.82671.78 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12814982 |issn=}}</ref> | ||
'''Rule of 30's''' | |||
* 30% will die in 30 days. | |||
* 30% will have recurrence in 10 years. The actual number at 10 years has been reported to be 36%<ref name="pmid31340984">{{cite journal| author=Khan F, Rahman A, Carrier M, Kearon C, Weitz JI, Schulman S et al.| title=Long term risk of symptomatic recurrent venous thromboembolism after discontinuation of anticoagulant treatment for first unprovoked venous thromboembolism event: systematic review and meta-analysis. | journal=BMJ | year= 2019 | volume= 366 | issue= | pages= l4363 | pmid=31340984 | doi=10.1136/bmj.l4363 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31340984 }} </ref> | |||
* 30% will develop [[post phlebitic syndrome]]. | |||
==Complications== | ==Complications== | ||
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* [[Phlegmasia cerulea dolens]] | * [[Phlegmasia cerulea dolens]] | ||
* [[Lemierre syndrome]] | * [[Lemierre syndrome]] | ||
* Septic | * Septic pelvic thrombophlebitis | ||
* | * Impairment of the quality of life might occur especially when [[post-thrombotic syndrome]] occurs.<ref name="pmid15911732">{{cite journal| author=Kahn SR, Ducruet T, Lamping DL, Arsenault L, Miron MJ, Roussin A et al.| title=Prospective evaluation of health-related quality of life in patients with deep venous thrombosis. | journal=Arch Intern Med | year= 2005 | volume= 165 | issue= 10 | pages= 1173-8 | pmid=15911732 | doi=10.1001/archinte.165.10.1173 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15911732 }} </ref> | ||
The rate of complications in lower extremity DVT is higher from that in upper extremity DVT. Shown below is a table summarizing the differences in the rate of occurrence of complications.<ref name="pmid21366477">{{cite journal| author=Kucher N| title=Clinical practice. Deep-vein thrombosis of the upper extremities. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 9 | pages= 861-9 | pmid=21366477 | doi=10.1056/NEJMcp1008740 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21366477 }} </ref> | |||
{| | |||
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| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center | '''Complications''' ||style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center | '''Upper extremity DVT'''|| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Lower extremity DVT''' | |||
|- | |||
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Pulmonary embolism]] || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |6% || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |15-32% | |||
|- | |||
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Recurrence of DVT ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | 2-5% || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |10% | |||
|- | |||
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Post thrombotic syndrome || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |5% || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |56% | |||
|} | |||
==Prognosis== | ==Prognosis== | ||
Probability of recurrence can be estimated with the HERDOO2 rule:<ref name="pmid28314711">{{cite journal| author=Rodger MA, Le Gal G, Anderson DR, Schmidt J, Pernod G, Kahn SR et al.| title=Validating the HERDOO2 rule to guide treatment duration for women with unprovoked venous thrombosis: multinational prospective cohort management study. | journal=BMJ | year= 2017 | volume= 356 | issue= | pages= j1065 | pmid=28314711 | doi=10.1136/bmj.j1065 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28314711 }} </ref> | |||
* | |||
** | * '''H'''yperpigmentation | ||
** | * '''E'''dema | ||
* | * '''R'''edness in either leg | ||
* '''D'''-dimer level ≥250 μg/L | |||
* '''O'''besity with body mass index ≥30 | |||
* '''O'''lder age, ≥65 years | |||
Per the authors, "Women with a first unprovoked VTE event and none or one of the HERDOO2 criteria have a low risk of recurrent VTE and can safely discontinue anticoagulants after completing short term treatment."<ref name="pmid28314711"/> | |||
==References== | ==References== | ||
Latest revision as of 12:21, 26 July 2019
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Resident Survival Guide |
Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] Kashish Goel, M.D.; Assistant Editor(s)-In-Chief: Justine Cadet
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Overview
Thrombus formation typically begins in the calf veins and naturally progresses to the proximal veins and ultimately, breaks free from the site formation and travels to the pulmonary artery where it is called a pulmonary embolism. In many cases, patients with a thrombus can be asymptomatic until it progresses into the proximal veins.
Natural History
- Many patients with a deep vein thrombosis (DVT) originating in the calf veins are asymptomatic until proximal vein involvement.[1] However, even assymptomatic DVTs are associated with increased risk of death[2].
- About half of all calf DVTs resolve spontaneously, without intervention.[1]
- One-sixth of all calf DVTs progress to involvement with the proximal veins.[1]
- Typical onset of thrombus formation may occur during the intraoperative period though there is a potential latent onset up to many months after the initial surgery.[1]
- Surgeries characteristically responsible for thrombus formation include:
- Knee replacement surgery is associated with twice the frequency of asymptomatic onset.[1]
- Without treatment, one-fourth to one-third of symptomatic, isolated distal thrombi in the deep veins involve proximal veins.[1]
- Patients with isolated calf DVT treated with five days of heparin therapy without a tandem oral anticoagulant therapy were at highest risk for recurrent or extension of DVT within three months of follow-up.[1]
- Patients with untreated DVT have the potential to develop:
- Post-phlebitic syndrome (occurs in 10-30% of all DVT cases)
- Pain
- Edema
- Skin discoloration
- Venous ulcers (10% of the cases)
- Chronic venous insufficiency
- Mortality rates associated with venous thrombosis can be very high.
Rule of 30's
- 30% will die in 30 days.
- 30% will have recurrence in 10 years. The actual number at 10 years has been reported to be 36%[4]
- 30% will develop post phlebitic syndrome.
Complications
Venous thrombosis may lead to any of the following major complications:
- Recurrence may occur unevenly across the sexes; with men being almost four times more likely than women for a venous thrombosis recurrence.[5]
- Major bleeding due to anticoagulation
- Death - Proximal vein thrombosis is responsible for more than ninety percent of acute pulmonary emboli. Acute PE is ultimately associated with a high mortality if not treated promptly. [6]
Other complications include:
- Post-thrombotic syndrome
- Phlegmasia alba dolens
- Phlegmasia cerulea dolens
- Lemierre syndrome
- Septic pelvic thrombophlebitis
- Impairment of the quality of life might occur especially when post-thrombotic syndrome occurs.[7]
The rate of complications in lower extremity DVT is higher from that in upper extremity DVT. Shown below is a table summarizing the differences in the rate of occurrence of complications.[8]
| Complications | Upper extremity DVT | Lower extremity DVT |
| Pulmonary embolism | 6% | 15-32% |
| Recurrence of DVT | 2-5% | 10% |
| Post thrombotic syndrome | 5% | 56% |
Prognosis
Probability of recurrence can be estimated with the HERDOO2 rule:[9]
- Hyperpigmentation
- Edema
- Redness in either leg
- D-dimer level ≥250 μg/L
- Obesity with body mass index ≥30
- Older age, ≥65 years
Per the authors, "Women with a first unprovoked VTE event and none or one of the HERDOO2 criteria have a low risk of recurrent VTE and can safely discontinue anticoagulants after completing short term treatment."[9]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Kearon C (2003). "Natural history of venous thromboembolism". Circulation. 107 (23 Suppl 1): I22–30. doi:10.1161/01.CIR.0000078464.82671.78. PMID 12814982. Unknown parameter
|month=ignored (help) - ↑ Kalayci A, Gibson CM, Chi G, Yee MK, Korjian S, Datta S; et al. (2018). "Asymptomatic Deep Vein Thrombosis is Associated with an Increased Risk of Death: Insights from the APEX Trial". Thromb Haemost. 118 (12): 2046–2052. doi:10.1055/s-0038-1675606. PMID 30419597.
- ↑ White RH (2003). "The epidemiology of venous thromboembolism". Circulation. 107 (23 Suppl 1): I4–8. doi:10.1161/01.CIR.0000078468.11849.66. PMID 12814979.
- ↑ Khan F, Rahman A, Carrier M, Kearon C, Weitz JI, Schulman S; et al. (2019). "Long term risk of symptomatic recurrent venous thromboembolism after discontinuation of anticoagulant treatment for first unprovoked venous thromboembolism event: systematic review and meta-analysis". BMJ. 366: l4363. doi:10.1136/bmj.l4363. PMID 31340984.
- ↑ Kyrle PA, Minar E, Bialonczyk C, Hirschl M, Weltermann A, Eichinger S (2004). "The risk of recurrent venous thromboembolism in men and women". N Engl J Med. 350 (25): 2558–63. doi:10.1056/NEJMoa032959. PMID 15201412. Review in: ACP J Club. 2004 Nov-Dec;141(3):78
- ↑ Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D, Boge G, van Kien AK, Gattolliat O, Bettarel-Binon C, Gris JC, Genty C, Quere I (2009). "Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study". Thromb. Haemost. 102 (3): 493–500. doi:10.1160/TH09-01-0053. PMID 19718469. Retrieved 2011-12-14. Unknown parameter
|month=ignored (help) - ↑ Kahn SR, Ducruet T, Lamping DL, Arsenault L, Miron MJ, Roussin A; et al. (2005). "Prospective evaluation of health-related quality of life in patients with deep venous thrombosis". Arch Intern Med. 165 (10): 1173–8. doi:10.1001/archinte.165.10.1173. PMID 15911732.
- ↑ Kucher N (2011). "Clinical practice. Deep-vein thrombosis of the upper extremities". N Engl J Med. 364 (9): 861–9. doi:10.1056/NEJMcp1008740. PMID 21366477.
- ↑ 9.0 9.1 Rodger MA, Le Gal G, Anderson DR, Schmidt J, Pernod G, Kahn SR; et al. (2017). "Validating the HERDOO2 rule to guide treatment duration for women with unprovoked venous thrombosis: multinational prospective cohort management study". BMJ. 356: j1065. doi:10.1136/bmj.j1065. PMID 28314711.