DVT

The typical symptoms and signs of symptomatic DVT are the pain, swelling, warmth, and redness of the calf or thigh. Cellulitis may complicate the clinical picture. Additionally, thrombosis at the site of the iliac bifurcation produces bilateral leg edema. Patients may have signs of PE prior to diagnosis of DVT.

PE

While the symptomology of PE may be non-specific, the clinical picture is characterized by dyspnea, pleuritic or retrosternal chest pain, cough, and hemoptysis [1]. Patients can become anxious and agitated while suffering from mental status changes. Moreover, these patients may exhibit signs of a DVT.

Remarkable findings on the physical exam include cyanosis, tachycardia, tachypnea, and fever. Cardiovascular features such as elevated jugular venous pressure may develop. Chest auscultation reveals abnormal sounds such as a gallop rhythm, a widely split S2, and a tricuspid valve regurgitant murmur [1].

Complications such as hypotension and cardiogenic shock may emerge. PEs may be rapidly deadly, even prior to recognition.

• Pain

  The swelling and pain were relieved and cured. Safety concerns are still a primary hurdle for stem cell therapy, and thromboembolism as a critical complication should be prevented appropriately. [ncbi.nlm.nih.gov]

• Inflammation

  Chronic inflammation plays a key role in the pathophysiology of atherothrombosis ( 5 ). Furthermore, modulation of inflammation with antiplatelet therapy ( 6 ) and statins reduces the risk of atherothrombotic events ( 7 ). [clinchem.aaccjnls.org]

  DESIGN: Multicenter case-control study using prospectively collected data from the Inflammation and Host Response to Injury program, with pathway and in silico gene expression analyses. SETTING: Eight level 1 US trauma centers. [ncbi.nlm.nih.gov]

  Scope Note Inflammation of a transverse portion of the spinal cord characterized by acute or subacute segmental demyelination or necrosis. [medvik.cz]

  Since the pleura is innervated, inflammation will produce localized pleuritic chest pain. Inflammation also increases the permeability of the pleural surface, leading to accumulation of exudative pleural fluid (pleural effusion). [pathophys.org]

  Evidence suggests that cancer itself is associated with a state of hypercoagulability, driven in part by the release of procoagulant factors, such as tissue factor, from malignant tissue as well as by inflammation-driven activation of endothelial cells [th.schattauer.de]

• Recurrent Pulmonary Embolism

  The first case is a 64-year-old female admitted for recurrent pulmonary embolism, and the second case is a 70-year-old female admitted for recurrent deep vein thrombosis. [ncbi.nlm.nih.gov]

  DVT: Deep vein thrombosis IVC: Inferior vena cava LMWH: Low-molecular weight heparin PE: Pulmonary embolism PESI: Pulmonary embolism severity index SSPE: Sub-segmental pulmonary embolism VKA: Vitamin K antagonists VTE: Venous thromboembolism References [thrombosisjournal.biomedcentral.com]

• Underweight

  Our population was categorized according to their BMI as obese (BMI>30 kg/m 2 ), overweight (25 2), normal weight (18 2) and underweight (BMI 2 ) according to the cut-off points proposed by the WHO. [hoajonline.com]

  […] platelet disorders • VTE prophylaxis for long distance travel • Abdominal surgery • Vascular surgery • Urological surgery • Gynecological surgery • Trauma with brain injury • Burns • Liver disease • Antiplatelet therapy • Bariatric surgery • Obese and underweight [f1000research.com]

• Dyspnea

  A 12-year-old boy presenting with chest pain and dyspnea was found to have bilateral pulmonary thromboembolism (PTE) secondary to left popliteal venous aneurysm (PVA) with thrombus. [ncbi.nlm.nih.gov]

  Whenever patient with pancreatic ascites presents with dyspnea, pulmonary thromboembolism must be ruled out. [pancreas.imedpub.com]

• Tachypnea

  Common signs — dyspnea, tachypnea, chest pain, shock, hemoptysis [strokecenter.org]

  Remarkable findings on the physical exam include cyanosis, tachycardia, tachypnea, and fever. Cardiovascular features such as elevated jugular venous pressure may develop. [symptoma.com]

  Tachypnea was present with a rate of 25/minute but without hypoxia. Per abdomen was tender with severe ascites. Decreased air entry in both lower zones was noted on respiratory examination. [pancreas.imedpub.com]

  It is often asymptomatic, but when symptoms and signs are present, they can include chest pain, cough, shortness of breath, anxiety, tachycardia, tachypnea, hypoxemia, and hypotension. [cancertherapyadvisor.com]

  Symptoms Corresponding sign(s) Mechanism Dyspnea* Tachypnea*, decreased air entry, localized rales, wheezing Hyperventilation to compensate for increased dead space and in response to chemical mediators from platelets.Dyspnea is a symptom of central, [pathophys.org]

• Pleuritic Pain

  He denied haemoptysis or pleuritic pain; there was no family history of VTE. [erj.ersjournals.com]

  The classic presentation for PE with pleuritic pain, dyspnea and tachycardia is likely caused by a large fragmented embolism causing both large and small PEs. [en.wikipedia.org]

  PE is a more challenging diagnosis, given its variable presentation and severity; typical symptoms of dyspnea, presyncope, syncope, and pleuritic pain overlap with numerous other clinical entities. [hindawi.com]

• Abdominal Pain

  A 46-year-old male airline pilot presented with a 2 week history of abdominal pain, nausea, vomiting, watery diarrhea, and daily recurrent fevers. [ncbi.nlm.nih.gov]

  All the patients had abdominal pain on presentation and distention of abdomen during the course. Dyspnea was present in all the patients. [pancreas.imedpub.com]

  We report the case of a 61-year-old male with a history of abdominal pain, chronic diarrhea and fever, with leukocytosis, and fecal samples containing leukocytes, partial ileal stenosis with multiple ulcers in the enteroscopy, with histologic findings [read.qxmd.com]

  PE: potentially extensive but specifically rule out chest infection and an intra-abdominal bleed (look for abdominal signs, shoulder tip pain from diaphragmatic irritation and a low JVP). [patient.info]

  This form of thrombosis presents with abdominal pain, ascites and enlarged liver. Treatment varies between therapy and surgical intervention by the use of shunts. [en.wikipedia.org]

• Nausea

  A 46-year-old male airline pilot presented with a 2 week history of abdominal pain, nausea, vomiting, watery diarrhea, and daily recurrent fevers. [ncbi.nlm.nih.gov]

  She experienced nausea, dizziness, had high blood pressure, but reported no chest pain and her main complaint Data Availability: Due to ethical restrictions, the data are available upon request from the corresponding author (ales. [stpaulrestaurantinc.com]

• Thrombosis

  Hyperhomocysteinemia has been suspected of favoring thrombosis. Several case-control studies and even a meta-analysis have confirmed a link between venous thrombosis and hyperhomocysteinemia. [ncbi.nlm.nih.gov]

  […] for the treatment of deep vein thrombosis Pharmacomechanical thrombectomy for iliofemoral deep vein thrombosis Thrombolysis for acute deep vein thrombosis Thrombolysis for acute upper extremity deep vein thrombosis Treatment for distal deep vein thrombosis [vascular.cochrane.org]

• Chest Pain

  A 38 years old male patient presented to the emergency department with acute severe retrosternal chest pain and was found to have pulmonary thromboembolism. [ncbi.nlm.nih.gov]

  […] from a vein wall and blocks some or all of the blood supply to the lungs, causing: Unexplained shortness of breath Rapid breathing Chest pain anywhere under the rib cage (may be worse with deep breathing) Fast heart rate Light headedness or passing out [heart.org]

  As the clot reaches your lungs, you may begin to have anxiety, chest pain and shortness of breath. Jums var rasties klepus līdz asinīm. Your heart may beat rapidly, and you may develop a fever. You may feel dizzy or faint, and you may collapse. [capitalcardiology.com]

• Tachycardia

  Remarkable findings on the physical exam include cyanosis, tachycardia, tachypnea, and fever. Cardiovascular features such as elevated jugular venous pressure may develop. [symptoma.com]

  Right-sided backward heart failure causes increased JVP, and eventually left-sided heart failure (tachycardia). Palpitations Hemodynamic signs: Tachycardia See above. Tachycardia is a sympathetic response to decreased cardiac output. [pathophys.org]

  The electrocardiogram showed sinus tachycardia and severe right heart strain (fig. 1⇓); arterial blood gases on room air showed pH 7.45, carbon dioxide arterial tension 3.86 kPa (29 mmHg), arterial oxygen tension 7.45 kPa (56 mmHg), bicarbonate 19 mmol [erj.ersjournals.com]

  The physical exam may reveal suggestive features such as: clinical signs of deep venous thrombosis (DVT) asymmetric pitting lower extremity edema prominent superficial collateral vessels tenderness to palpation along the deep venous system tachycardia [radiopaedia.org]

  It is often asymptomatic, but when symptoms and signs are present, they can include chest pain, cough, shortness of breath, anxiety, tachycardia, tachypnea, hypoxemia, and hypotension. [cancertherapyadvisor.com]

• Homans' Sign

  Although calf pain on dorsiflexion of the foot (Homans' sign) is the classic assessment finding for DVT, don't rely heavily on this sign; nearly half of all patients with DVT have no physical symptoms or obvious clinical signs. [journals.lww.com]

  Homans sign First observed by surgeon Dr. John Homans, the sign is elicited by passive dorsiflexion of the ankle. [pathophys.org]

  Even in the non-pregnant woman, individual signs and symptoms are of little value and ‘Homan’s sign’ is of no value. In pregnancy, pitting oedema may be physiological and structured clinical models for diagnosis may not be valid1,20. [academic.oup.com]

• Retrosternal Chest Pain

  A 38 years old male patient presented to the emergency department with acute severe retrosternal chest pain and was found to have pulmonary thromboembolism. [ncbi.nlm.nih.gov]

  PE While the symptomology of PE may be non-specific, the clinical picture is characterized by dyspnea, pleuritic or retrosternal chest pain, cough, and hemoptysis. Patients can become anxious and agitated while suffering from mental status changes. [symptoma.com]

• Arthritis

  The increased frequency of DVT and PE in patients with chronic inflammatory disorders such as rheumatoid arthritis highlights the role of inflammation in VTE ( 9 ). [clinchem.aaccjnls.org]

  OBJECTIVE: Rheumatoid arthritis (RA) is associated with cardiovascular disease (CVD), but little is known about its association with another form of vascular disorder, venous thromboembolism (VTE). [ncbi.nlm.nih.gov]

  Sem Arthritis Rheum 1994; 23: 357-366. Bertolaccini ML, Hughes GRV. Antiphospholipid antibody testing: Which are most useful for diagnosis? Rheum Dis Clin N Am 2006; 32: 455-463. Pelletier S, Landi B, Piette JC. [medigraphic.com]

  The Juvenile Arthritis Multidimensional Assessment Report (JAMAR) is a new parent/patient reported outcome measure that enables a thorough assessment of the disease status in children with juvenile idiopathic arthritis (JIA). Email Tomsic: Matija. [stpaulrestaurantinc.com]

• Calf Pain

  Patients may complain of a dull ache in the calf that may worsen with ambulation, or they may say their legs feel heavy or tight. On examination the limb may be swollen, red, or warm and may be painful when touched. [journals.lww.com]

  DVT classically presents with calf pain, thigh pain, or cramping. [hindawi.com]

• Back Pain

  NB: if you suspect an iliac vein thrombosis (back pain and swelling of the entire limb), magnetic resonance venography or conventional contrast venography may be considered. [patient.info]

• Irritability

  Whether functional gastrointestinal disorders, such as irritable bowel syndrome (IBS), are associated with VTE has not been determined. This nationwide study aimed to determine the risk of VTE in IBS outpatients in primary and specialist care. [ncbi.nlm.nih.gov]

  Positive findings include increased resistance to dorsiflexion or knee flexion, both in response to irritation of the posterior calf muscles. This sign is neither sensitive nor specific. N Engl J Med. 1946 Aug 1;235(5):163-7. [pathophys.org]

  PE: potentially extensive but specifically rule out chest infection and an intra-abdominal bleed (look for abdominal signs, shoulder tip pain from diaphragmatic irritation and a low JVP). [patient.info]

  Stimulation of irritant receptors causes alveolar hyperventilation. Reflex bronchoconstriction occurs and augments airway resistance. Lung edema decreases pulmonary compliance. [emedicine.medscape.com]

• Renal Insufficiency

  Oncologic, cardiovascular diseases, polymyositis and renal insufficiency have a slightly significant correlation with incidental PATE (p<0,05). [publications.lsmuni.lt]

  […] of all study medication in patients with severe renal insufficiency • Occurrence of CRNM bleeding through 7 days after discontinuation of all study medication in patients with severe renal insufficiency • Occurrence of stroke, as adjudicated by the CEC [clinicaltrialsregister.eu]

  (Korean J Med 2011;81:464-469) 키워드, , Atrial fibrillation; Thromboembolism; Renal insufficiency, Chronic KCI 0 회 [kci.go.kr]

  LMWH can also be given in patients with renal insufficiency (creatinine clearance [CrCL] < 30 mL/minute) after dose adjustment. [clevelandclinicmeded.com]

  Exclusion criteria included history of inherited thrombophilia, a previous episode of VTE or anticoagulant treatment, thrombocytosis, malignancy, and renal impairment (because the normal K/L ratio has been determined in patients with normal renal function [hematologyandoncology.net]

The clinical assessment consists of the patient's history including risk factors for VTE, a physical exam, and the appropriate studies.

Laboratory tests

An arterial blood gas (ABG) test will reveal hypoxemia. There is an increased alveolar-arterial oxygen gradient in PE patients. Additionally, a D-dimer test is done when there is high suspicion for DVT. Note that a positive result is not specific and should warrant further testing. A coagulation panel should be obtained if indicated.

Imaging

Doppler ultrasonography is the initial test used for detection of a venous clot. Other modalities include but are not limited to venography and plethysmography.

Pulmonary angiography, the long-standing criterion standard for diagnosis of PE, displays the pulmonary vessels and demonstrates absent blood flow to embolized segment(s). Another useful study is the spiral computed tomography (CT) scan with IV contrast, which provides visualization of the pulmonary vasculature. Furthermore, the commonly employed ventilation-perfusion scan assesses the airflow and blood circulation throughout the lungs. Finally, a chest x-ray yields mostly normal results in PE patients although it can depict an enlarged pulmonary artery, reduced vascularity, and other similar findings.

Other

Electrocardiogram (EKG) is performed to evaluate the patient for myocardial infarction. Findings suggestive of PE may include sinus tachycardia, right axis deviation, inverted T waves in leads V1 to V3, and a right bundle branch block. The "classic" S1Q3T3 pattern is present in only 20% of PE patients.

Another useful test is the echocardiogram which can indicate right heart strain.

• Right Axis Deviation

  Findings suggestive of PE may include sinus tachycardia, right axis deviation, inverted T waves in leads V1 to V3, and a right bundle branch block. The "classic" S1Q3T3 pattern is present in only 20% of PE patients. [symptoma.com]

  […] heart strain pattern incomplete or complete right bundle branch block prominent R wave in lead V1 right axis deviation T-wave inversion in the right precordial leads +/- the inferior leads is seen in up to 34% of patients and is associated with high [radiopaedia.org]

  The most commonly seen signs in the ECG are sinus tachycardia, right axis deviation, and right bundle branch block. [61] Sinus tachycardia, however, is still only found in 8–69% of people with PE. [62] ECG findings associated with pulmonary emboli may [en.wikipedia.org]

There should be aggressive and prompt evaluation and treatment of DVT and PE since PE can be rapidly fatal. Also, clinicians should consult guidelines when choosing the medication(s), duration of treatment, and prophylaxis. Crucial details that must be considered include preexisting diseases, inherited thrombophilias, underlying malignancies, and high-risk situations such as recent surgery.

Standard anticoagulants used to treat acute episodes include unfractionated heparin (UFH), low molecular weight heparin (LMWH), and fondaparinux. Patients on these agents are transitioned to warfarin therapy early. Furthermore, target specific agents such as rivaroxaban and dabigatran may be used as well. First-time events should be treated with anticoagulation for at least 3 months and therapy is extended if there is an underlying disease.

Patients who cannot take anticoagulants are candidates for vena cava filter placement, which serves as the treatment and secondary prophylaxis. In rare cases, embolectomy may be necessary for large clots in the lungs.

Note that there are contraindications and serious complications associated with these medications. Therefore, thorough knowledge about the various agents and the patient's medical history is paramount to help reduce and prevent adverse outcomes.

The outcome of a major episode of PE depends on the size of the embolus and the preexisting cardiopulmonary status [6]. Specifically, the prognosis of patients with PE is stratified by the Pulmonary Embolism Severity Index (PESI), which categorizes the mortality risk following PE.

DVT is fatal when it is associated with massive PE, which accounts for as much as 300,000 deaths in the US every year [7]. One European study reported that 34% of VTE-related deaths were sudden fatal PE [8].

Patients with small PE exhibit a recurrence rate that is below 5% during the anticoagulation period but this increases to 30% a decade later [9]. Another major long-term complication is post-phlebitic syndrome.

The cause of DVT and PE is explained by the Virchow's triad, which consists of venous stasis, vessel wall injury, and hypercoagulability [1]. These factors threaten the tightly regulated coagulation system that normally ensures a blood clot formation in the presence of vessel wall injury [2].

Risk factors for DVT include a recent surgery or trauma especially of the pelvis, hip or lower extremity, malignancy, recent hospitalization, underlying illness, inherited thrombophilias, etc [3].

The incidence of DVT in the general population is 1 in 2000 individuals annually [4]. In the United States, it is estimated that there were approximately 550,000 hospitalizations with VTE in patients 18 years of age or greater between 2007 and 2009 [5], with a slight predilection for females. Additionally, advanced age is a significant risk factor. With regards to race, thromboembolism occurs more commonly in African Americans than Caucasians.

A blood clot is formed by fibrin, platelets, and red blood cells due to obstruction, hypercoagulability, or damage to the endothelial cells of the vessel wall. The mass may then separate or propagate and embolize to the pulmonary arteries. Consequently, the pulmonary embolus triggers a series of mechanisms that ultimately alter the hemodynamics of the pulmonary circulation such as increasing the pulmonary vascular resistance. The resultant right ventricular dysfunction and failure may finally cause cardiogenic shock, which can be fatal.

There are guidelines to help clinicians and patients to make appropriate decisions regarding prophylaxis. There are also risk stratification measures to identify which patients should be treated prophylactically. Ambulation, compression stockings, and possibly early prophylaxis are used in post-surgical patients.

Thromboembolism may affect the venous or arterial vasculature. With regards to venous thromboembolism (VTE), it is comprised of two interrelated processes known as deep venous thrombosis (DVT) and pulmonary embolism (PE), in which an embolus originating from a deep vein circulates to the pulmonary vessels. In arterial thromboembolism, an embolus arising from the heart could impact in arteries leading to the brain, gut, kidneys, spleen and lower extremities .Thromboemboli originating from common carotid arteries impact in arteries of the brain, while those originating from the abdominal aorta frequently end in arteries of the kidneys and lower extremities.

This article will focus on DVT and PE. As with all vascular events, it is imperative to establish a prompt diagnosis and initiate early treatment.

What is thromboembolism?

The most typical example is venous thromboembolism (VTE). It is made up of two conditions: deep venous thrombosis (DVT) and pulmonary embolism (PE). DVT is a blood clot that forms in deep veins of the lower extremities which separate and travels as an embolus to the lungs to form a PE.

What are the signs and symptoms?

DVT can be asymptomatic but its typical signs are:

• Painful, swollen, red, and warm limb below the site of the blood clot

PE:

• Shortness of breath
• Chest pain
• Coughing with blood
• Light-headedness
• Fainting
• Cardiac arrest

How is it diagnosed?

The clinician will obtain the patient's history, perform a physical exam, and order the appropriate blood tests and imaging studies such as :

• CT angiography
• Ventilation/perfusion scanning
• Ultrasound of the affected limb

How is it treated?

• Anticoagulants(s)
• Possibly thrombolytics
• Possibly surgical removal of clot
• Placement of filter in the inferior vena cava
• Also, preventative treatment is started when necessary

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2. Saha P, Humphries J, Modarai B, et al. Leukocytes and the natural history of deep vein thrombosis: current concepts and future directions. Arterioscler Thromb Vasc Biol. 2011;31(3):506-512.
3. Risk of and prophylaxis for venous thromboembolism in hospital patients. Thromboembolic Risk Factors (THRIFT) Consensus Group. BMJ. 1992;305(6853):567-574.
4. Fowkes FJ, Price JF, Fowkes FG. Incidence of diagnosed deep vein thrombosis in the general population: Systematic review. Eur J Vasc Endovasc Surg. 2003;25:1–5.
5. Venous thromboembolism in adult hospitalizations - United States, 2007-2009. MMWR Morb Mortal Wkly Rep. 2012; 61(22):401-404.
6. Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest. 2002; 121(3):877-905.
7. Tapson VF. Acute pulmonary embolism. N Engl J Med. 2008;358(10):1037-52.
8. Cohen AT, Agnelli G, Anderson FA, et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost. 2007;98(4):756-764.

9. Meyer G, Planquette B, Sanchez O. Long-term outcome of pulmonary embolism. Curr Opin Hematol. 2008;15(5):499-503.