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Thromboembolism

Thromboembolisms

Thromboembolism is a spectrum of conditions in which a fragment of a blood clot (embolus) originating from one blood vessel, vein or artery, travels to another vessel thereby occluding it.


Presentation

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.

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]
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
  • Remarkable findings on the physical exam include cyanosis, tachycardia, tachypnea, and fever. Cardiovascular features such as elevated jugular venous pressure may develop.[symptoma.com]
  • Common signs — dyspnea, tachypnea, chest pain, shock, hemoptysis[strokecenter.org]
  • 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.[clinicaladvisor.com]
  • Pleuritic chest pain, cough, or hemoptysis (with a smaller PE near the pleura) Syncope (with a massive PE) Sense of impending doom, with apprehension and anxiety Complaints related to signs of DVT, lower-extremity swelling, and warmth to touch or tenderness Tachypnea[emedicine.medscape.com]
Pleuritic Pain
  • 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]
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]
  • There may also be abdominal pain. The difficulty is that some of these symptoms may be found in normal pregnancies. The patient may also be asymptomatic with a retrospective diagnosis being made following a PE.[patient.info]
  • 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]
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]
Regurgitation
  • Chest auscultation reveals abnormal sounds such as a gallop rhythm, a widely split S2, and a tricuspid valve regurgitant murmur. Complications such as hypotension and cardiogenic shock may emerge.[symptoma.com]
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]
  • As the clot reaches your lungs, you may begin to have anxiety, chest pain and shortness of breath. You may cough up blood. 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]
  • 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.[clinicaladvisor.com]
  • ECG had sinus tachycardia. Moderate pulmonary arterial hypertension (PAH) with dilated right atrium and ventricle were noted on 2D echo.[pancreas.imedpub.com]
  • 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]
  • ., dyspnea, chest pain, tachycardia) occurred. Recurrent DVT was diagnosed by ascending phlebography until the mid 1990s, and then by compression ultrasound, followed by venography in the case of indeterminate findings.[haematologica.org]
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]
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]
Calf Pain
  • 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]
Guillain-Barré Syndrome
  • The Zika and Chikungunya viral infections spread through the South and Central American continents, moving to North America in 2016, with severe cases of polyarthralgia, fever, and Guillain-Barré syndrome leading eventually to death.[ncbi.nlm.nih.gov]
Neglect
  • This case demonstrates presence of both elements of abuse and neglect in one victim.[ncbi.nlm.nih.gov]

Workup

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]
  • 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]

Treatment

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.

Prognosis

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.

Etiology

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].

Epidemiology

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.

Sex distribution
Age distribution

Pathophysiology

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.

Prevention

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.

Summary

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.

Patient Information

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:

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

References

Article

  1. Cervantes J, Rojas G. Virchow's legacy: deep vein thrombosis and pulmonary embolism. World J Surg. 2005;29(Suppl 1):S30-S34.
  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.

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Last updated: 2019-07-11 21:53