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Venous Thrombosis

Thromboses Venous

Venous thrombosis refers to the formation of a blood clot in any vein. While this condition may interfere with blood drainage from dependent tissues, morbidity and mortality are primarily associated with thromboembolism.


Presentation

Symptoms presented by VT patients depend on the site and degree of thrombotic vessel occlusion. Individuals suffering from deep vein thrombosis, an entity typically compromising the veins of the lower limbs, may present with edema and erythema of the affected region. Tissues damaged by venous stasis may be tender or painful, and patients typically claim their discomfort to intensify after prolonged standing or walking. Homans' sign may be present. In severe cases, phlegmasia cerulea dolens or gangrene may be observed [6].

The occlusion of pulmonary arteries by thrombi that formed in the venous system causes acute-onset chest pain, dyspnea, tachycardia, and cyanosis. Affected individuals may also claim dizziness, sweating, and cough. A low-grade fever may be detected. A considerable subset of patients suffering from pulmonary embolism has a medical history of deep vein thrombosis.

Gangrene
  • Although surgery may be required when venous gangrene of the intestine occurs, early diagnosis may allow successful conservative management with anticoagulation.[casesjournal.biomedcentral.com]
  • In severe cases, phlegmasia cerulea dolens or gangrene may be observed. The occlusion of pulmonary arteries by thrombi that formed in the venous system causes acute-onset chest pain, dyspnea, tachycardia, and cyanosis.[symptoma.com]
  • In advanced cases of arteriosclerosis, a thrombus may fill up whatever channel remains through a vessel, completely blocking off circulation and causing gangrene.[medical-dictionary.thefreedictionary.com]
  • This case series describes 55 instances of Fournier gangrene in diabetic adults being treated with sodium–glucose cotransporter-2 inhibitors.[annals.org]
  • […] less than 14 days, good functional status, a life expectancy greater than 1 year, and a low risk of bleeding. 3, 4 This is in contrast to the 2008 CHEST guidelines that recommended patients who have extensive proximal DVT, who have a high risk of limb gangrene[clevelandclinicmeded.com]
Sore Throat
  • A previously well woman aged 43 years presented with a history of a sore throat and worsening dyspnoea.[ncbi.nlm.nih.gov]
Abdominal Distension
  • Clinical evaluation revealed a painless abdominal distension and marked bilateral edema of the legs. A computed tomography (CT) scan showed gross dilatation of the colon and rectum, with FI.[ncbi.nlm.nih.gov]
Oral Ulcers
  • In the interim, he had been diagnosed with Behcet's disease by a rheumatologist who was consulted due to oral ulcers and skin lesions and accordingly started on prednisone, colchicine, and azathioprine.[ncbi.nlm.nih.gov]
Cyanosis
  • The occlusion of pulmonary arteries by thrombi that formed in the venous system causes acute-onset chest pain, dyspnea, tachycardia, and cyanosis. Affected individuals may also claim dizziness, sweating, and cough. A low-grade fever may be detected.[symptoma.com]
  • Syncope Hypotension, cyanosis Decreased left ventricular filling, causing forward heart failure. Diagnosis of DVT JAMA. 2006 Jan 11;295(2):199-207.[pathophys.org]
Left Ventricular Dysfunction
  • Here we report a case of a middle-aged male with systolic left ventricular dysfunction who presented with a stroke due to embolization from a pulmonary vein thrombus diagnosed on CT scan.[ncbi.nlm.nih.gov]
Bone Pain
  • PATIENT CONCERNS: A 50-year-old female developed headache, weakness of the right lower extremity, fever, and bone pain after chemotherapy including pegaspargase for the treatment of acute lymphoblastic leukemia.[ncbi.nlm.nih.gov]
Tonic-Clonic Seizure
  • Five days later, he was transported to our hospital via ambulance due to a tonic-clonic seizure. Head MRI showed cerebral venous thrombosis (CVT). He confessed to having recently taken a large doses of tadalafil.[ncbi.nlm.nih.gov]
Radiculopathy
  • KEYWORDS: Acute radiculopathy; Back pain; Disc herniation; Epidural venous thrombosis[ncbi.nlm.nih.gov]

Workup

Thrombi interfering with venous blood flow may be depicted employing duplex sonography, magnetic resonance imaging or computed tomography [7]. The former is preferred if the affected vein can be visualized by means of sonography, e.g., in patients suffering from thrombosed varicose veins or deep vein thrombosis of the extremities. Certain sites may not be accessible, so, for example, magnetic resonance flow imaging or contrast-enhanced computed tomography scans have to be carried out to depict cerebral vein thrombosis [8]. Of note, imaging techniques as described before have largely replaced contrast venography, an invasive approach to diagnosing VT. Still, venograms may provide useful information in case of subacute or chronic VT [8] [9].

Anamnestic data may reveal a predisposition for VT. For instance, thrombosis of isolated veins may be related to catheter insertion, surgery or trauma. In contrast, patients suffering from thrombophilia or other systemic conditions facilitating thrombus formation generally present with multiple VT. The underlying disease may be associated with additional disorders that should be considered when planning diagnostic measures:

  • Laboratory analyses of blood samples may reveal thrombophilia, enhanced levels of D-dimer [10], or altered concentrations of coagulation factors.
  • Coagulation studies should be conducted to test for a systemic prothrombotic condition.
  • Diagnostic imaging is helpful to assess the condition of lungs and heart.
  • Genetic screenings may be indicated to diagnose hereditary diseases.
Brain Edema
  • The main cause of acute death with CVT is transtentorial herniation secondary to a large hemorrhagic lesion, 5 followed by herniation due to multiple lesions or to diffuse brain edema.[ahajournals.org]

Treatment

  • Our results emphasize that corticosteroids are essential for the treatment of BD-associated CVT, and that anticoagulant therapy may be safely stopped during follow-up in the presence of optimal BD treatment (steroids alone or with immunosuppressive drugs[ncbi.nlm.nih.gov]

Prognosis

  • […] for monitoring LDVT prognosis and risk.[ncbi.nlm.nih.gov]
  • Table 4: Predictors influencing the prognosis of pregnancy-related CVT patients.[nature.com]

Etiology

  • LESSONS: This case report demonstrates the importance of considering jugular vein lesions as an etiology of CVT.[ncbi.nlm.nih.gov]

Epidemiology

  • Smith, A Genome‐Wide Association Study for Venous Thromboembolism: The Extended Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) Consortium, Genetic Epidemiology, 37, 5, (512-521), (2013).[dx.doi.org]
  • This section focuses on deep-vein thrombosis and discusses its risk factors, epidemiology and associated complications In this section: Venous thrombi Venous thromboembolism Risk factors Incidence and prevalence Associated complications Venous Thrombosis[thrombosisadviser.com]
  • General epidemiology Venous thrombosis by age and sex Deep vein thrombosis and pulmonary embolism occur in 1–2 per 1000 individuals per year.[thrombosisjournal.biomedcentral.com]
Sex distribution
Age distribution

Pathophysiology

  • Therefore, this case provides the opportunity to review the pathophysiology of MVT, APS and their medical management including current trends in anticoagulation. BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018.[ncbi.nlm.nih.gov]
  • […] straight sinus, and then to the internal jugular vein (IJV) Superficial venous system has numerous anastomses and predominantly drain the SSS and the LS Deep white matter and basal ganglia are drained by the deep venous system toward the vein of Galen Pathophysiology[lifeinthefastlane.com]
  • "Thrombotic risk factors: basic pathophysiology". Crit Care Med. 38 (suppl 2): S3–9. doi : 10.1097/CCM.0b013e3181c9cbd9. PMID 20083911. a b c d e f g Bovill EG, van der Vliet A (2011).[en.wikipedia.org]
  • Previous research has generally suggested that the hypercoagulable state of pregnancy and puerperium is one of the main pathophysiology associated with pregnancy-related CVT 6 .[nature.com]

Prevention

  • We conducted this meta-analysis to evaluate its benefits for the prevention of deep venous thrombosis (DVT) after lower extremity orthopedic surgery.[ncbi.nlm.nih.gov]
  • "Aspirin for the prevention of recurrent venous thromboembolism: the INSPIRE collaboration". Circulation. 130 (13): 1062–71. doi : 10.1161/circulationaha.114.008828.[en.wikipedia.org]

Summary

Venous thrombosis (VT) refers to the formation of a blood clot in any vein. In general, VT may be triggered by endothelial lesions or may be the result of a systemic prothrombotic state. The latter may be observed in patients suffering from certain hereditary disorders (e.g., protein C deficiency, protein S deficiency, hereditary deficiency of antithrombin III) or acquired conditions associated with venous stasis (e.g., forced immobilization, pregnancy, neoplasms, cardiac disease) [1] [2]. In this context, VT may be considered as a manifestation of an underlying disorder. It is of utmost importance to identify this pathology if causative treatment is to be provided.

On the other hand, VT may lead to serious complications. The formation of small thrombi within venous vessels does not necessarily cause venous stasis, but it does provoke alterations of local fluid mechanics. At such sites, erythrocytes are likely to form so-called red thrombi. These are secondary thrombi that increase the volume of the initial blood clot. Eventually, dependent tissues may be compromised and patients may develop symptoms consistent with chronic venous insufficiency [3], postphlebitic syndrome, or Budd-Chiari syndrome [4], among others. Venous thrombi may also be dragged away, reach the right heart and pulmonary circulation. As the blood clot advances through the pulmonary circulation, the diameter of arteries is constantly declining. This increases the likelihood of the thrombus becoming lodged in these vessels, thus causing a potentially fatal pulmonary embolism, pulmonary infarction or chronic thromboembolic pulmonary hypertension [5].

References

Article

  1. Khan S, Dickerman JD. Hereditary thrombophilia. Thromb J. 2006;4:15.
  2. Trenor CC, 3rd, Chung RJ, Michelson AD, et al. Hormonal contraception and thrombotic risk: a multidisciplinary approach. Pediatrics. 2011;127(2):347-357.
  3. Yamaki T, Nozaki M. Patterns of venous insufficiency after an acute deep vein thrombosis. J Am Coll Surg. 2005;201(2):231-238.
  4. Shin N, Kim YH, Xu H, et al. Redefining Budd-Chiari syndrome: A systematic review. World J Hepatol. 2016;8(16):691-702.
  5. Goldhaber SZ. Venous thromboembolism: epidemiology and magnitude of the problem. Best Pract Res Clin Haematol. 2012;25(3):235-242.
  6. Bhatt S, Wehbe C, Dogra VS. Phlegmasia cerulea dolens. J Clin Ultrasound. 2007;35(7):401-404.
  7. Steven A, Raghavan P, Altmeyer W, Gandhi D. Venous Thrombosis: Causes and Imaging Appearance. Hematol Oncol Clin North Am. 2016;30(4):867-885.
  8. Saposnik G, Barinagarrementeria F, Brown RD, Jr., et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(4):1158-1192.
  9. Mendichovszky IA, Priest AN, Bowden DJ, et al. Combined MR direct thrombus imaging and non-contrast magnetic resonance venography reveal the evolution of deep vein thrombosis: a feasibility study. Eur Radiol. 2016.
  10. Riley RS, Gilbert AR, Dalton JB, Pai S, McPherson RA. Widely Used Types and Clinical Applications of D-Dimer Assay. Lab Med. 2016;47(2):90-102.

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Last updated: 2019-07-11 21:34