1. Deep Venous Thrombosis and its Complications
M.A.Kubtan M.D-F.R.C.S.(U.K)
Dept of General Surgery
Al Mouasat University Hospital
Damascus
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2. The Role of Clotting
In the blood vascular system the clotting mechanism guards against the danger of haemorrhage
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3. Is the formation of a solid mass
Thrombosis
Is the formation of a solid mass
( Thrombus ) in the circulation from the constituents of streaming blood
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4. Causes of Phlebothrombosis
Changes in the vessel Wall .
Changes in the Blood flow .
Changes in the composition of the Blood .
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5. Changes in the Vessel Wall
Pressure on the veins by the heavy calf tissues when the patient is immobilised in bed .
Local hypoxia due to pressure on the vessles associated with immobility .
Direct trauma by a fracture edges .
Ill applied tourniquets and plaster of Paris .
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6. The Blood Flow Stasis (The usual cause of venous thrombosis)
Increased viscosity of blood
In polycythaemia Vera
Dehydration
Eddy Current
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7. The Composition of Blood
Platelets ( Thrombocytosis ).
Clotting Factors .
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8. Transient ( after Parturition, Trauma,
Platelets
Thrombocytosis
Transient ( after Parturition, Trauma,
Sever Haemorrhage, and
after Splenectomy ).
Persistent ( Polycythaemia Vera ).
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9. Platelets Function
Platelet Aggregation .
Platelet Adhesiveness .
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10. The Role of Clotting Mechanism
The Clotting Time Is shortened after
Sever Haemorrhage .
Trauma .
Sever Infections ( Typhoid Fever ).
Administration of Corticosteroids .
Oral Contraceptive .
Lipaemia shortens the clotting time and inhibits fibrinolysis .
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11. Venous Thrombosis
Thrombophlebitis .
Phlebothrombosis .
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12. Thrombophlebitis
is a condition in which there is both inflammation and a blood clot in a vein. Thrombophlebitis can occur in either superficial or deep veins.
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13. Phlebothrombosis It is essentially due to Stasis .
It may be caused by local injury to the venous endothelium .
There is no obvious local infective element.
It is common postoperative compliction
Frequently encountered in Heart disease .
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14. A DVT is a condition where in a blood ,clot (thrombus) forms in a vein of the deep system.
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15. Pathogenesis of Phlebothrombosis
Primary platelet Thrombus .
The Coralline Thrombus .
Occluding Thrombus .
Consecutive Clot .
Propagated Clot .
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16. Primary Platelet Thrombosis خثرة الصفيحات البدئية الشاحبة
Platelet adhere to the vein wall and aggregate to form a pale thrombus .
This allows clotting factors to accumulate in the area .
Promote an increase in the fibrin element .
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18. Coralline Thrombus الخثرة المرجانية اللون A mixed thrombus
Due to fibrin deposition on the primary platelet thrombus .
Leads to further platelet deposition
Consist of alternate layers of fused platelets and fibrin with entrapped blood cells .
They are bent in the direction of blood flow .
Ripple appearance (Line of Zahn ) .
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20. Occluding Thrombs الخثرة السادة
The growth of coralline thrombus progressively occludes the vein .
Composed of blood clot with smaller platelet element.
It is red.
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22. Consecutive Clot الخثرة المتعاقبة
Once the vein is occluded
The stationary column of blood undergoes coagulation forming a Consecutive clot .
When consecutive clot extend to the next venous tributary it may become endothelialised , or there is the development of more thrombus or clot.
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24. Propagated Clot الخثرة المتمادية
When clot reaches to the entrance of venous tributary , it may lead to formation of another consecutive clot .
Stagnation of column of blood above the consecutive clot may produce propagated clot en mass .
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30. A thrombosis in a deep vein is a much more serious problem than one in a superficial vein. The reason for this is that a piece of the clot in DVT may break off and travel through the deep veins back to the heart, and eventually be pumped by the heart into the arteries of the lung.
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31. DVTs can occur anywhere in the body but are most frequently found in the deep veins of the legs, thighs, and pelvis.
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32. DVT is a common condition that affects almost 2 million Americans each year. Among patients with DVT, pulmonary embolism will occur in 30%. Pulmonary embolism causes 600,000 deaths each year.
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34. What Are The Symptoms of a DVT
In the affected leg
swelling
Pain
no symptoms at all unless the clot dislodges
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36. Common Sites Affected by Thrombosis
Deep Veins of the Calf .
It may extend to PTV or the POPV.
At the beginning of Femoral Vein .
Commonly in Lt CIV due to pressure from the Rt CIA .
Following Pelvic Operation .
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37. Plsmatic D-dimers Fibrin is the main constituent of a thrombus.
Its formation is rapidly followed by activation of fibrionlytic system leading to lysis of fibrin clot.
Dissolution of stabilized fibrin releases specific breakdown products D-dimers (DD).
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39. DD assay as a useful first stage diagnostic tool
Negative result can rule out thromboembolic event.
False positive ( Specificity 40% ).
Test used
1. ELISA (Enzyme-linked
immunosorbant assays ).
2. Latex tests less sensitive .
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41. Venography
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42. MR
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43. Special Clinical Types
Phlegmasia alba dolens.
Phlegmasia Coerulea dolens.
Trousseu,s Syndrome.
Pregnancy-related thrombosis.
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44. Iliac Femoral Vein Thrombosis
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48. Isotope Scan
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50. Local Causes i ) lack of Muscular Activity . ii ) Incompetent Valves .
iii ) Pressure from outside ( Tumours, Ascites ,
Plasters and Bandages .)
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51. Predisposing Factors 1. Fatal complication of D.V.T.
2. Secondary to non surgical disorders.
Congestive Heart Failure.
Cerebrovascular Accidents.
Chronic Pulmonary Diseases.
Systemic Infection.
Disseminated Carcinomatosis.
Miscellaneous.
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54. Size
An emboli prove fatal if it measures 1.5 cm in diameter and 50 cm or more in length.
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55. Areas are commonly affected
Rt pulmonary artery is more commonly affected than the left.
Lower lobes are more commonly affected than the upper lobes.
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56. Origin of PE 80% originated from iliac and femoral veins.
20% originated from I.V.C. , Subclavien, Axillary, Internal jagular, Cavernous Sinuses of the Brain, and Cardiac Tumors arising in the Rt Atrium or Rt Ventricle.
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57. Preventing the occurrence of D.V.T.
Prevention of PE
Preventing the occurrence of D.V.T.
Early ambulation.
Elevation of lower extremities.
Elastic stockings.
Mechanical compression.
Anti platelets agents (Aspirin, Dipyridamol).
S/C LMWH
Insertion of stainless steel Umbrella
( Greenfield).
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60. Complications of Umbrella
Migration.
Protrusion of struts through the
caval wall.
Formation of thrombus.
Misplacement of the umbrella.
Retroperitoneal haemorhage.
Perforation of duodenum and
ureter.
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61. The Massage
As a precaution installation of the Greenfield umbrella should be the treatment of choice to combat the risk of fatal pulmonary embolus whenever possible
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