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Venous Thromboembolism: Risk Factors, Assessment, & Prevention

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Presentation on theme: "Venous Thromboembolism: Risk Factors, Assessment, & Prevention"— Presentation transcript:

1 Venous Thromboembolism: Risk Factors, Assessment, & Prevention
Stacey Graven, ACNP Vascular Surgery, Springfield Clinic Springfield, Illinois

2 VTE In September 2008, Surgeon General issued a “Call to Action to Prevent Deep Venous Thrombosis and Pulmonary Embolism” Recognized as significant public health problem Limited awareness about DVT -- < 1 in 10 Americans are familiar with DVT

3 Incidence of VTE VTE defined as patients with DVT, PE or both
In US, 300,00-600,000 cases per year Occur more often in elderly population Over 80 year old population, 1 per 100 Am J Prev Med 2010;38(4S)S495-S501

4 Incidence of VTE Higher incidence in black and white populations
Higher incidence in men Except women during reproductive years Am J Prev Med 2010;38(4S)S495-S501

5 Morbidity and Mortality of VTE
VTE is often fatal Leading cause of preventable hospital death and maternity deaths in US Over 100,00 people die every year from VTE 10%-30% of VTE patients die within 30 days of diagnosis About ¼ of deaths are sudden Circulation. 2009; 119: e480-e482, Am J Prev Med 2010;38(4S)S495-S501

6 Morbidity and Mortality of VTE
Despite standard anticoagulation therapy-- 1/3 suffer recurrence within 10 years. Highest risk of recurrence within 1st year About ½ of DVT patients develop chronic health-related problems: Post-thrombotic syndrome Chronic venous insufficiency with venous ulcerations Pulmonary hypertension Am J Prev Med 2010;38(4S)S495-S501

7 Risk Factors for VTE-Acquired
Chronic disease Advanced age Obesity Antiphospholipid antibodies Malignancy Travel Prior history of VTE Smoking Pregnancy, hormone therapy, oral contraceptives

8 Risk Factor- Hospitalization
> 50% of cases linked to hospitalization Often occur within 3 months of discharge Multiple risk factors Surgery Trauma Central line catheters Immobilization Am J Prev Med 2010;38(4S)S495-S501

9 Genetic Risk Factors Genetic disorders < 1%-5% population
increase VTE risk 3-10 fold in heterozygous state Factor V Leiden Protein S Deficiency Protein C Deficiency Antithrombin Deficiency Sickle Cell Trait Am J Prev Med 2010;38(4S)S495-S501

10 Virchow’s Triad Three factors contributing to thrombus formation
Hypercoagulability—hormone therapy, genetic disorder Interrupted blood flow/stasis--immobility, varicose veins Endothelial dysfunction/injury– shear stress, catheters/devices

11 Clotting Cascade Thrombin inhibitors (Pradaxa), Factor Xa Inhibitors (Eliquis), LMWH…..block clotting pathways

12 Familiar Faces of VTE

13 Deep Venous Thrombosis
Thrombus in deep vein Most common in legs, arms Deep veins empty into vena cava

14 Deep & Superficial Veins
Superficial veins communicate with deep veins via perforator veins SVT (superficial thrombophlebitis) can develop into DVT

15 Signs & Symptoms DVT Lower leg swelling, tightness of skin
Calf tenderness Warmth Redness Can also occur in upper extremity- venous catheters

16 Diagnosing DVT Ultrasound- sensitivity 98% Inexpensive
Difficult in obese patients Limitations with duplicate vein systems Normal vein compression Unable to compress in DVT

17 Diagnosing DVT Ultrasound—color flow images Normal flow Thrombus

18 Diagnosing DVT D-dimer- reflects presence of degradation products of fibrin and fibrinogen Sensitivity 97% for DVT Nonspecific – 35% Elevated D-dimer Infection Post-op states Malignancy Recent trauma Better used in conjunction with duplex Rutherford’s Vascular Surgery, 7th edition, 2010

19 Diagnosing DVT MRV and CTV Noninvasive More expensive than duplex
Better images in pelvic region in obese patients If duplex not diagnostic

20 MRV Left common iliac vein DVT Right common femoral vein DVT

21 CTV Right common femoral DVT

22 Calf DVT versus Proximal DVT
Location of DVT -- Proximal DVT - higher risk of PE and long- term complications

23 Calf versus proximal DVT
Calf vein DVT 20-30% of DVTs Includes anterior tibial, peroneal, and posterior tibial veins Recanalize faster 50% reduction in thrombus by 1 month and complete in one year Proximal vein DVT Includes femoral, iliac, and inferior vena cava Higher risk of PE, phlegmasia, and post thrombotic syndrome

24 Post Thrombotic Syndrome (PTS)
Common complication of proximal DVT - venous hypertension Valves are dysfunctional due to thrombus Blood moves in both directions causing hypertension in venous system

25 Post Thrombotic Syndrome
Post thrombotic syndrome – most important late effects of proximal DVT Chronic pain Swelling Ulcerations Hyperpigmentation- leaking of blood products

26 Complication of Proximal DVT
Post Thrombotic Syndrome

27 Complication of Proximal DVT
Phlegmasia --limb threatening Severe DVT with complete or near complete occlusion of proximal vein Venous congestion causes arterial compression Leg very painful, cyanotic, no pedal pulse Gangrene

28 Pulmonary Embolism Embolism travels to pulmonary arterial bed and occludes blood flow to lungs. Hemodynamically significant – >30-50% arterial bed occluded

29 Pathophysiology of PE

30 Pulmonary Embolism In most cases, PE is associated with DVT
50% of PE related to proximal DVT Occurs 3-7 days after onset of DVT

31 Signs & Symptoms PE Sudden shortness of breath -- 80% confirmed PE
Chest pain (pleuritic, substernal) -- 52% Hemoptysis -- 11% Syncope -- 19% Tachycardia -– 26% Fever ( > 38.5 ) -- 7% Cyanosis – 11% European Heart Journal (2008) 29,

32 Pathophysiology of PE Multiple emboli increase pulmonary vascular resistance– RV strain, increased afterload

33 Pathophysiology of PE

34 Markers of PE Elevated right heart pressures Abnormal echo—RV strain
Elevated BNP and troponin EKG changes – RV hypertrophy/strain, leads V1-V4 Hypotension, hypoxia  shock

35 RV Strain on Echo Right ventricular dilatation and hypokinesis

36 Pulmonary Embolism Varying degrees of PE depending on thrombus burden
Massive PE 5-10% --- hypotension, pulselessness Submassive PE 20-25% --- myocardial infarction w/o hypotension Low risk PE 70% --- no significant hemodynamic changes Treatment is dictated by severity Circulation(2011) 123,

37 Diagnosing PE Often when presenting with chest pain/SOB:
EKG – rule out myocardial infarction Chest x-ray – rule out pneumonia, atelectasis, pulmonary edema Arterial blood gas – 20% of PE have P02 > 80% Labs – D-dimer, cardiac markers

38 Diagnosing PE CT chest Most common diagnostic tool used to confirm PE
Improving visualization of thrombus

39 Diagnosing PE Ventilation Perfusion Scan (V/Q scan)
Second line of imaging Used when CT contrast allergy Use radioisotope Compares ventilation (air flow into/out of lungs) and perfusion (blood flow into/out of lungs) V/Q mismatch--seen in other conditions, i.e. emphysema, pneumonia Radiology reads as “probability” of PE

40 Diagnosing PE Pulmonary Angiogram – gold standard

41 Treatment VTE Anticoagulation—UFH, LMWH, Factor Xa Inhibitor, Direct thrombin inhibitor, Vitamin K antagonist Thrombolysis– indicated in proximal DVT/PE. Lowers incidence PTS Embolectomy– mechanical removal of thrombus, catheter vs surgical IVC Filter– temporary/permanent Compression – all DVT patients, prevent PTS

42 Prevention is the Key Growing health problem—often preventable
Reduce mortality and long-term effects

43 Prevention/Screening
VTE is the #1 preventable causes of death in hospital patient 2/3 of VTE are result of hospitalization Inpatients with VTE -- < 30% received prophylaxis Every hospital patient -- must risk-assessed for VTE

44 Risk assessment of VTE Prophylaxis treatment based on:
specific disease process and patient’s risk More risk factors  greater risk VTE > 40 years of age Smoking Overweight Personal/Family history of blood clots Birth control pills or HRT Malignancy Varicose Veins Surgery, especially hip, knee, or abdominal surgery, and Decreased mobility due to long illness or surgery

45 Prophylaxis in Hospital
Mechanical Pneumatic compression boots in bed Pharmacological LMWH – enoxaparin (Lovenox) 40 mg SQ daily or dalteparin (Fragmin) 5000 u SQ daily Fondaparinux (Arixtra) 2.5 mg SQ daily used after orthopedic surgery UFH (Heparin) 5000 u SQ every 8 hours Warfarin

46 Long-term Prevention Compression stockings daily
Avoid sitting for long periods of time – travel Avoid dehydration--alcohol

47 Venous Thromboembolism

48 Thank you Questions??

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