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Flashcards in Venous thromboembolic diseases Deck (19)
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What are provoked and unprovoked DVTs?

  • Provoked DVT: associated with a transient risk factor, which can be removed to reduce risk of recurrence.
  • Unprovoked DVT: absence of a transient risk factor, person is at increased risk of recurrence.


Name four continuous or intrinsic risk factors for DVT

  • Previous DVT
  • Cancer
  • Age over 60
  • Overweight; obesity
  • Male
  • Heart failure
  • Acquired/familial thrombophilia
  • Inflammatory disorders: eg. vasculitis; IBD
  • Varicose veins
  • Smoking


Name four transient risk factors for DVT

  • Recent major surgery; hospitilisation; trauma
  • Chemotherapy
  • Significant immobility
  • Prolonged travel (>4h)
  • Significant trauma; direct trauma to vein
  • Pregnancy; postpartum period
  • Dehydration


Name two complications of deep venous thrombosis

  • Pulmonary embolism
  • Post-thrombotic syndrome
  • Bleeding associated with anticoagulation treatment
  • Heparin-induced thrombocytopenia


What is post-thrombotic syndrome?

DVT complication affecting up to 50% (within two years)

  • Chronic venous HTN, causing:
    • Limb pain; swelling
    • Hyperpigmentation; dermatitis
    • Ulcers
    • Venous gangrene
    • Lipodermatosclerosis


Name three differential diagnoses for DVT

  • Physical trauma
  • Cardiovascular disorders:
    • Superficial thrombophlebitis
    • Post-thrombotic syndrome
    • Venous obstruction; insufficiency
  • Ruptured baker's cyst
  • Cellulitis
  • Dependent oedema
  • Nephrotic syndrome; cirrhosis
  • Compartment syndrome


List four presenting features of a DVT

  • Unilateral swollen leg (esp >3cm difference)
  • Localised pain: typically throbbing
  • Tender
  • Oedematous; erythematous; warm
  • Vein distension


What scoring system is used to assess DVT risk?

Two-level DVT Wells score


Outline the initial investigation of patients with likely DVT (2+ Wells score)

  • Proximal leg vein USS within 4h
    • D-dimer if scan result is negative
    • Repeat scan if D-dimer positive
  • If unable to obtain scan within 4h:
    • D-dimer test
    • Interim 24h treatment-dose LMWH
    • Proximal leg USS within 24h


Outline the initial investigation of patients with unlikely DVT (<2 Wells score)?

D-dimer test:

  • If +ve: proximal leg vein USS within 4h
  • If -ve: consider alternative diagnosis


What investigations should be offered in unprovoked DVT?

  • Investigations for possible malignancy
    • CT abdomen and pelvis
  • Thrombophilia testing


Give three ECG findings in pulmonary embolism

  • Sinus tachycardia
  • RV strain: T wave inversion in V1-4
  • RBBB
  • Dominant R wave in V1
  • S1Q3T3: non-specific
    • -S wave in lead I
    • -Q wave in lead III
    • -T wave inversion in lead III


What scoring system is used to assess PE risk?

PE Wells score - original or simplified


Outline the initial investigation of patients with likely PE (>4 Wells score)

  • CTPA immediately
  • V/Q SPECT scan if:
    • Allergy to contrast media
    • Severe renal impairment (eGFR <30ml/min)
    • High risk from irradiation
  • If either is delayed, offer interim anticoagulation
    • eg. apixaban; rivaroxaban


Outline the initial investigation of patients with unlikely PE (4 or less Wells score)

D-dimer test, results within 4h

  • If +ve: investigate as likely PE
    • CTPA or V/Q SPECT scan, ± interim anticoagulation
  • If -ve: consider alternative Dx


Outline the anticoagulation treatment for confirmed DVT/PE

  • Apixaban or rivaroxaban
    • Consider LMWH/VKA if renal impairment or APLS
  • Duration before reassessing to continue, stop, or change
    • Provoked: 3+ months
    • Unprovoked: 6+ months
    • Active cancer: 3-6+ months



Name two contraindications for DVT maintenance treatment with oral anticoagulation therapy

  • Cancer
  • Pregnancy


Differentiate venous and arterial insufficiency

  • Venous:
    • Heavy, aching
    • Swelling esp around ulcers, and end of day
    • Worsens on standing; improves with elevation/activity
    • Pulses present
  • Arterial:
    • Sharp cramping pain; tired leg/hip muscles
    • Swelling is rare
    • Worsens with activity; improves with rest
    • Pulses absent or diminished


What investigations are for determining which anticoagulation to give for confirmed DVT/PE?

  • FBC
  • U+E
  • LFTs
  • Clotting

Renal impairment, active cancer, and antiphospholipid syndrome require modifications to choice of anticoagulation