Deep vein thrombosis

1
Venous Thromboembolism
Treatment

• Deep vein thrombosis
• Pulmonary embolism

All the same?
2
Acute DVT
Management
What is the goal of therapy?
3
Acute DVT
Therapeutic Goals/Options
Caval Filter
Anticoagulation
Thrombolytic Rx
Thrombectomy
No Rx
Reduce PE

X

X

X

X

Prevent Extension

X

X


Reduce Recurrence

X

X



Restore Patency


X

X

Preserve Valve Function


X

X


Reduce CVI


X

X

4
Isolated Calf DVT
51 patients randomized Rx
Heparin x 5 days
Heparin x 5 days Warfarin x 3 mos
No recurrent VTE
29 recurrent VTE
19 proximal DVT
4 pulmonary emboli
Langerstedt CI, et al. Lancet 1985.
5
Deep Vein Thrombosis
Treatment

• Initial treatment
• Importance of therapeutic levels
• Compression
• Ambulation
• Long-term treatment
• 5 patient categories

6
Acute DVT
Importance of Early Rx
Recurrent VTE
PTT lt1.5x (24 hrs.)
24.5
(151)
PTT gt1.5x
1.6
lt0.001
most occur gt 4 weeks association with poor
initial response not appreciated by
attending MDs
Hull, RD et al NEJM 1990
7
Heparin/LMWH Bioavailability
Heparin for Acute DVT
Plasma Level After SQ - Volunteers
Single Subcutaneous Injection
Plasma Recovery
LMWH
90
Unfractionated heparin (UFH)
20
Bratt G, et al. Thromb Rea 198642(5)613-620.
Bara L, et al. Thromb Res. 198539(5)631-636.
8
LMWH vs. UFH for Acute DVT
A Meta-Analysis of 10 Studies (n759)

• Prospective
• Adjusted dose unfractionated heparin
• Fixed dose SQ LMWH
• Objective outcome measures
• Symptomatic recurrent DVT
• Change in thrombus size
• Major bleeding
• Mortality

Bratt G, et al. Thromb Rea 198642(5)613-620.
Bara L, et al. Thromb Res. 198539(5)631-636.
9
LMWH vs. UFH for Acute DVT
A Meta-Analysis of 10 Studies (n759)
Risk Reduction
UFH
LMWH
P-value




Venographic Change
6.5
3.1
53
lt0.01





52
63
-

Improved




12
6
lt0.001

Worse




Major Bleed
2.8
0.8
68
lt0.005





Mortality
7.1
3.9
47
lt0.04











Lensing AWA, et al Arch Intern Med 1995
10
Deep Vein Thrombosis
Initial Treatment Compression Ambulation

• Proximal DVT- 53 patients
• LMWH...then randomize
• Bed rest
• Ambulation 35 mm Hg stocking
• Ambulation 50 mm Hg compression bandage
• Activity measured - pedometer
• Venous duplex days 0 9

1. Blattler W., et al Intl Angiol. 2003 32
861-9 2. Partsch H. et al J Vasc Surg 2000
32 861-9