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| {{Infobox_Disease |
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| Name = {{PAGENAME}} |
| | {{Thromboembolism}} |
| Image = |
| | '''For the patient information page on deep vein thrombosis, click [[Deep vein thrombosis (patient information)|here]]''' |
| Caption = |
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| DiseasesDB = |
| | '''For the patient information page on pulmonary embolism, click [[Pulmonary embolism (patient information)|here]]''' |
| ICD10 = |
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| ICD9 = |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = |
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| eMedicineSubj = |
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| eMedicineTopic = |
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| MeshID = |
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| {{SI}}
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| {{CMG}} | | {{CMG}} |
| '''Associate Editor-In-Chief:''' {{CZ}} | | '''Associate Editor-In-Chief:''' {{CZ}} |
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| ==Overview== | | ==[[Thromboembolism overview|Overview]]== |
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| '''Thromboembolism''' is a general term describing both [[thrombosis]] and its main complication which is [[embolism|embolisation]].
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| ==Differential Diagnosis of Causes of Thromboembolism==
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| * [[Acute lymphoblastic leukemia]]
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| * [[Acute myelocytic leukemia]]
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| * [[Antiphospholipid antibody syndrome]]
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| * [[Atrial fibrillation]]
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| * [[Bacterial meningitis]]
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| * [[Baker’s cyst]]
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| * [[Central nervous system tumors]]
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| * [[Congenital heart disease]]
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| * [[Consumption coagulopathy]]
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| * [[Head trauma]]
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| * [[Hypertrophic cardiomyopathy]]
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| * [[Nephrotic syndrome]]
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| * [[Pneumonia]]
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| * [[Sepsis]]
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| * [[Thrombophlebitis]]
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| * [[Trauma]]
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| * [[Vasculitis]]
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| ==Etymology==
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| The term was coined in 1848 by [[Rudolph Carl Virchow]].<ref>{{cite book|title=The Timetables of Science| first=Alexander| last=Hellemans| coauthors=Bryan Bunch| publisher=Simon and Schuster| location=New York, New York| year=1988| isbn=0671621300 |pages=317}}</ref>
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| ==Incidence==
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| In the United States:
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| * 300,000–600,000 people have [[deep venous thrombosis]] ([[DVT]]) or [[pulmonary embolism]] ([[PE]]).
| | ==[[Thromboembolism historical perspective|Historical Perspective]]== |
| :* 200,000–400,000 people have [[deep venous thrombosis]].
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| ::*Nearly one-third of people who have had [[deep venous thrombosis]] have post-thrombotic syndrome, a chronic disabling condition characterized by swelling, pain, discoloration, and scaling in the affected limb.
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| :* 100,000–200,000 people have a [[pulmonary embolism]].
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| ::*Nearly one-third of people (30,000–60,000) who have a [[pulmonary embolism]] die.
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| * 5-8% of people have [[thrombophilia]] (inherited blood clotting disorders).
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| ==Demographics== | | ==[[Thromboembolism classification|Classification]]== |
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| ==Pathophysiology== | | ==[[Thromboembolism pathophysiology|Pathophysiology]]== |
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| The formation of a thrombus is usually caused by the top three causes, known as ([[Rudolf Virchow|Virchow]]'s triad): (Classically, thrombosis is caused by abnormalities in one or more of the following)
| | ==[[Thromboembolism causes|Causes]]== |
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| * The composition of the blood ([[hypercoagulability]])
| | ==[[Thromboembolism differential diagnosis|Differentiating Thromboembolism from other Diseases]]== |
| * Quality of the vessel wall ([[endothelial cell]] [[injury]])
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| * Nature of the blood flow ([[hemostasis]])
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| To elaborate, the pathogenesis includes:
| | ==[[Thromboembolism epidemiology and demographics|Epidemiology and Demographics]]== |
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| * an injury to the vessel's wall (such as by [[trauma]], [[infection]], or turbulent flow at bifurcations);
| | ==[[Thromboembolism risk factors|Risk Factors]]== |
| * by the slowing or stagnation of blood flow past the point of injury (which may occur after long periods of [[sedentary behavior]] (for example, sitting on a long airplane flight);
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| * by a blood state of [[hypercoagulability]] (caused for example, by genetic deficiencies or [[autoimmune disorders]]).
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| High altitude has also been known to induce thrombosis <ref>Kuipers S, Cannegieter SC, Middeldorp S, Robyn L, Büller HR, et al. The Absolute Risk of Venous Thrombosis after Air Travel: A Cohort Study of 8,755 Employees of International Organisations PLoS Medicine Vol. 4, No. 9, e290 doi:10.1371/journal.PMID 0040290</ref> <ref>http://www.mounteverest.net/news.php?news=16349 Mount Everest experience</ref>. Occasionally, abnormalities in [[coagulation]] are to blame. Intravascular [[coagulation]] follows, forming a structureless mass of [[red blood cell]]s, [[leukocyte]]s, and [[fibrin]].
| | ==[[Thromboembolism screening|Screening]]== |
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| ==Classification== | | ==[[Thromboembolism natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ===A. Thrombosis===
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| There are two distinct forms of [[thrombosis]]:
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| ====Venous thrombosis====
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| {{main|Venous thrombosis}}
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| * [[Deep venous thrombosis]] (with or without [[pulmonary embolism]]; together classified as '''venous thromboembolism'''/VTE)
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| * [[Portal vein thrombosis]]
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| * [[Renal vein thrombosis]]
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| * [[Budd-Chiari syndrome|hepatic vein thrombosis]] ([[Budd-Chiari syndrome]])
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| * [[Paget-Schroetter disease]]
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| * [[Cerebral venous sinus thrombosis]]
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| * [[Thoracic outlet syndrome]] (the cause of most [[Subclavian vein]] thrombosis unrelated to trauma)
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| ====Arterial thrombosis====
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| * [[Stroke]]
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| * [[Myocardial infarction]]
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| * [[Thoracic outlet syndrome]]
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| ===B. Embolism===
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| If a bacterial infection is present at the site of thrombosis, the thrombus may break down, spreading particles of infected material throughout the [[circulatory system]] ([[pyemia]], [[septic embolus]]) and setting up metastatic abscesses wherever they come to rest.
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| Without an infection, the [[thrombus]] may become detached and enter circulation as an [[embolus]], finally lodging in and completely obstructing a blood vessel (an [[infarction]]). The effects of an [[infarction]] depend on where it occurs.
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| The pathway of the embolism can be one of three types:
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| * Anterograde
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| * Retrograde
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| * Paradoxical
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| In anterograde embolism, the movement of emboli is in the direction of blood flow. In retrograde embolism, however, the emboli move in opposition to the blood flow direction; this is usually significant only in blood vessels with low pressure (veins) or with emboli of high weight. In [[paradoxical embolism]], also known as crossed embolism, an embolus from the veins crosses to the arterial blood system. This is generally found only with heart problems such as septal defects between the atria or ventricles.
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| ====Sources of Systemic Embolism====
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| * [[Left ventricular thrombus]]
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| * Left atrial thrombus
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| * Pelvic veins or lower extremity thrombus
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| * [[Native cardiac valves]]
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| * [[Prosthetic cardiac valves]]
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| * [[Cardiac tumors]]
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| * [[Aortic aneurysm]]
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| * Invasive manipulations
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| * [[Left ventricular aneurysm]]
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| <gallery>
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| Image:LV-thrombus-001.jpg|Sources of Systemic Embolism: Large left ventricular thrombus in a patient with myocardial infarction
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| Image:LV-thrombus-002.jpg|Sources of Systemic Embolism: Large left ventricular thrombus in a patient with myocardial infarction
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| </gallery>
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| ==Risk Factors==
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| Almost anyone can have thromboembolic event. However, certain factors can increase the risk of developing this condition. The risk increases even more for someone who has more than one risk factor at the same time.
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| * [[Sedentary life style]]
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| * [[Elderly]]
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| * [[Atrial fibrillation]]
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| * [[Sepsis]]
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| * Prolonged bed rest and / or immobility
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| * [[Pregnancy]]
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| * [[Hyperemesis]]
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| * [[Dehydration]]
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| * [[Cesarean delivery]]
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| * [[Congestive heart failure]]
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| * [[Nephrotic syndrome]]
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| * [[Severe varicose veins]]
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| * Family history of thromboembolism
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| * [[Thrombophilia]]
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| :* [[Factor V Leiden mutation]]
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| :* Prothrombin G20210A mutation
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| * Decreased [[antithrombin]] level
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| * Decreased [[Protein C]] level
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| * Decreased [[Protein S]] level
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| * [[Antiphospholipid syndrome]]
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| * Long air travel
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| * [[Oral contraceptive]]s
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| * [[Obesity]]
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| * Smoking
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| * Minor injuries<ref name=Stralen>{{cite journal
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| | volume= 168 No. 1|date= January 14, 2008 |title=Minor Injuries as a Risk Factor for Venous Thrombosis
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| |author=Karlijn J. van Stralen, MSc; Frits R. Rosendaal, MD, PhD; Carine J. M. Doggen, PhD
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| |url=http://archinte.ama-assn.org/cgi/content/short/168/1/21
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| |journal=Arch Intern Med|pages=21–26 |pmid=18195191|doi=10.1001/archinternmed.2007.5}}</ref>
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| ===Following is a list of factors that increase the risk of developing deep vein thrombosis===
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| [http://www.cdc.gov Source: CDC]
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| * Injury to the vein, often caused by:
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| :* Fractures,
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| :* Severe muscle injury,
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| :* Major surgery (particularly involving the abdomen, pelvis, hip, or legs).
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| *Slow blood flow, often caused by:
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| :* Confinement to bed (e.g., due to a medical condition or after surgery);
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| :* Limited movement (e.g., a cast on a leg to help heal an injured bone;
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| :* Sitting for a long time, especially with crossed legs; or
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| :* Paralysis.
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| * Increased [[estrogen]], often caused by:
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| :* [[Birth control pills]];
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| :* [[Hormone replacement therapy]], sometimes used after [[menopause]]; or
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| :* [[Pregnancy]], for up to 6 weeks after giving birth.
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| * Certain chronic medical illnesses, such as:
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| :* [[Heart disease]]
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| :* [[Lung disease]]
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| :* [[Cancer]] and its treatment
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| :* [[Inflammatory bowel disease]] ([[Crohn’s disease]] or [[ulcerative colitis]])
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| :* [[Vasculitis]]
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| :* [[Systemic lupus erythematosus]] ([[SLE]])
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| :* [[Behçet's syndrome]]
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| :* [[Homocystinuria]]
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| * Trauma
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| :* Multiple trauma
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| :* CNS/spinal cord injury
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| :* Burns
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| :* Lower extremity fractures
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| * Other risk factors include:
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| :* Previous [[DVT]]
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| :* [[Family history of DVT]]
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| :* Age (risk increases as age increases)
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| :* [[Obesity]]
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| :* [[Smoking]]
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| :* [[High blood pressure]]
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| :* A catheter located in a central vein
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| :* Inherited clotting disorders. An inherited clotting disorder might be suspected when a person has repeated DVTs that cannot be linked to any specific cause (such as recent surgery) or develops DVT in a vein at an unusual location, such as a vein in the liver, kidney, or brain.
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| ==Diagnosis== | | ==Diagnosis== |
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| Diagnostic modalities may differ for [[deep venous thrombosis]] and [[pulmonary embolism]]. Some patients may have the both clinical situations.
| | [[Thromboembolism diagnostic criteria|Diagnostic Criteria]] | [[Thromboembolism history and symptoms|History and Symptoms]] | [[Thromboembolism physical examination|Physical Examination]] | [[Thromboembolism laboratory findings|Laboratory Findings]] | [[Thromboembolism electrocardiogram|EKG]] | [[Thromboembolism chest x ray|Chest X ray]] | [[Thromboembolism CT|CT]] | [[Thromboembolism MRI|MRI]] | [[Thromboembolism ultrasound|Ultrasound]] | [[Thromboembolism other imaging findings|Other Imaging Findings]] | [[Thromboembolism other diagnostic studies|Other Diagnostic Studies]] |
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| ===History and Symptoms===
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| There are several techniques during physical examination to increase the detection of DVT, such as measuring the circumference of the affected and the contralateral limb at a fixed point (to objectivate [[edema]]), and palpating the [[vein|venous]] tract, which is often tender. '''Physical examination alone is unreliable for excluding the diagnosis of deep vein thrombosis.'''
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| In '''phlegmasia alba dolens''', the leg is pale and cool with a diminished arterial pulse due to spasm. It usually results from acute occlusion of the iliac and [[femoral vein]]s due to [[DVT]].
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| In '''phlegmasia cerulea dolens''', there is an acute and nearly total venous occlusion of the entire extremity outflow, including the iliac and femoral veins. The leg is usually painful, cyanosed and oedematous. Venous gangrene may supervene.
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| It is vital that the possibility of [[pulmonary embolism]] be included in the history, as this may warrant further investigation (''see'' [[pulmonary embolism]]).
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| A careful history has to be taken considering [[risk factors of thromboembolism]], including the use of estrogen-containing methods of [[hormonal contraception]], recent long-haul flying, and a history of [[miscarriage]] (which is a feature of several disorders that can also cause thrombosis). A family history can reveal a [[genetic disorder|hereditary]] factor in the development of [[DVT]].
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| The symptoms and signs of thromboembolism may include:
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| * [[Tachypnea]]
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| * [[Dyspnea]]
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| * [[Chest pain]]
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| * Discomfort in the legs
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| * [[Pleuritic pain]]
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| * Apprehension and [[anxiety]]
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| * [[Cough]]
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| * [[Tachycardia]]
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| * [[Syncope]]
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| * [[Right heart failure]]
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| :* [[Jugular venous distention]]
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| :* [[Hepatomegaly]]
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| :* Left parasternal [[heave]]
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| * Fixed splitting of the [[second heart sound]]
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| * Dilation of the surface veins
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| * [[Hemoptysis]]
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| * [[Fever]]
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| * [[Hyperemia]] in [[thrombosis]], [[pallor]] in [[embolism]]
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| * Local swelling
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| * [[Pain|Local pain]]
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| * [[Tenderness]]
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| * [[Very low blood pressure]]
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| * [[Lightheadedness]]
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| ===Physical Examination===
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| * [[Homans' sign]]
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| * Pratt's sign: Squeezing of posterior calf elicits pain.
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| However, these [[medical sign]]s do not perform well and are not included in [[clinical prediction rule]]s that combine best findings in order to diagnose DVT.<ref name="pmid16403932">{{cite journal |author=Wells PS, Owen C, Doucette S, Fergusson D, Tran H |title=Does this patient have deep vein thrombosis? |journal=JAMA |volume=295 |issue=2 |pages=199-207 |year=2006 |pmid=16403932 |doi=10.1001/jama.295.2.199}}</ref>
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| (Images courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, California)
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| <gallery>
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| Image:Extremities dvt.jpg|Deep venous thrombosis: Right Lower Extremity DVT
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| Image:Extremities dvt2.jpg|Deep venous thrombosis: Left Lower Extremity DVT
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| Image:Extremities dvt3.jpg|Deep venous thrombosis: Left Lower Extremity DVT
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| <gallery>
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| </gallery>
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| Image:upper dvt.jpg|Deep venous thrombosis: Diffusely swollen RUE resulting from a PICC line induced thrombosis.
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| Image:extremities_dvt4.jpg|Left Lower Extremity DVT:Note diffusely swollen left leg. skin changes on left are due to chronic venous insufficiency.
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| </gallery>
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| [http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
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| <gallery>
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| Image:Thrombus in popliteal artery.jpg|Thromboembolic event of [[popliteal artery]]
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| Image:Central retinal vein thrombosis.jpg|Fundoscopy: [[Central retinal vein]] thrombosis
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| </gallery>
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| ===Probability scoring===
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| In 2006, Scarvelis and Wells overviewed a set of [[clinical prediction rule]]s for DVT,<ref>{{cite journal | author = Scarvelis D, Wells P | title = Diagnosis and treatment of deep-vein thrombosis. | journal = CMAJ | volume = 175 | issue = 9 | pages = 1087-92 | year = 2006 | id = PMID 17060659. [http://www.cmaj.ca/cgi/content/full/175/9/1087 Free Full Text] }}</ref> on the heels of a widely adopted set of clinical criteria for pulmonary embolism.<ref>Neff MJ. ACEP releases clinical policy on evaluation and management of pulmonary embolism. ''American Family Physician''. 2003; '''68'''(4):759-?. Available at: [http://www.aafp.org/afp/20030815/practice.html http://www.aafp.org/afp/20030815/practice.html]. Accessed on: December 8, 2006.</ref> <ref name="Wells"> Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000 Mar;83(3):416-20. PMID 10744147</ref>
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| ===Wells score or criteria===
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| (Possible score -2 to 9)
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| :1) Active cancer (treatment within last 6 months or palliative) -- 1 point
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| :2) Calf swelling >3 cm compared to other calf (measured 10 cm below tibial tuberosity) -- 1 point
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| :3) Collateral superficial veins (non-varicose) -- 1 point
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| :4) Pitting edema (confined to symptomatic leg) -- 1 point
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| :5) Swelling of entire leg - 1 point
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| :6) Localized pain along distribution of deep venous system -- 1 point
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| :7) Paralysis, paresis, or recent cast immobilization of lower extremities -- 1 point
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| :8) Recently bedridden > 3 days, or major surgery requiring regional or general anesthetic in past 12 weeks -- 1 point
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| :9) Previously documented DVT -- 1 point
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| :10) Alternative diagnosis at least as likely -- Subtract 2 points
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| ====Interpretation====
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| Traditional interpretation <ref name="Wells"> Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000 Mar;83(3):416-20. PMID 10744147</ref> <ref name="Wells2"> Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001 Jul 17;135(2):98-107. PMID 11453709</ref>
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| * Score >6.0 - High (probability 59% based on pooled data <ref name="pmid17185658">{{cite journal |author=Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD |title=Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators |journal=Radiology |volume=242 |issue=1 |pages=15-21 |year=2007 |doi=10.1148/radiol.2421060971 | pmid=17185658}}</ref>)
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| * Score 2.0 to 6.0 - Moderate (probability 29% based on pooled data<ref name="pmid17185658"/>)
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| * Score <2.0 - Low (probability 15% based on pooled data<ref name="pmid17185658"/>)
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| ====Alternate interpretation====
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| * Score > 4 - [[PE]] likely. Consider diagnostic imaging.<ref name="Wells"> Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000 Mar;83(3):416-20. PMID 10744147</ref> <ref>van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW, Kramer MH, Kruip MJ, Kwakkel-van Erp JM, Leebeek FW, Nijkeuter M, Prins MH, Sohne M, Tick LW; Christopher Study Investigators. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006 Jan 11;295(2):172-9. PMID 16403929</ref>
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| * Score 4 or less - [[PE]] unlikely. Consider [[D-dimer]] to rule out [[PE]].
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| ===Laboratory Tests===
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| In low/moderate suspicion of PE, a normal [[D-dimer]] level (shown in a blood test) is enough to exclude the possibility of thrombotic PE.<ref name="pmid8165626">{{cite journal |author=Bounameaux H, de Moerloose P, Perrier A, Reber G |title=Plasma measurement of D-dimer as diagnostic aid in suspected venous thromboembolism: an overview |journal=Thromb. Haemost. |volume=71 |issue=1 |pages=1-6 |year=1994 |pmid=8165626 |doi=}}</ref>
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| When a PE is being suspected, a number of blood tests are done, in order to exclude important secondary causes of PE. This includes a [[full blood count]], [[coagulation|clotting status]] ([[prothrombin time|PT]], [[APTT]], [[thrombin time|TT]]), and some screening tests ([[erythrocyte sedimentation rate]], [[renal function]], [[liver enzyme]]s, [[electrolyte]]s). If one of these is abnormal, further investigations might be warranted.
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| Plasma [[D-dimer]] level: [[D-dimer]] is a [[fibrin]] degradation product and an important marker of activated [[fibrinolysis]]. [[Enzyme linked immunoassay]] and latex turbidimetric assays methods provide its quantity. It can be elevated in [[pneumonia]], [[cancer]], [[sepsis]], and after [[surgery]]. [[D-dimer]] values increase progressively throughout [[pregnancy]], and the ranges for normal values by gestational week are not yet universally established. With low or moderate clinical suspicion, a negative [[d-dimer]] test rules out [[pulmonary embolism]].
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| ===Arterial Blood Gas===
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| * Acid-base status may demonstrate a [[respiratory alkalosis]].
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| * The [[arterial blood gas]] in room temperature demonstrates [[hypoxemia]] (PaO<sub>2</sub> <80 mm Hg) and an elevated alveolar / arterial oxygen gradient.
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| ===Electrocardiography===
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| * [[Sinus tachycardia]]
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| * [[Right axis deviation]]
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| * [[Right bundle branch block]]
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| * Deep and inverted [[T wave]]s in V<sub>1</sub> - V<sub>3</sub>
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| * S<sub>1</sub>Q<sub>3</sub>T<sub>3</sub> pattern
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| <gallery>
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| Image:Pulm embolism.jpg|ECG of a patient with pulmonary embolism <small>Image courtesy of [http://www.ecgpedia.org ecgpedia]</small>
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| Image:pulm_embolism_ecg2.jpg|Another example; a patient with pulmonary embolism. Note the tachycardia and right axis.<small>Image courtesy of [http://www.ecgpedia.org ecgpedia]</small>
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| Image:V18.ht22.jpg|Pulmonary embolism. S1-Q3 and signs of right frontal axis are shown. <small>Image courtesy of Dr Jose Ganseman [http://www.ganseman.com/ecgbibnl.htm#_top000 Dr Ganseman's webpage]</small>
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| </gallery>
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| ===X-ray===
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| * In normal range in majority of cases
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| * [[Chest x ray]]s may reveal an enlarged right descending [[pulmonary artery]]
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| * Decreased pulmonary vascularity ([[Westermark sign]])
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| * A wedge shaped infiltrate
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| * An elevation of the hemidiaphragm ([[Hampton's hump]])
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| * [[Pleural effusion]] (usually predicts the presence of an infarction)
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| ===Doppler Ultrasonography===
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| [http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology] </small>
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| <gallery>
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| Image:Deep venous thrombosis 1.jpg|Deep venous thrombosis
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| Image:Deep venous thrombosis 2.jpg|Deep venous thrombosis
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| Image:Deep venous thrombosis 3.jpg|Deep venous thrombosis
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| Image:Deep venous thrombosis 4.jpg|Deep venous thrombosis
| |
| </gallery>
| |
| | |
| (Images shown below are courtesy of RadsWiki)
| |
| | |
| <gallery>
| |
| Image:Greater saphenous vein thrombosis 001.jpg|Greater saphenous vein thrombosis
| |
| Image:Greater saphenous vein thrombosis 002.jpg|Greater saphenous vein thrombosis
| |
| </gallery>
| |
| | |
| | |
| <gallery>
| |
| Image:Upper extremity deep vein thrombosis 001.jpg|Upper extremity deep vein thrombosis
| |
| Image:Upper extremity deep vein thrombosis 002.jpg|Upper extremity deep vein thrombosis
| |
| Image:Upper extremity deep vein thrombosis 003.jpg|Upper extremity deep vein thrombosis
| |
| Image:Upper extremity deep vein thrombosis 004.jpg|Upper extremity deep vein thrombosis
| |
| </gallery>
| |
| | |
| ===Echocardiography===
| |
| | |
| * '''Thrombus in Left Atrial Appendage'''
| |
| | |
| | |
| <googlevideo>1194621255843080155&hl=en</googlevideo>
| |
| | |
| | |
| ===Computed Tomography and CT Angiography===
| |
| | |
| ''[[Computed tomography]] with [[radiocontrast]]'', effectively a [[pulmonary angiography|pulmonary angiogram]] imaged by CT and also known as [[CT pulmonary angiogram|CT pulmonary angiography]] (CTPA), is increasingly used as the mainstay in diagnosis. Advantages are clinical equivalence, its non-invasive nature, its greater availability to patients, and the possibility of picking up other lung disorders from the [[differential diagnosis]] in case there is no pulmonary embolism.
| |
| | |
| ====CT findings in Acute PE====
| |
| *Thrombus is located centrally within the vascular lumen or occludes the vessel (vessel cut-off sign)
| |
| *Commonly causes distention of the involved vessel.
| |
| | |
| ====CT findings in Chronic PE====
| |
| *Eccentric and contiguous changes of the vessel wall
| |
| *Reduces the arterial diameter by more than 50%
| |
| *Evidence of recanalization within the thrombus
| |
| *An arterial web is present
| |
| | |
| <gallery>
| |
| Image:DVT-001.jpg|Left leg. [[Deep venous thrombosis]]
| |
| Image:DVT-002.jpg|Left leg. [[Deep venous thrombosis]]
| |
| Image:PE on CT angiogram.jpg|CT pulmonary angiogram. Clots in both the left and the right pulmonary arteries (red arrows). [http://www.e-radiography.net Source]
| |
| </gallery>
| |
| | |
| | |
| '''Patient with Shortness of Breath'''
| |
| | |
| <gallery>
| |
| Image:Pulmonary embolism 001.jpg|[[Pulmonary embolism]]: Patient presented with [[Shortness of breath]]
| |
| Image:Pulmonary embolism 002.jpg|[[Pulmonary embolism]]: Patient presented with [[Shortness of breath]]
| |
| Image:Pulmonary embolism 003.jpg|[[Pulmonary embolism]]: Patient presented with [[Shortness of breath]]
| |
| Image:Pulmonary embolism 004.jpg|[[Pulmonary embolism]]: Patient presented with [[Shortness of breath]]
| |
| </gallery>
| |
| | |
| | |
| '''Patient with Acute RBBB'''
| |
| | |
| <gallery>
| |
| Image:Pulmonary-embolism-101.jpg|[[Pulmonary embolism]]: Patient presented with Acute [[RBBB]]
| |
| Image:Pulmonary-embolism-102.jpg|[[Pulmonary embolism]]: Patient presented with Acute [[RBBB]]
| |
| </gallery>
| |
| | |
| ===MR and MR Angiography===
| |
| | |
| * Gadolinium-enhanced MRI is a non-invasive diagnostic modality and has the advantage of no contrast exposure.
| |
| * A potential benefit of MR, is that is incredibly sensitive, perhaps even better than contrast venography, in imaging clot in the inferior vena cava (IVC) and pelvic veins, and these images can be obtained at the same time as the lung scan.
| |
| * It needs to be pointed out, that although the criticism of using CT and MR angio lacks sensitivity when examining the subsegmental arteries, inter-reader agreement was only 66% with pulmonary angiography in PIOPED.
| |
| | |
| {Images shown below are courtesy of RadsWiki)
| |
| | |
| <gallery>
| |
| Image:Deep-vein-thrombosis-on-MRV-001.jpg|2D TOF GRE MRV images: Bilateral [[deep vein thrombosis]]
| |
| Image:Deep-vein-thrombosis-on-MRV-002.jpg|2D TOF GRE MRV images: Bilateral [[deep vein thrombosis]]
| |
| Image:Deep-vein-thrombosis-on-MRV-003.jpg|2D TOF GRE MRV images: Bilateral [[deep vein thrombosis]]
| |
| </gallery>
| |
| | |
| | |
| <gallery>
| |
| Image:Superficial_vein_thrombosis_MRI_001.jpg|MRI: Superficial vein thrombosis
| |
| Image:Superficial_vein_thrombosis_MRI_002.jpg|MRI: Superficial vein thrombosis
| |
| Image:Superficial_vein_thrombosis_MRI_003.jpg|MRI: Superficial vein thrombosis
| |
| </gallery>
| |
| | |
| ===Contrast Venography===
| |
| | |
| Contrast venography (also called '''Venography''' or '''phlebography''') is the definitive test for diagnosing [[deep venous thrombosis]] which taken after a special dye is injected into the vein or even bone marrow.
| |
| | |
| Contrast venography can also help;
| |
| | |
| * to distinguish blood clots from obstructions in the veins
| |
| * to evaluate congenital vein problems
| |
| * to evaluate veins prior to treatment of chronic venous insufficiency
| |
| * to control functioning of deep leg vein valves
| |
| * to identify a vein graft for coronary artery bypass surgery
| |
| | |
| <gallery>
| |
| Image:DVT 1.jpg|Venography: Deep venous thrombosis. [http://www.lakeridgehealth.on.ca Source]
| |
| Image:Venous thrombosis with collateral.jpg|An occluded vein with collateral vessel formation. [http://www.lakeridgehealth.on.ca Source]
| |
| </gallery>
| |
| | |
| ===Pulmonary Angiography===
| |
| | |
| '''Pulmonary angiography''' (or '''pulmonary arteriography''') is a [[cardiology|cardiological]] [[medicine|medical]] procedure. Pulmonary arteries are visualized to detect [[blood clot]]s (such as a [[pulmonary embolism]]) or [[arteriovenous malformation]]s.
| |
| | |
| The use of pulmonary angiography has been largely replaced by spiral CT in diagnosis of [[pulmonary embolism]].
| |
| | |
| <gallery>
| |
| Image:Pe on pulmonary angiography.jpg|Pulmonary angiogram in a patient with [[pulmonary embolus]]. A thrombus is observed in the area within the yellow circle. [http://www.e-radiography.net Source]
| |
| </gallery>
| |
| | |
| ===Ventilation / Perfusion Scan===
| |
| | |
| ''[[Ventilation/perfusion scan]]'' (or ''V/Q scan'' or ''lung [[scintigraphy]]''), which shows that some areas of the lung are being ventilated but not perfused with blood (due to obstruction by a clot). This type of examination is used less often because of the more widespread availability of CT technology, however, it may be useful in patients who have an allergy to [[iodinated contrast]] or in [[pregnancy]] due to lower radiation exposure than CT. * The ventilation/perfusion ratio (V/Q) Scan: The PIOPED data suggests that normal perfusion scans are almost never associated with recurrent pulmonary embolism, even if anticoagulation is withheld.
| |
| | |
| ===Other Methods===
| |
| | |
| ====Impedance plethysmography====
| |
| | |
| Impedance phlebography or impedance plethysmography is a [[non-invasive (medical)|non-invasive]] medical test that measures small changes in [[electrical resistance]] of the chest, calf or other regions of the body. These measurements reflect [[blood volume]] changes, and can indirectly indicate the presence or absence of [[venous thrombosis]]. This procedure provides an alternative to [[venography]], which is invasive and requires a great deal of skill to execute adequately and interpret accurately.
| |
| | |
| For the chest, the technique was developed by NASA to measure the split second impedance changes within the chest, as the heart beats, to calculate both cardiac output and lung water content. This technique has progressed clinically (often now called BioZ, i.e. biologic impedance) and allows low cost, non-invasive estimations of [[cardiac output]] and [[total peripheral resistance]], using only 4 skin electrodes, oscillometric [[blood pressure]] measurement and lung water volumes with minimal removal of clothing in physician offices having the needed equipment.
| |
| | |
| For leg veins, the test measures blood volume in the lower leg due to temporary venous obstruction. This is accomplished by inflating a pneumatic cuff around the thigh to sufficient pressure to cut off venous flow but not arterial flow, causing the venous blood pressure to rise until it equals the pressure under the cuff. When the cuff is released there is a rapid venous runoff and a prompt return to the resting blood volume. Venous thrombosis will alter the normal response to temporary venous obstruction in a highly characteristic way, causing a delay in emptying of the venous system after the release of the [[tourniquet]]. The increase in blood volume after cuff inflation is also usually diminished.
| |
|
| |
|
| ==Treatment== | | ==Treatment== |
|
| |
|
| ===A. Deep Venous Thrombosis===
| | [[Thromboembolism medical therapy|Medical Therapy]] | [[Thromboembolism surgery|Surgery]] | [[Thromboembolism primary prevention|Primary Prevention]] | [[Thromboembolism secondary prevention|Secondary Prevention]] | [[Thromboembolism cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Thromboembolism future or investigational therapies|Future or Investigational Therapies]] |
| | |
| ====Hospitalization====
| |
| Treatment at home is an option according to a [[meta-analysis]] by the [[Cochrane Collaboration]].<ref name="pmid17636714">{{cite journal |author=Othieno R, Abu Affan M, Okpo E |title=Home versus in-patient treatment for deep vein thrombosis |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD003076 |year=2007 |pmid=17636714 |doi=10.1002/14651858.CD003076.pub2}}</ref>
| |
| | |
| Hospitalization should be considered in patients with more than two of the following risk factors as these patients may have more risk of complications during treatment<ref name="pmid16926081">{{cite journal |author=Trujillo-Santos J, Herrera S, Page MA, ''et al'' |title=Predicting adverse outcome in outpatients with acute deep vein thrombosis. findings from the RIETE Registry |journal=J. Vasc. Surg. |volume=44 |issue=4 |pages=789-93 |year=2006 |pmid=16926081 |doi=10.1016/j.jvs.2006.06.032}}</ref>:
| |
| | |
| * bilateral [[deep venous thrombosis]]
| |
| * [[renal insufficiency]]
| |
| * body weight <70 kg
| |
| * recent prolonged immobility
| |
| * [[chronic heart failure]]
| |
| * [[cancer]]
| |
| | |
| ====Anticoagulation====
| |
| {{main|Anticoagulation}}
| |
| [[Anticoagulation]] is the usual treatment for DVT. In general, patients are initiated on a brief course (i.e., less than a week) of [[heparin]] treatment while they start on a 3- to 6-month course of [[warfarin]] (or related [[vitamin K]] inhibitors). [[Low molecular weight heparin]] ([[LMWH]]) is preferred,<ref name="pmid17261857">{{cite journal |author=Snow V, Qaseem A, Barry P, ''et al'' |title=Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians |journal=Ann. Intern. Med. |volume=146 |issue=3 |pages=204-10 |year=2007 |pmid=17261857 |doi=|url=http://www.annals.org/cgi/content/full/146/3/204}}</ref> though [[unfractionated heparin]] is given in patients who have a contraindication to [[LMWH]] (e.g., [[renal failure]] or imminent need for invasive procedure). In patients who have had ''recurrent DVTs'' (two or more), anticoagulation is generally "life-long." The [[Cochrane Collaboration]] has meta-analyzed the risk and benefits of prolonged anti-coagulation.<ref name="pmid16437432">{{cite journal |author=Hutten BA, Prins MH |title=Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism |journal=Cochrane database of systematic reviews (Online) |volume= |issue=1 |pages=CD001367 |year=2006 |pmid=16437432 |doi=10.1002/14651858.CD001367.pub2}}</ref> | |
| | |
| An abnormal [[D-dimer]] level at the end of treatment might signal the need for continued treatment among patients with a first unprovoked proximal deep-vein thrombosis.<ref name="pmid17065639">{{cite journal |author=Palareti G, Cosmi B, Legnani C, ''et al'' |title=D-dimer testing to determine the duration of anticoagulation therapy |journal=N. Engl. J. Med. |volume=355 |issue=17 |pages=1780-9 |year=2006 |pmid=17065639 |doi=10.1056/NEJMoa054444}}</ref>
| |
| | |
| ====Thrombolysis====
| |
| {{main|Thrombolysis}}
| |
| [[Thrombolysis]] is generally reserved for extensive clot, e.g. an iliofemoral thrombosis. Although a [[meta-analysis]] of [[randomized controlled trials]] by the [[Cochrane Collaboration]] shows improved outcomes with [[thrombolysis]],<ref name="pmid15495034">{{cite journal |author=Watson L, Armon M |title=Thrombolysis for acute deep vein thrombosis |journal=Cochrane Database Syst Rev |volume= |issue= |pages=CD002783 |year= |id=PMID 15495034}}</ref> there may be an increase in serious bleeding complications.
| |
| | |
| ====Inferior vena cava filter====
| |
| | |
| {{main|Inferior vena cava filter}}
| |
| [[Inferior vena cava filter]] reduces pulmonary embolism<ref name="pmid9459643">{{cite journal |author=Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral F, Huet Y, Simonneau G |title=A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group |journal=N Engl J Med |volume=338 |issue=7 |pages=409-15 |year=1998 |id=PMID 9459643}}</ref> and is an option for patients with an absolute contraindiciation to anticoagulant treatment (e.g., cerebral hemorrhage) or those rare patients who have objectively documented recurrent PEs while on anticoagulation, an [[inferior vena cava filter]] (also referred to as a ''[[Greenfield filter]]'') may prevent pulmonary embolisation of the leg clot. However these filters are themselves potential foci of thrombosis,<ref name="pmid16009794">{{cite journal |author= |title=Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d'Embolie Pulmonaire par Interruption Cave) randomized study |journal=Circulation |volume=112 |issue=3 |pages=416-22 |year=2005 |id=PMID 16009794}}</ref> IVC filters are viewed as a temporizing measure for preventing life-threatening pulmonary embolism.<ref name="pmid17636834">{{cite journal |author=Young T, Aukes J, Hughes R, Tang H |title=Vena caval filters for the prevention of pulmonary embolism |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD006212 |year=2007 |pmid=17636834 |doi=10.1002/14651858.CD006212.pub2}}</ref> | |
| | |
| ====Compression stockings====
| |
| Elastic [[compression stockings]] should be routinely applied "beginning within 1 month of diagnosis of proximal DVT and continuing for a minimum of 1 year after diagnosis".<ref name="pmid17261857">{{cite journal |author=Snow V, Qaseem A, Barry P, ''et al'' |title=Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians |journal=Ann. Intern. Med. |volume=146 |issue=3 |pages=204-10 |year=2007 |pmid=17261857 |doi=|url=http://www.annals.org/cgi/content/full/146/3/204}}</ref> Starting within one week may be more effective.<ref name="pmid15313740">{{cite journal |author=Prandoni P, Lensing AW, Prins MH, ''et al'' |title=Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial |journal=Ann. Intern. Med. |volume=141 |issue=4 |pages=249-56 |year=2004 |pmid=15313740 |doi=}}</ref> The stockings in almost all trials were ''stronger than routine anti-embolism stockings'' and created either 20-30 mm Hg or 30-40 mm Hg. Most trials used knee-high stockings. A [[meta-analysis]] of [[randomized controlled trials]] by the [[Cochrane Collaboration]] showed reduced incidence of post-phlebitic syndrome.<ref name="pmid14974060">{{cite journal |author=Kolbach D, Sandbrink M, Hamulyak K, Neumann H, Prins M |title=Non-pharmaceutical measures for prevention of post-thrombotic syndrome |journal=Cochrane Database Syst Rev |volume= |issue= |pages=CD004174 |year= |id=PMID 14974060 | doi = 10.1002/14651858.CD004174.pub2}}</ref> The [[number needed to treat]] is quite potent at 4 to 5 patients need to prevent one case of post-phlebitic syndrome.<ref name="pmid17003920">{{cite journal |author=Kakkos S, Daskalopoulou S, Daskalopoulos M, Nicolaides A, Geroulakos G |title=Review on the value of graduated elastic compression stockings after deep vein thrombosis |journal=Thromb Haemost |volume=96 |issue=4 |pages=441-5 |year=2006 |id=PMID 17003920}}</ref>
| |
| | |
| ====Surgical Therapy====
| |
| | |
| * Thrombectomy
| |
| * Venous ligation: Not used anymore
| |
| | |
| ===B. Pulmonary Embolism===
| |
| | |
| Emergency treatment at a hospital is necessary to treat [[pulmonary embolism]].
| |
| | |
| ===Acute Pharmacotherapy===
| |
| | |
| ===Chronic Pharmacotherapy===
| |
| | |
| ===Surgical Therapy===
| |
| | |
| * Pulmonary embolectomy: it has a high mortality rate.
| |
| | |
| ===Treatment in Special Population===
| |
| | |
| ====1. Pregnancy====
| |
| | |
| * [[Warfarin]] is '''contraindicated''' during [[pregnancy]]. It crosses the placenta and increases the risk of [[miscarriage]], [[stillbirth]], embryopathy (nasal hypoplasia or stippled epiphyses), [[central nervous system]] abnormalities, maternal hemorrhage and fetal hemorrhage. It is safe to use it in [[postpartum period]] and is compatible with [[breastfeeding]].
| |
| * [[Low-molecular-weight heparin]] has largely replaced [[unfractionated heparin]] for prophylaxis and treatment.
| |
| | |
| ====2. Elderly====
| |
| | |
| ====3. Renal Failure====
| |
| | |
| ====4. Newborn and Early Childhood====
| |
| | |
| ==American Heart Association's Guidelines==
| |
| | |
| ==American Family Physician's Guidelines==
| |
| | |
| ==Complications==
| |
| | |
| * Postthrombotic syndrome
| |
| * Chronic thromboembolic pulmonary hypertension
| |
|
| |
|
| ==Prevention== | | ==Related Chapters== |
| | |
| ==Pathological Findings==
| |
| | |
| [http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
| |
| | |
| A 67-year-old male was hospitalized because of extensive atherosclerotic cardiovascular disease. Following surgery, during which diseased portions of the femoral arteries were bypassed, he developed massive pulmonary embolism and expired. At autopsy, thrombi were found in the femoral and iliac veins, as well as in the larger pulmonary arteries.
| |
| | |
| [[Image:Thromboembolus 1.jpg|left|thumb|400px|This is a gross photograph of a cut section of lung demonstrating thromboemboli in the pulmonary arteries (arrows).]]
| |
| <br clear="left"/>
| |
| | |
| [[Image:Thromboembolus 2.jpg|left|thumb|400px|This is a gross photograph of the heart with the main pulmonary artery opened. Note the thromboembolus filling the pulmonary artery (arrows).]]
| |
| <br clear="left"/>
| |
| | |
| [[Image:Thromboembolus 3.jpg|left|thumb|400px|This is a gross photograph of portions of muscle from the legs including sections of leg veins. Note that the leg veins contain thrombus (arrows). ]]
| |
| <br clear="left"/>
| |
| | |
| [[Image:Thromboembolus 4.jpg|left|thumb|400px|This is a low-power photomicrograph of lung. A large thrombus is lodged at this branch point in the pulmonary artery. Note the hemorrhage and congestion in the surrounding lung parenchyma.]]
| |
| <br clear="left"/>
| |
| | |
| [[Image:Thromboembolus 5.jpg|left|thumb|400px|This is a photomicrograph of the wall of the pulmonary artery (1) containing the thromboembolus. In this case the artery wall looks normal. If this was a thrombus instead of a thromboembolus, you would expect to see some damage in the artery wall that would have initiated the thrombus. Note the lines of Zahn in the thromboembolus (arrows).]]
| |
| <br clear="left"/>
| |
| | |
| [[Image:Thromboembolus 6.jpg|left|thumb|400px|This is a low-power photomicrograph of the infarcted lung. The tissue is congested and has a very bland appearance due to coagulation necrosis of the lung parenchyma. You can still see the outlines of the alveoli and the cells that make-up the alveoli but there is almost complete loss of nuclei throughout this section.]]
| |
| <br clear="left"/>
| |
| | |
| ===Thromboembolism: Testes===
| |
| | |
| [[Image:Thromboembolus 7.jpg|left|thumb|400px|This is a gross photograph of an infarcted testis. Because of the anatomy of the blood supply to the testis, torsion or the blood vessels often leads to venous occlusion (due to compression of the thin walled veins) but not arterial occlusion. Thus, blood still flows into the testis but it can’t get out! This leads to hypoxia and eventually to hemorrhagic necrosis. ]]
| |
| <br clear="left"/>
| |
| | |
| [[Image:Thromboembolus 8.jpg|left|thumb|400px|This is a gross photograph of cut section of testis from previous image. The tissue is filled with blood. ]]
| |
| <br clear="left"/>
| |
| | |
| ===Thromboembolism: Bowel infarction===
| |
| | |
| [[Image:Thromboembolus 9.jpg|left|thumb|400px|This is a gross photograph of an opened abdomen at autopsy demonstrating loops of infarcted bowel (arrow). Vascular occlusion can lead to ischemic necrosis of the bowel. In this case, a section of bowel herniated through a fibrous connective tissue band and was strangulated, leading to ischemic necrosis.]]
| |
| <br clear="left"/>
| |
| | |
| [[Image:Thromboembolus 10.jpg|left|thumb|400px|This is a gross photograph of the fibrous band between the uterus and adjacent tissues. This fibrous scar tissue is probably left over from a previous surgery or an infection. A loop of bowel herniated through the opening produced by this fibrous band and became incarcerated leading to the ischemic necrosis seen in the previous image.]]
| |
| <br clear="left"/>
| |
| | |
| ===Coronary thrombosis===
| |
| | |
| [http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
| |
| | |
| [[Image:Coronary thrombosis 1.jpg|left|thumb|400px|This is a gross photograph of thrombosed coronary artery (arrows).]]
| |
| <br clear="left"/>
| |
|
| |
| [[Image:Coronary thrombosis 2.jpg|left|thumb|400px|This is a low-power photomicrograph of thrombosed coronary artery. The thrombus (1) completely occludes the vessel. Note the layering of the thrombus. The fibrous cap is ruptured (arrow) and there is hemorrhage into the atherosclerotic plaque. Note the cholesterol crystals in the plaque.]]
| |
| <br clear="left"/>
| |
| | |
| [[Image:Coronary thrombosis 3.jpg|left|thumb|400px|This is a higher-power photomicrograph of the ruptured fibrous cap (arrows) with hemorrhage (1) into the atherosclerotic plaque.]]
| |
| <br clear="left"/>
| |
| | |
| [[Image:Coronary thrombosis 4.jpg|left|thumb|400px|This is another high-power photomicrograph of the ruptured fibrous cap (arrows) with hemorrhage (1) into the atherosclerotic plaque. Note the presence of cholesterol crystals.]]
| |
| <br clear="left"/>
| |
| | |
| [[Image:Coronary thrombosis 5.jpg|left|thumb|400px|This is a high-power photomicrograph of thrombus attached to the wall of the vessel. There is early organization of the thrombus (arrow). ]]
| |
| <br clear="left"/>
| |
| | |
| [[Image:Coronary thrombosis 6.jpg|left|thumb|400px|This is a higher-power photomicrograph of thrombus attached to the wall of the vessel. Note the early organization with in-growth of fibroblasts and small blood vessels from the wall of the artery (arrows).]]
| |
| <br clear="left"/>
| |
| | |
| [[Image:Coronary thrombosis 7.jpg|left|thumb|400px|In this low-power photomicrograph of another coronary artery from this patient, a mural thrombus has undergone re-organization. The mural thrombus has been invaded by the in-growth of fibroblasts and small blood vessels from the wall of the artery. The thrombotic material has been phagocytosed and removed by macrophages and is replaced by fibrous connective tissue and blood vessels. This re-organized thrombus still compromises the lumen of this vessel. ]]
| |
| <br clear="left"/>
| |
| | |
| [[Image:Coronary thrombosis 8.jpg|left|thumb|400px|This is a higher-power photomicrograph of the vessel wall. The adventitia (1) and the media (2) contain inflammatory cells. The recanalized portion of the vessel is composed of fibrous connective tissue and contains numerous small blood vessels. There is a small area of hemorrhage (arrow) in the central portion of this image.]]
| |
| <br clear="left"/>
| |
|
| |
| [[Image:Coronary thrombosis 9.jpg|left|thumb|400px|This is a higher-power photomicrograph of another region of the vessel wall. The adventitia (1) and the media (2) contain inflammatory cells. The recanalized portion of the vessel (3) is composed of fibrous connective tissue and contains numerous small blood vessels (arrows). ]]
| |
| <br clear="left"/>
| |
| | |
| [[Image:Coronary thrombosis 10.jpg|left|thumb|400px|This is a high-power photomicrograph of the luminal surface of a re-canalized vessel. Note that the vessel lumen is lined by endothelial cells (arrows). ]]
| |
| <br clear="left"/>
| |
| | |
| ===Artificial heart valve thrombosis===
| |
| | |
| [[Image:Artificial heart valve thrombosis.jpg|left|thumb|400px|Artificial heart valve thrombosis: Gross, [[aortic valve]] prosthesis with acute thrombus, ventricular view]]
| |
| <br clear="left"/>
| |
| | |
| [[Image:Artificial mitral valve thrombosis.jpg|left|thumb|400px|[[Mitral valve]] prosthesis with thrombosis: Gross, natural color, view from the left atrium, thrombus around rim of caged ball prosthesis. ]]
| |
| <br clear="left"/>
| |
| | |
| ==References==
| |
| {{Reflist|2}}
| |
| | |
| ==Additional Resources==
| |
| | |
| * [http://www.themdtv.org The MD TV: Comments on Hot Topics, State of the Art Presentations in Cardiovascular Medicine, Expert Reviews on Cardiovascular Research]
| |
| * [http://www.clinicaltrialresults.org Clinical Trial Results: An up to dated resource of Cardiovascular Research]
| |
| * [http://www.venousdiseasecoalition.org Venous Disease Coalition]
| |
| * [http://www.stoptheclot.org The National Alliance for Thrombosis and Thrombophilia]
| |
| | |
| ==See Also==
| |
|
| |
|
| * [[Pulmonary embolism case studies]] | | * [[Pulmonary embolism case studies]] |
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| * [[Thrombosis]] | | * [[Thrombosis]] |
| * [[Embolism]] | | * [[Embolism]] |
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| ==External Links==
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| * [http://www.venous-info.com American Venous Forum]
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| * [http://www.phlebology.org American College of Phlebology]
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| * [http://www.vdf.org Vascular Disease Foundation]
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| * [http://www.lymphnet.org National Lymphedema Network]
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| * [http://www.mylymphedema.com MyLymphedema]
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| {{Circulatory system pathology}} | | {{Circulatory system pathology}} |
| {{Electrocardiography}} | | {{Electrocardiography}} |
| {{Symptoms and signs}} | | {{Symptoms and signs}} |
| {{SIB}}
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| | [[Category:Disease]] |
| [[Category:Cardiology]] | | [[Category:Cardiology]] |
| | [[Category:Hematology]] |
| | [[Category:Angiology]] |
| | [[Category:Cardiovascular diseases]] |
| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
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| {{WikiDoc Help Menu}} | | {{WikiDoc Help Menu}} |
| {{WikiDoc Sources}} | | {{WikiDoc Sources}} |