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| {{Infobox_Disease |
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| Name = {{PAGENAME}} |
| | {| class="infobox" style="float:right;" |
| Image = |
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| Caption = |
| | | [[File:Siren.gif|30px|link=Deep vein thrombosis resident survival guide]]|| <br> || <br> |
| DiseasesDB = 3498 |
| | | [[Deep vein thrombosis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| ICD10 = {{ICD10|I|80|2|i|80}} |
| | |} |
| ICD9 = {{ICD9|453.40}} |
| | {{Deep vein thrombosis}} |
| ICDO = |
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| OMIM = |
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| MedlinePlus = |
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| MeshID = D020246 |
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| {{SI}}
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| {{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
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| ==Overview==
| | '''For patient information page, click [[{{PAGENAME}} (patient information)|here]]''' |
| '''Deep-vein thrombosis''' (also known as '''deep-venous thrombosis''' or '''DVT''' and colloquially as '''economy class syndrome''') is the formation of a [[blood clot]] ("thrombus") in a [[deep vein]]. It commonly affects the [[leg]] [[vein]]s, such as the [[femoral vein]] or the [[popliteal vein]] or the deep veins of the pelvis. Occasionally the veins of the [[arm]] are affected (known as ''[[Paget-Schrötter disease]]''). [[Thrombophlebitis]] is the more general class of pathologies of this kind. There is a significant risk of the thrombus embolizing and traveling to the lungs causing a [[pulmonary embolism]]. | |
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| ==Epidemiology==
| | '''For economy class syndrome, click [[economy class syndrome|here]]''' |
| DVTs occur in about 1 per 1000 persons per year. About 1-5% will die from the complications (i.e. [[pulmonary embolism]]).
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| DVT is much less common in the pediatric population. About 1 in 100,000 people under the age of 18 experiences deep vein thrombosis, possibly due to a child's high rate of heartbeats per minute, relatively active lifestyle when compared with adults, and fewer comorbodities (e.g. malignancy).
| | '''For main page on venous thrombosis, click [[Venous thrombosis|here]]''' |
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| ==Etiology==
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| {{main|Thrombosis}}
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| [[Virchow's triad]] is a group of 3 factors known to affect clot formation: rate of flow, the consistency (thickness) of the blood, and qualities of the vessel wall. Virchow noted that more deep venous thrombosis occurred in the left leg than in the right and proposed compression of the left common iliac vein by the overlying right common iliac artery as the underlying cause (see [[May-Thurner syndrome]]).<ref>Virchow R. Ueber die Erweiterung kleinerer Gefäfse. Arch Pathol Anat Physiol Klin Med 1851;3:427-62. </ref>
| | '''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; {{AE}} {{CZ}}; [[User:Kashish Goel|Kashish Goel, M.D.]]; [[User:Justine Cadet|Justine Cadet]]; {{Rim}} |
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| The most common risk factors are recent surgery or hospitalization.<ref name="pmid17646600">{{cite journal |author=Spencer FA, Lessard D, Emery C, Reed G, Goldberg RJ |title=Venous thromboembolism in the outpatient setting |journal=Arch. Intern. Med. |volume=167 |issue=14 |pages=1471-5 |year=2007 |pmid=17646600 |doi=10.1001/archinte.167.14.1471}}</ref> 40% of these patients did not receive heparin prophylaxis. Other risk factors include advanced age, obesity, infection, immobilization, female sex, use of combined (estrogen-containing) forms of [[hormonal contraception]], tobacco usage and air travel ("[[economy class syndrome]]", a combination of immobility and relative dehydration) are some of the better-known causes.<ref>{{cite journal | author = Tsai A, Cushman M, Rosamond W, Heckbert S, Polak J, Folsom A | title = Cardiovascular risk factors and venous thromboembolism incidence: the longitudinal investigation of thromboembolism etiology. | journal = Arch Intern Med | volume = 162 | issue = 10 | pages = 1182-9 | year = 2002 | id = PMID 12020191}}</ref> [[Thrombophilia]] (tendency to develop thrombosis) often expresses itself with recurrent thromboses.
| | {{SK}} DVT |
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| It is recognized that thrombi usually develop first in the calf veins, "growing" in the direction of flow of the vein. DVTs are distinguished as being above or below the [[popliteal]] vein. Very extensive DVTs can extend into the [[iliac vein]]s or the [[inferior vena cava]]. The risk of pulmonary embolism is higher in the presence of more extensive clots.
| | ==[[Deep vein thrombosis overview|Overview]]== |
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| Who Is At Risk for Deep Vein Thrombosis?
| | ==[[Deep vein thrombosis classification scheme|Classification]]== |
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| Many factors increase your risk for deep vein thrombosis (DVT). They include:
| | ==[[Deep vein thrombosis pathophysiology|Pathophysiology]]== |
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| * A history of DVT.
| | ==[[Deep vein thrombosis causes|Causes]]== |
| * Disorders or factors that make your blood thicker or more likely to clot than normal. Certain inherited blood disorders (such as factor V Leiden) will do this. This also is true of treatment with hormone replacement therapy or using birth control pills.
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| * Injury to a deep vein from surgery, a broken bone, or other trauma.
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| * Slow blood flow in a deep vein from lack of movement. This may occur after surgery, if you're ill and in bed for a long time, or if you're traveling for a long time.
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| * Pregnancy and the first 6 weeks after giving birth.
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| * Recent or ongoing treatment for cancer.
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| * A central venous catheter. This is a tube placed in vein to allow easy access to the bloodstream for medical treatment.
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| * Being older than 60 (although DVT can occur in any age group).
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| * Being overweight or obese.
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| ==Diagnosis== | | ==[[Deep vein thrombosis differential diagnosis|Differentiating Deep Vein Thrombosis from other Diseases]]== |
| The [[gold standard (test)|gold standard]] is ''intravenous venography'', which involves injecting a peripheral [[vein]] of the affected limb with a [[contrast agent]] and taking [[X-ray]]s, to reveal whether the [[vein|venous]] supply has been obstructed. Because of its invasiveness, this test is rarely performed.
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| ===Signs and symptoms=== | | ==[[Deep vein thrombosis epidemiology and demographics|Epidemiology and Demographics]]== |
| There may be no symptoms referrable to the location of the DVT, but the classical symptoms of DVT include [[Pain and nociception|pain]], [[swelling]] and redness of the [[leg]] and dilation of the surface veins. In up to 25% of all hospitalized patients, there may be ''some'' form of DVT, which often remains clinically inapparent (unless [[pulmonary embolism]] develops).
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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 is unreliable for excluding the diagnosis of deep vein thrombosis.
| | ==[[Deep vein thrombosis risk factors|Risk Factors]]== |
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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 veins due to DVT.
| | ==[[Deep vein thrombosis triggers|Triggers]]== |
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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.
| | ==[[Deep vein thrombosis screening|Screening]]== |
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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]]).
| | ==[[Deep vein thrombosis natural history|Natural History, Complications and Prognosis]]== |
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| A careful history has to be taken considering ''risk factors'' (see below), 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.
| | ==Diagnosis== |
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| <gallery>
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| Image:Extremities dvt.jpg|Deep venous thrombosis
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| Image:Extremities dvt2.jpg|Deep venous thrombosis
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| Image:Extremities dvt3.jpg|Deep venous thrombosis
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| </gallery>
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| ===Physical examination=== | |
| # [[Homan's test]]: Dorsiflexion of foot elicits pain in posterior calf
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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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| ===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>{{cite journal | author = Wells P, Anderson D, Rodger M, Ginsberg J, Kearon C, Gent M, Turpie A, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J | title = Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. | journal = Thromb Haemost | volume = 83 | issue = 3 | pages = 416-20 | year = 2000 | id = 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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| : Score of 2 or higher - deep vein thrombosis is likely. Consider imaging the leg veins.
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| : Score of less than 2 - deep vein thrombosis is unlikely. Consider blood test such as [[d-dimer]] test to further rule out deep vein thrombosis.
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| ===Blood tests===
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| ====D-dimer====
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| {{main|d-dimer}}
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| In a low-probability situation, current practice is to commence investigations by testing for [[D-dimer]] levels. This cross-linked [[fibrin degradation product]] is an indication that [[thrombosis]] is occurring, and that the [[blood clot]] is being dissolved by [[plasmin]]. A low D-dimer level should prompt other possible diagnoses (such as a ruptured [[Baker's cyst]], if the patient is at sufficiently low clinical probability of DVT.<ref name="pmid14507948">{{cite journal |author=Wells PS, Anderson DR, Rodger M, ''et al'' |title=Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis |journal=N. Engl. J. Med. |volume=349 |issue=13 |pages=1227-35 |year=2003 |pmid=14507948 |doi=10.1056/NEJMoa023153}}</ref><ref name="pmid12755550">{{cite journal |author=Bates SM, Kearon C, Crowther M, ''et al'' |title=A diagnostic strategy involving a quantitative latex D-dimer assay reliably excludes deep venous thrombosis |journal=Ann. Intern. Med. |volume=138 |issue=10 |pages=787-94 |year=2003 |pmid=12755550 |doi=}}</ref>
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| ====Other blood tests====
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| Other blood tests usually performed at this point are:
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| * [[complete blood count]]
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| * Primary [[coagulation]] studies: [[prothrombin time|PT]], [[APTT]], [[Fibrinogen]]
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| * [[liver enzyme]]s
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| * [[renal function]] and [[electrolyte]]s
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| ===Imaging the leg veins===
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| [[Impedance plethysmography]], Doppler ultrasonography, compression [[medical ultrasonography|ultrasound]] scanning of the leg veins, combined with duplex measurements (to determine blood flow), can reveal a [[blood clot]] and its extent (i.e. whether it is below or above the [[knee]]).
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| ====Examples====
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| [http://www.radswiki.net Images courtesy of RadsWiki]
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| *'''Example #1: CT images: DVT at left leg'''
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| <br>
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| <div align="left">
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| <gallery heights="125" widths="125">
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| Image:DVT-001.jpg
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| Image:DVT-002.jpg
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| </gallery>
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| </div>
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| *'''Example #2: 2D TOF GRE MRV images: Bilateral deep vein thromboses'''
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| [http://www.radswiki.net Images courtesy of RadsWiki]
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| <div align="left">
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| <gallery heights="125" widths="125">
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| Image:Deep-vein-thrombosis-on-MRV-001.jpg
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| Image:Deep-vein-thrombosis-on-MRV-002.jpg
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| Image:Deep-vein-thrombosis-on-MRV-003.jpg
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| </gallery>
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| </div>
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| ==Therapy==
| | [[Deep vein thrombosis diagnostic approach|Diagnostic Approach]] | [[Deep vein thrombosis assessment of clinical probability and risk scores|Assessment of Clinical Probability and Risk Scores]] | [[Deep vein thrombosis assessment of probability of subsequent VTE and risk scores|Assessment of Probability of Subsequent VTE and Risk Scores]] | [[Deep vein thrombosis history and symptoms|History and Symptoms]] | [[Deep vein thrombosis physical examination|Physical Examination]] | [[Deep vein thrombosis laboratory tests|Laboratory Findings]] | [[Deep vein thrombosis ultrasound| Ultrasound]] | [[Deep vein thrombosis venography| Venography]] | [[Deep vein thrombosis CT|CT]] | [[Deep vein thrombosis MRI|MRI]] | [[Deep vein thrombosis other imaging findings|Other Imaging Findings]] |
| ===Hospitalization===
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| 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>:
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| * bilateral DVT, renal insufficiency, body weight <70 kg, recent immobility, chronic heart failure, and cancer
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| ===Anticoagulation=== | | ==Treatment== |
| {{main|Anticoagulation}}
| | [[Deep vein thrombosis treatment approach|Treatment Approach]] | [[Deep vein thrombosis medical therapy|Medical Therapy]] | [[Deep vein thrombosis compression stockings|Compression stockings]] | [[Deep vein thrombosis IVC filter|IVC filter]] | [[Deep vein thrombosis invasive therapy|Invasive Therapy]] | [[Deep vein thrombosis surgery|Surgery]] | [[Deep vein thrombosis prevention|Prevention]] | [[Deep vein thrombosis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Deep vein thrombosis future or investigational therapies|Future or Investigational Therapies]] |
| [[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> | |
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| 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>
| | == Special Scenarios == |
| | [[Deep vein thrombosis special scenario upper extremity|Upper Extremity DVT]] | [[Deep vein thrombosis special scenario recurrence|Recurrence]] | [[Deep vein thrombosis special scenario pregnancy|Pregnancy]] |
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| ===Thrombolysis=== | | ==Trials== |
| {{main|Thrombolysis}}
| | [[Deep vein thrombosis landmark trials in treatment|Landmark Trials]] |
| [[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. | |
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| ===Compression stockings=== | | ==Case Studies== |
| 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"/> 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>
| | [[Deep vein thrombosis case study one|Case #1]] |
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| ===Inferior vena cava filter===
| | [[Category:Medicine]] |
| {{main|Inferior vena cava filter}}
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| [[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>
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| ==Prognosis==
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| [[Post-thrombotic syndrome|Post-phlebitic syndrome]] occurs in 10% of patients with deep vein thrombosis (DVT). It presents with leg oedema, pain, nocturnal cramping, venous claudication, skin pigmentation, dermatitis and [[venous ulcer|ulceration]] (usually on the medial aspect of the lower leg).
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| ==Prophylaxis (Prevention)==
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| [[Clinical practice guidelines]] by the American College of Chest Physicians (ACCP) provide recommendations on DVT prophylaxis in hospitalized patients <ref name="pmid15383478">Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
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| Chest. 2004 Sep;126 (3 Suppl):338S-400S. http://www.chestjournal.org/cgi/content/full/126/3_suppl/338S PMID 15383478</ref>.
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| ===General Medical Inpatients===
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| Regarding general medical inpatients the guidelines state, "In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, including active cancer, previous VTE, [[sepsis]], acute neurologic disease, or inflammatory bowel disease, we recommend prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A)<ref name="pmid15383478">.</ref>." Enoxaparin or unfractionated heparin may be used.<ref>{{cite journal|title=Twice vs three times daily heparin dosing for thromboembolism prophylaxis in the general medical population: A metaanalysis|author=King CS, Holley AB, Jackson JL, Shorr AF, Moores LK|journal=Chest|year=2007|volume=131|issue=2|pages=507–16|pmid=17296655}}</ref> LMWH may be more effective than UFH. If UFH heparin is used, 5000 U 3 times daily may be more effective.<ref name="pmid17646601">{{cite journal |author=Wein L, Wein S, Haas SJ, Shaw J, Krum H |title=Pharmacological Venous Thromboembolism Prophylaxis in Hospitalized Medical Patients: A Meta-analysis of Randomized Controlled Trials |journal= |volume=167 |issue=14 |pages=1476-1486 |year=2007 |pmid=17646601 |doi=10.1001/archinte.167.14.1476}}</ref>
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| Since publication of the ACCP guidelines, an additional [[randomized controlled trial]] <ref name="pmid16431185">Lederle FA, Sacks JM, Fiore L, Landefeld CS, Steinberg N, Peters RW, Eid AA, Sebastian J, Stasek JE Jr, Fye CL. The prophylaxis of medical patients for thromboembolism pilot study. Am J Med. 2006;119:54-9. PMID 16431185</ref> and [[meta-analysis]] <ref name="pmid17310052">Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA. [http://annals.org/cgi/content/full/146/4/278 Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients]. Ann Intern Med. 2007;146:278-88. PMID 17310052</ref> including the trial have been published. The [[meta-analysis]] concluded " Anticoagulant prophylaxis is effective in preventing symptomatic venous thromboembolism during anticoagulant prophylaxis in at-risk hospitalized medical patients. Additional research is needed to determine the risk for venous thromboembolism in these patients after prophylaxis has been stopped." With regards to which patients are at risk, most studies in the meta-analysis were of patients with [[New York Heart Association Functional Classification]] (NYHA) III-IV heart failure. Regarding patients at lesser risk of DVT, the trial above<ref name="pmid16431185">.</ref> and an earlier trial<ref name="pmid">Gardlund B. Randomised, controlled trial of low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases. The Heparin Prophylaxis Study Group. Lancet. 1996 May 18;347(9012):1357-61. PMID 8637340</ref> are relevant yet inconclusive.
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| Chronic renal dialysis patients may be at increased risk of thromboembolism<ref name="pmid11979344">{{cite journal |author=Tveit DP, Hypolite IO, Hshieh P, ''et al'' |title=Chronic dialysis patients have high risk for pulmonary embolism |journal=Am. J. Kidney Dis. |volume=39 |issue=5 |pages=1011-7 |year=2002 |pmid=11979344 |doi=}}</ref>, but [[randomized controlled trial]]s have not addressed the risk benefit of prophylaxis.
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| ===Surgery Patients===
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| In patients who have undergone [[surgery]], [[low molecular weight heparin]]s (LMWH) are routinely administered to prevent thrombosis. LMWH can only currently be administered subcutaneously by injection. Prophylaxis for pregnant women who have a history of thrombosis may be limited to LMWH injections or may not be necessary if their risk factors are mainly temporary.
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| Early and regular ambulation (walking) is a treatment that predates anticoagulants and is still recognized and used today. Walking activates the body's muscle pumps, increasing venous velocity and preventing [[stasis]]. Intermittent pneumatic compression (IPC) machines have proven protective in bed- or chair-ridden patients at very high risk or with contraindications to heparins. IPC machines use air bladders that are wrapped around the thigh and/or calf. The bladders alternately inflate and deflate, squeezing the muscles and increasing blood velocity by as much as 500%. IPC machines have been proven effective on knee and hip surgery patients (a population with a risk as high as 80% with no prophylactic treatment) of developing DVT and PE.
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| Alternatively, between 150-300mg of aspirin can be taken.
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| ===Travelers===
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| {{main|Economy class syndrome}}
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| There is clinical evidence to suggest that wearing compression socks while travelling also reduces the incidence of thrombosis in people on long haul flights. A randomised study in 2001 compared two sets of long haul airline passengers, one set wore travel compression hosiery the others did not. The passengers were all scanned and blood tested to check for the incidence of DVT. The results showed that asymptomatic DVT occurred in 10% of the passengers who did not wear compression socks. The group wearing compression had no DVTs. The authors concluded that wearing elastic compression hosiery reduces the incidence of DVT in long haul airline passengers. J Scurr et al. 2001 Lancet.<ref>Scurr JH, Machin SJ, Bailey-King S, Mackie IJ, McDonald S, Smith PD. Frequency and prevention of symptomless deep-vein thrombosis in long-haul flights: a randomised trial. ''[[The Lancet|Lancet]] 2001;12(9267):1485-9. PMID 11377600.</ref>.
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| ==Living With Deep Vein Thrombosis==
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| If you've had a deep vein blood clot, you're at greater risk for another one. During treatment and after, it's important to:
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| * Take steps to prevent deep vein thrombosis (DVT). (See "How Can Deep Vein Thrombosis Be Prevented?")
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| * Check your legs for signs and symptoms of DVT. These include swollen areas, pain or tenderness, increased warmth in swollen or painful areas, or red or discolored skin on the legs.
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| * Contact your doctor right away if you have signs and symptoms of DVT.
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| ===Ongoing Health Care Needs===
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| Medicines that thin your blood and prevent blood clots are used to treat DVT. These medicines can thin your blood too much and cause bleeding (sometimes inside the body). This side effect can be life threatening.
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| Bleeding may occur in the digestive system or the brain. Signs and symptoms of bleeding in the digestive system include:
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| * Bright red vomit or vomit that looks like coffee grounds
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| * Bright red blood in your stools or black, tarry stools
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| * Pain in your abdomen
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| Signs and symptoms of bleeding in the brain include:
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| * Severe pain in your head
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| * Sudden changes in your vision
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| * Sudden loss of movement in your arms or legs
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| * Memory loss or confusion
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| If you have any of these signs or symptoms, get treatment right away.
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| ==References==
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| {{Reflist|2}}
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| ==See also==
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| *[[Venogram (medical)]]
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| {{Circulatory system pathology}}
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| {{SIB}}
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| [[ar:تجلط الوريد العميق]]
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| [[it:Trombosi venosa profonda]]
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| [[nl:Diep-veneuze trombose]]
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| [[pt:Trombose venosa profunda]]
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| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| [[Category:Vascular surgery]] | | [[Category:Vascular surgery]] |
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