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'''Editors-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]] '''Associate Editor-In-Chief''': [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]
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'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' {{CZ}}; [[User:Kashish Goel|Kashish Goel, M.D.]]; {{Rim}} ;'''Assistant Editor(s)-In-Chief:''' [[User:Justine Cadet|Justine Cadet]]


{{Deep vein thrombosis}}
{{Deep vein thrombosis}}


==Overview==
==Overview==
Deep vein thrombosis is classified based on the '''site''' of occlusion or clot formation. Symptom presentation and complication is largely influenced by the location of the embolus.
Deep vein thrombosis (DVT) is classified based on the site of occlusion or clot formation into lower extremity DVT and upper extremity DVT. Lower extremity DVT can further be classified into proximal and distal.  Symptoms presentation of DVT and complications are largely influenced by the location of the [[thrombus]].
==Classification based on site of thrombus formation==
*Upper extremity DVT: DVT of upper limb.
*Lower extremity DVT: DVT of lower limb. DVT of the lower extremity is subdivided into two categories:
**Proximal vein thrombosis.
**Distal (calf) vein thrombosis.


==Proximal vein thrombosis==
==Classification==
Proximal vein thrombosis occurs when thrombosis involves the proximal veins like [[popliteal vein|popliteal]], [[femoral vein|femoral]], or [[iliac vein]].
===Classification Based on Site of Thrombus Formation===
Clinically proximal vein thrombosis is of greater importance as it is more commonly associated with serious, chronic diseases like:
{{Family tree/start}}
* Active [[cancer]].
{{familytree | | | | A01 | | | A01= '''Deep vein thrombosis (DVT)'''}}
* [[Congestive heart failure]].
{{familytree | | |,|-|^|-|.| | }}
* Old age (greater than 75 years).
{{familytree | | B01 | | B02 | B01= '''Lower extremity DVT'''| B02= '''Upper extremity DVT'''}}
* [[Respiratory insufficiency]].
{{familytree | |,|^|-|-|.| | | | }}
Proximal vein thrombosis is responsible for more than ninety percent of [[Pulmonary embolism|acute Pulmonary embolism]] and thus higher mortality. <ref name="pmid19718469">{{cite journal |author=Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D, Boge G, van Kien AK, Gattolliat O, Bettarel-Binon C, Gris JC, Genty C, Quere I |title=Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study |journal=Thromb. Haemost. |volume=102 |issue=3 |pages=493–500 |year=2009 |month=September|pmid=19718469 |doi=10.1160/TH09-01-0053 |url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th09-01-0053&no_cache=1|accessdate=2011-12-14}}</ref>
{{familytree | C01 | | C02 | | | C01= Proximal <br> (popliteal, femoral, and/or iliac veins)| C02= Isolated distal <br> (calf veins)}}
{{familytree/end}}


==Distal vein thrombosis==
In studies including symptomatic inpatients, 80% of DVTs are proximal and isolated distal DVT accounts for only 20% of all DVTs.<ref name="pmid9546569">{{cite journal |author=Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS |title=Does this patient have deep vein thrombosis? |journal=JAMA |volume=279 |issue=14 |pages=1094–9 |year=1998 |month=April |pmid=9546569 |doi= |url=}}</ref><ref name="pmid7752753">{{cite journal |author=Wells PS, Hirsh J, Anderson DR, ''et al.'' |title=Accuracy of clinical assessment of deep-vein thrombosis |journal=Lancet |volume=345 |issue=8961 |pages=1326–30 |year=1995 |month=May |pmid=7752753 |doi= |url=}}</ref><ref name="pmid8257253">{{cite journal |author=Cogo A, Lensing AW, Prandoni P, Hirsh J |title=Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound |journal=Arch. Intern. Med. |volume=153 |issue=24 |pages=2777–80 |year=1993 |month=December |pmid=8257253 |doi= |url=}}</ref>
Distal vein thrombosis is one in which thrombi remain confined to the deep [[calf veins]]. It is often associated with transient risk factors like travel, prolonged immobilization and recent surgery.<ref name="pmid19718469">{{cite journal |author=Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D, Boge G, van Kien AK, Gattolliat O, Bettarel-Binon C, Gris JC, Genty C, Quere I |title=Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study |journal=Thromb. Haemost. |volume=102 |issue=3 |pages=493–500 |year=2009 |month=September |pmid=19718469 |doi=10.1160/TH09-01-0053 |url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th09-01-0053&no_cache=1 |accessdate=2011-12-14}}</ref>
 
====Proximal Vein Thrombosis====
Proximal vein thrombosis involves the proximal veins, including the [[popliteal vein|popliteal]], [[femoral vein|femoral]], or [[iliac vein]]. Proximal vein thrombosis is responsible for the majority of [[Pulmonary embolism|acute pulmonary emboli]] and is associated with higher mortality.<ref name="pmid19718469">{{cite journal |author=Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D, Boge G, van Kien AK, Gattolliat O, Bettarel-Binon C, Gris JC, Genty C, Quere I |title=Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study |journal=Thromb. Haemost. |volume=102 |issue=3 |pages=493–500 |year=2009 |month=September|pmid=19718469|doi=10.1160/TH09-01-0053 |url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th09-01-0053&no_cache=1|accessdate=2011-12-14}}</ref> Clinically, proximal vein thrombosis is considered severe, and it is more commonly associated with serious chronic diseases than distal DVT, such as:<ref name="pmid18718469">{{cite journal| author=Alberts JL, Hass CJ, Vitek JL, Okun MS| title=Are two leads always better than one: an emerging case for unilateral subthalamic deep brain stimulation in Parkinson's disease. | journal=Exp Neurol | year= 2008 | volume= 214 | issue= 1 | pages= 1-5 | pmid=18718469 | doi=10.1016/j.expneurol.2008.07.019 | pmc=PMC2888769 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18718469  }} </ref>
* Active [[cancer]]
* [[Congestive heart failure]]
* [[Respiratory insufficiency]]
 
Shown below is the distribution of involved veins in proximal DVT:<ref name="pmid8257253">{{cite journal| author=Cogo A, Lensing AW, Prandoni P, Hirsh J| title=Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound. | journal=Arch Intern Med | year= 1993 | volume= 153 | issue= 24 | pages= 2777-80 | pmid=8257253 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8257253  }} </ref>
* [[Popliteal vein]]: 10%
* [[Popliteal vein|Popliteal]] and [[superficial femoral vein]]s: 42%
* [[Popliteal vein|Popliteal]], [[superficial femoral vein|superficial]] and common femoral veins: 5%
* All proximal veins: 35%
* Common femoral vein and/or superficial ilieofemoral or [[iliac vein]]s: 8%
 
====Distal Vein Thrombosis====
Distal or calf [[deep vein thrombosis]] involves the infrapopliteal veins [ie, posterior tibial veins, peroneal veins, anterior tibial veins and muscular calf veins (soleal or gemellar veins)]. It is often associated with transient risk factors, such as:<ref name="pmid19718469">{{cite journal |author=Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D, Boge G, van Kien AK, Gattolliat O, Bettarel-Binon C, Gris JC, Genty C, Quere I |title=Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study |journal=Thromb. Haemost. |volume=102 |issue=3 |pages=493–500 |year=2009 |month=September |pmid=19718469 |doi=10.1160/TH09-01-0053 |url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th09-01-0053&no_cache=1 |accessdate=2011-12-14}}</ref>
* Recent [[surgery]]
* Immobilization
* Travel
 
It may also be associated with permanent risk factors such as:
 
* Hypercoaguable state (genetic predisposition)
* May Thurner Syndrome
 
====Upper Extremity DVT====
 
* It is uncommon and accounts for 1-5 % of all [[DVT]].<ref name="pmid15353493">{{cite journal |author=Joffe HV, Kucher N, Tapson VF, Goldhaber SZ |title=Upper-extremity deep vein thrombosis: a prospective registry of 592 patients |journal=[[Circulation]] |volume=110 |issue=12 |pages=1605–11 |year=2004 |month=September |pmid=15353493 |doi=10.1161/01.CIR.0000142289.94369.D7 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15353493 |accessdate=2012-10-07}}</ref><ref name="pmid20406709">{{cite journal| author=Isma N, Svensson PJ, Gottsäter A, Lindblad B| title=Upper extremity deep venous thrombosis in the population-based Malmö thrombophilia study (MATS). Epidemiology, risk factors, recurrence risk, and mortality. | journal=Thromb Res | year= 2010 | volume= 125 | issue= 6 | pages= e335-8 | pmid=20406709 | doi=10.1016/j.thromres.2010.03.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20406709  }} </ref><ref name="pmid17925416">{{cite journal| author=Muñoz FJ, Mismetti P, Poggio R, Valle R, Barrón M, Guil M et al.| title=Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry. | journal=Chest | year= 2008 | volume= 133 | issue= 1 | pages= 143-8 | pmid=17925416 | doi=10.1378/chest.07-1432 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17925416  }} </ref>
 
* It is most likely due to:<ref name="pmid21366477">{{cite journal| author=Kucher N| title=Clinical practice. Deep-vein thrombosis of the upper extremities. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 9 | pages= 861-9 | pmid=21366477 | doi=10.1056/NEJMcp1008740 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21366477  }} </ref><ref name="pmid15353493">{{cite journal| author=Joffe HV, Kucher N, Tapson VF, Goldhaber SZ, Deep Vein Thrombosis (DVT) FREE Steering Committee| title=Upper-extremity deep vein thrombosis: a prospective registry of 592 patients. | journal=Circulation | year= 2004 | volume= 110 | issue= 12 | pages= 1605-11 | pmid=15353493 | doi=10.1161/01.CIR.0000142289.94369.D7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15353493  }} </ref>
** [[Central venous catheter]]
** [[Cardiac pacemaker]]
** [[Implantable cardioverter defibrillator]]
** [[Effort thrombosis]] ([[Paget–Schroetter disease]])
** [[Cancer]]
 
* Risk of embolization in upper extremity DVT is less than that with lower extremity DVT.<ref name="pmid21366477">{{cite journal| author=Kucher N| title=Clinical practice. Deep-vein thrombosis of the upper extremities. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 9 | pages= 861-9 | pmid=21366477 | doi=10.1056/NEJMcp1008740 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21366477  }} </ref>
 
===Classification Based on the Acuity of the Clinical Presentation===
*Subacute and acute DVT can be differentiated not only through the timing of the clinical presentation, bust also through ultrasound findings.<ref name="pmid21343802">{{cite journal| author=Cassou-Birckholz MF, Engelhorn CA, Salles-Cunha SX, Engelhorn AL, Zanoni CC, Gosalan CJ et al.| title=Assessment of deep venous thrombosis by grayscale median analysis of ultrasound images. | journal=Ultrasound Q | year= 2011 | volume= 27 | issue= 1 | pages= 55-61 | pmid=21343802 | doi=10.1097/RUQ.0b013e31820e157d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21343802  }} </ref>
*Subacute thrombosis refers to thrombosis formation involving a narrowing of the vein involved and a hyperechogenic clot; flow may be partially obstructed by this narrowing.
* Acute thrombosis can refer to:
:*A vein with a thrombus that is normal or, even, wider than usual with the contralateral side of the vein being unaffected.
:*A clot that, during ultrasound echos, is not dense.
:*A clot that may totally or partially obstruct blood flow.
:*In the evaluation of the upper extremity, the [[Subclavian vein|subclavian]] and [[Brachiocephalic vein|brachiocephalic veins]] inability to be compressed may pose challenges for determining subacute versus acute status.


==References==
==References==
{{reflist|2}}
{{reflist|2}}


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Latest revision as of 14:53, 12 November 2019
Resident
Survival
Guide

Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Kashish Goel, M.D.; Rim Halaby, M.D. [3] ;Assistant Editor(s)-In-Chief: Justine Cadet

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Overview

Deep vein thrombosis (DVT) is classified based on the site of occlusion or clot formation into lower extremity DVT and upper extremity DVT. Lower extremity DVT can further be classified into proximal and distal. Symptoms presentation of DVT and complications are largely influenced by the location of the thrombus.

Classification

Classification Based on Site of Thrombus Formation

 
 
 
Deep vein thrombosis (DVT)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lower extremity DVT
 
Upper extremity DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal
(popliteal, femoral, and/or iliac veins)
 
Isolated distal
(calf veins)
 
 

In studies including symptomatic inpatients, 80% of DVTs are proximal and isolated distal DVT accounts for only 20% of all DVTs.[1][2][3]

Proximal Vein Thrombosis

Proximal vein thrombosis involves the proximal veins, including the popliteal, femoral, or iliac vein. Proximal vein thrombosis is responsible for the majority of acute pulmonary emboli and is associated with higher mortality.[4] Clinically, proximal vein thrombosis is considered severe, and it is more commonly associated with serious chronic diseases than distal DVT, such as:[5]

Shown below is the distribution of involved veins in proximal DVT:[3]

Distal Vein Thrombosis

Distal or calf deep vein thrombosis involves the infrapopliteal veins [ie, posterior tibial veins, peroneal veins, anterior tibial veins and muscular calf veins (soleal or gemellar veins)]. It is often associated with transient risk factors, such as:[4]

  • Recent surgery
  • Immobilization
  • Travel

It may also be associated with permanent risk factors such as:

  • Hypercoaguable state (genetic predisposition)
  • May Thurner Syndrome

Upper Extremity DVT

  • Risk of embolization in upper extremity DVT is less than that with lower extremity DVT.[9]

Classification Based on the Acuity of the Clinical Presentation

  • Subacute and acute DVT can be differentiated not only through the timing of the clinical presentation, bust also through ultrasound findings.[10]
  • Subacute thrombosis refers to thrombosis formation involving a narrowing of the vein involved and a hyperechogenic clot; flow may be partially obstructed by this narrowing.
  • Acute thrombosis can refer to:
  • A vein with a thrombus that is normal or, even, wider than usual with the contralateral side of the vein being unaffected.
  • A clot that, during ultrasound echos, is not dense.
  • A clot that may totally or partially obstruct blood flow.
  • In the evaluation of the upper extremity, the subclavian and brachiocephalic veins inability to be compressed may pose challenges for determining subacute versus acute status.

References

  1. ↑ Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS (1998). "Does this patient have deep vein thrombosis?". JAMA. 279 (14): 1094–9. PMID 9546569. Unknown parameter |month= ignored (help)
  2. ↑ Wells PS, Hirsh J, Anderson DR; et al. (1995). "Accuracy of clinical assessment of deep-vein thrombosis". Lancet. 345 (8961): 1326–30. PMID 7752753. Unknown parameter |month= ignored (help)
  3. ↑ 3.0 3.1 Cogo A, Lensing AW, Prandoni P, Hirsh J (1993). "Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound". Arch. Intern. Med. 153 (24): 2777–80. PMID 8257253. Unknown parameter |month= ignored (help)
  4. ↑ 4.0 4.1 Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D, Boge G, van Kien AK, Gattolliat O, Bettarel-Binon C, Gris JC, Genty C, Quere I (2009). "Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study". Thromb. Haemost. 102 (3): 493–500. doi:10.1160/TH09-01-0053. PMID 19718469. Retrieved 2011-12-14. Unknown parameter |month= ignored (help)
  5. ↑ Alberts JL, Hass CJ, Vitek JL, Okun MS (2008). "Are two leads always better than one: an emerging case for unilateral subthalamic deep brain stimulation in Parkinson's disease". Exp Neurol. 214 (1): 1–5. doi:10.1016/j.expneurol.2008.07.019. PMC 2888769. PMID 18718469.
  6. ↑ 6.0 6.1 Joffe HV, Kucher N, Tapson VF, Goldhaber SZ (2004). "Upper-extremity deep vein thrombosis: a prospective registry of 592 patients". Circulation. 110 (12): 1605–11. doi:10.1161/01.CIR.0000142289.94369.D7. PMID 15353493. Retrieved 2012-10-07. Unknown parameter |month= ignored (help)
  7. ↑ Isma N, Svensson PJ, Gottsäter A, Lindblad B (2010). "Upper extremity deep venous thrombosis in the population-based Malmö thrombophilia study (MATS). Epidemiology, risk factors, recurrence risk, and mortality". Thromb Res. 125 (6): e335–8. doi:10.1016/j.thromres.2010.03.005. PMID 20406709.
  8. ↑ Muñoz FJ, Mismetti P, Poggio R, Valle R, Barrón M, Guil M; et al. (2008). "Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry". Chest. 133 (1): 143–8. doi:10.1378/chest.07-1432. PMID 17925416.
  9. ↑ 9.0 9.1 Kucher N (2011). "Clinical practice. Deep-vein thrombosis of the upper extremities". N Engl J Med. 364 (9): 861–9. doi:10.1056/NEJMcp1008740. PMID 21366477.
  10. ↑ Cassou-Birckholz MF, Engelhorn CA, Salles-Cunha SX, Engelhorn AL, Zanoni CC, Gosalan CJ; et al. (2011). "Assessment of deep venous thrombosis by grayscale median analysis of ultrasound images". Ultrasound Q. 27 (1): 55–61. doi:10.1097/RUQ.0b013e31820e157d. PMID 21343802.

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