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===Classification Based on Site of Thrombus Formation===
===Classification Based on Site of Thrombus Formation===
{{Family tree/start}}
{{Family tree/start}}
{{familytree | | | | | A01 | | | A01= Deep vein thrombosis (DVT)}}
{{familytree | | | | A01 | | | A01= '''Deep vein thrombosis (DVT)'''}}
{{familytree | | | |,|-|^|-|.| | }}
{{familytree | | |,|-|^|-|.| | }}
{{familytree | | | B01 | | B02 | B01= Lower extremity DVT| B02= Upper extremity DVT}}
{{familytree | | B01 | | B02 | B01= '''Lower extremity DVT'''| B02= '''Upper extremity DVT'''}}
{{familytree | |,|-|^|-|.| | | | }}
{{familytree | |,|^|-|-|.| | | | }}
{{familytree | C01 | | C02 | | | C01= Proximal <br> (popliteal, femoral, and/or iliac veins)| C02= Isolated distal (calf veins)}}
{{familytree | C01 | | C02 | | | C01= Proximal <br> (popliteal, femoral, and/or iliac veins)| C02= Isolated distal <br> (calf veins)}}
{{familytree/end}}
{{familytree/end}}


* Upper extremity [[deep vein thrombosis]] (DVT): DVT of the upper limbs.
In studies including symptomatic inpatients, 80% of DVTs are proximal and 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> while studies with outpatients report a proportion of distal DVT as high as 60–70%.<ref name="pmid11521998">{{cite journal |author=Bressollette L, Nonent M, Oger E, ''et al.'' |title=Diagnostic accuracy of compression ultrasonography for the detection of asymptomatic deep venous thrombosis in medical patients--the TADEUS project |journal=Thromb. Haemost. |volume=86 |issue=2 |pages=529–33 |year=2001 |month=August |pmid=11521998 |doi= |url=}}</ref><ref name="pmid10823257">{{cite journal |author=Oger E |title=Incidence of venous thromboembolism: a community-based study in Western France. EPI-GETBP Study Group. Groupe d'Etude de la Thrombose de Bretagne Occidentale |journal=Thromb. Haemost. |volume=83 |issue=5 |pages=657–60 |year=2000 |month=May |pmid=10823257 |doi= |url=}}</ref>
* Lower extremity DVT: DVT of the lower limbs, which is subdivided into two categories:
** Proximal vein thrombosis: Occur in the legs, and involve the popliteal, femoral or iliac veins
** Distal (calf) vein thrombosis: Confined to the deep calf veins
 
In studies including inpatients, 80% of DVTs are proximal and 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> while studies with outpatients report a proportion of distal DVT as high as 60–70%.<ref name="pmid11521998">{{cite journal |author=Bressollette L, Nonent M, Oger E, ''et al.'' |title=Diagnostic accuracy of compression ultrasonography for the detection of asymptomatic deep venous thrombosis in medical patients--the TADEUS project |journal=Thromb. Haemost. |volume=86 |issue=2 |pages=529–33 |year=2001 |month=August |pmid=11521998 |doi= |url=}}</ref><ref name="pmid10823257">{{cite journal |author=Oger E |title=Incidence of venous thromboembolism: a community-based study in Western France. EPI-GETBP Study Group. Groupe d'Etude de la Thrombose de Bretagne Occidentale |journal=Thromb. Haemost. |volume=83 |issue=5 |pages=657–60 |year=2000 |month=May |pmid=10823257 |doi= |url=}}</ref>


====Proximal Vein Thrombosis====
====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 more than 90% 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, as it is more commonly associated with serious, chronic diseases, such as:
Proximal vein thrombosis involves the proximal veins, including the [[popliteal vein|popliteal]], [[femoral vein|femoral]], or [[iliac vein]]. Proximal vein thrombosis is responsible for more than 90% 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]].
* Active [[cancer]]
* [[Congestive heart failure]].
* [[Congestive heart failure]]
* [[Respiratory insufficiency]].
* [[Respiratory insufficiency]]


More than 90% of cases of acute [[pulmonary embolism]] are due to emboli emanating from the proximal, rather than the distal vein, veins of the lower extremities. <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>
More than 90% of cases of acute [[pulmonary embolism]] are due to emboli emanating from the proximal, rather than the distal vein, veins of the lower extremities. <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>
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====Distal Vein Thrombosis====
====Distal Vein Thrombosis====
Distal or calf [[deep vein thrombosis]] involves 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,<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> such as:
Distal or calf [[deep vein thrombosis]] involves 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,<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> such as:
* Recent [[surgery]].
* Recent [[surgery]]  
* Immobilization.
* Immobilization
* Travel.
* Trave
 
;Calf Vein Thrombosis
 
* It causes 50% of DVTs.
 
* High risk of embolization.
 
* Recurrence rate is low compared to proximal DVTs.
 
;ACCP Guidelines for Calf Vein Thrombosis -
 
* If symptoms are not severe with no risk factors, repeat ultrasound can be done weekly. (Grade 2C recommendation)
 
* If symptoms are severe, then treatment is required.(Grade 2C recommendation)
 
* If there is propagation of a [[thrombus]], treatment is required. (Grade 1B recommendation)
 
* Duration treatment is low, 3 months.


====Upper Extremity DVT====
====Upper Extremity DVT====


* It is uncommon and accounts for 4 % of all [[VTE]]. <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>
* It is uncommon and accounts for 1-5 % of all [[VTE]].<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:
* 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 catheters
** [[Central venous catheter]]
** [[Cardiac pacemaker]]
** [[Implanted defibrillator]]
** Effort thrombosis ([[Paget schoroeder syndrome]])
** Effort thrombosis ([[Paget schoroeder syndrome]])
** [[Cancer]]
** [[Cancer]]


* Risk of embolizing to PE is less. (10%)
* Risk of embolizing to PE 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>
* Risk of fatality is very low (1%).
* Catheter directed thrombolytic therapy.
* Anticoagulants for a period of 3 months.


===Classification Based on Depth of Thrombus Formation===
===Classification Based on Depth of Thrombus Formation===

Revision as of 21:32, 15 July 2014
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.; Assistant Editor(s)-In-Chief: Justine Cadet

Deep Vein Thrombosis Microchapters

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Assessment of Clinical Probability and Risk Scores

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Overview

Deep vein thrombosis (DVT) is classified based on the site of occlusion or clot formation. Symptom presentation and complication is largely influenced by location of the embolus.

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 distal DVT accounts for only 20% of all DVTs, [1][2][3] while studies with outpatients report a proportion of distal DVT as high as 60–70%.[4][5]

Proximal Vein Thrombosis

Proximal vein thrombosis involves the proximal veins, including the popliteal, femoral, or iliac vein. Proximal vein thrombosis is responsible for more than 90% of acute pulmonary emboli and is associated with higher mortality.[6] Clinically, proximal vein thrombosis is considered severe, and it is more commonly associated with serious chronic diseases than distal DVT, such as:[7]

More than 90% of cases of acute pulmonary embolism are due to emboli emanating from the proximal, rather than the distal vein, veins of the lower extremities. [6]

Distal Vein Thrombosis

Distal or calf deep vein thrombosis involves 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,[6] such as:

  • Recent surgery
  • Immobilization
  • Trave

Upper Extremity DVT

  • Risk of embolizing to PE is less than that with lower extremity DVT.[11]

Classification Based on Depth of Thrombus Formation

Superficial Versus Deep

Classification Based on Clinical Presentation

Subacute versus acute:

  • 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. ↑ 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. ↑ Bressollette L, Nonent M, Oger E; et al. (2001). "Diagnostic accuracy of compression ultrasonography for the detection of asymptomatic deep venous thrombosis in medical patients--the TADEUS project". Thromb. Haemost. 86 (2): 529–33. PMID 11521998. Unknown parameter |month= ignored (help)
  5. ↑ Oger E (2000). "Incidence of venous thromboembolism: a community-based study in Western France. EPI-GETBP Study Group. Groupe d'Etude de la Thrombose de Bretagne Occidentale". Thromb. Haemost. 83 (5): 657–60. PMID 10823257. Unknown parameter |month= ignored (help)
  6. ↑ 6.0 6.1 6.2 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)
  7. ↑ 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.
  8. ↑ 8.0 8.1 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)
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ 11.0 11.1 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.

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