Deep vein thrombosis of the lower extremities

Deep vein thrombosis of the lower extremities

Deep vein thrombosis of the lower extremities – the formation of one or more blood clots within the deep veins of the lower extremities or pelvis, accompanied by inflammation of the vascular wall. May be complicated by impaired venous outflow and trophic disorders of the lower extremities, phlegmon of the thigh or lower leg, and pulmonary embolism

    • Phlebothrombosis – primary thrombosis of the veins of the lower extremities, characterized by unstable fixation of the thrombus to the vein wall
    • Thrombophlebitis is a secondary thrombosis caused by inflammation of the inner lining of a vein (endophlebitis). The thrombus is firmly fixed to the vessel wall. Therefore, PE with thrombophlebitis occurs less frequently than with phlebothrombosis. Frequency. In developed countries -1:1,000 of the population, more often in people over 40 years old.

Etiology

    • Injury
    • Venous stasis due to obesity, pregnancy, pelvic tumors, prolonged bed rest
    • bacterial infection
    • postpartum period
    • Taking oral contraceptives
    • Oncological diseases (especially cancer of the lungs, stomach, pancreas)
    •  ICE. Pathomorphology
    • A red thrombus formed during a sharp slowdown in blood flow consists of erythrocytes, a non-cordial number of platelets and fibrin attached to the vascular wall from one end of the thrombus, its proximal end floats freely in the lumen of the vessel
    • The most important feature of thrombus formation is the progression of the process: blood clots reach a large extent along the length of the vessel
    • The head of the thrombus, as a rule, is fixed at the valve of the vein, and its tail fills all or most of its large branches.
    • In the first 3-4 days, the thrombus is weakly fixed to the vessel wall, the separation of the thrombus and PE is possible
    • After 5-6 days, inflammation of the inner lining of the vessel joins, contributing to the fixation of the thrombus.

Clinical picture

    • Deep venous thrombosis (confirmed by phlebography) has classic clinical manifestations in only 50% of cases.
    • The first manifestation of the disease in many patients may be PE.
    • Complaints: a feeling of heaviness in the legs, arching pain, persistent swelling of the lower leg or the entire limb.
    • Acute thrombophlebitis: an increase in body temperature up to 39 ° C and above.
    • Local changes
    • Symptom Pratt: the skin becomes glossy, the pattern of saphenous veins is clearly visible
    • Payr’s symptom: spread of pain along the inner plane of the foot, lower leg or thigh
    • Homans sign: Pain in the lower leg with dorsiflexion of the foot
    • Lowenberg’s symptom: pain when the lower leg is squeezed by the cuff of the device for measuring blood pressure at a value of 80-100 mm Hg, while compression of a healthy lower leg is up to 150-180 mm Hg. does not cause discomfort
    • To the touch, the diseased limb is colder than the healthy one.
    • With pelvic vein thrombosis, mild peritoneal symptoms and sometimes dynamic intestinal obstruction are observed.

Special Studies

    • Phlebography (distal ascending) is the most accurate diagnostic method for detecting deep vein thrombosis. The radiopaque agent is injected into one of the saphenous veins of the foot below the tourniquet, which slightly compresses the ankle to direct the movement of the contrast agent into the deep vein system
    • Doppler ultrasound confirms deep vein thrombosis above the level of the knee with an accuracy of 80-90%. Signs of thrombosis
    • Absence of changes in blood flow in the femoral vein during breathing, indicating obstruction of the venous system between the femoral vein and the heart
    • The absence of an increase in blood flow in the femoral vein with the rapid expulsion of blood from the veins of the leg indicates obstruction of the deep veins between the leg and thigh
    • Deceleration of blood flow velocity in the femoral, popliteal and anterior tibial veins
    • Differences between ultrasound findings on the affected and healthy limb
    • Impedance plethysmography. After loosening the cuff, which squeezed the lower leg with a force sufficient for temporary occlusion of the veins, the change in the volume of blood filling of the lower leg is determined. The test allows diagnosing deep venous thrombosis above the level of the knee with an accuracy of 90%
    • Scanning using 1251-fibrinogen. To determine the inclusion of radioactive fibrinogen in a blood clot, a serial scan of both lower extremities is performed. The method is most effective for diagnosing calf vein thrombosis.

Differential Diagnosis

    • Cellulite
    • Rupture of a synovial cyst (Baker’s cyst)
    • Lymphedema (lymphedema)
    • Compression of a vein from the outside by a tumor or enlarged lymph nodes
    • Stretching or tearing of muscles.

Treatment:

Mode

    • Patients with deep phlebothrombosis of the lower leg (i.e., distal to the popliteal vein system) are managed conservatively on an outpatient basis. All other patients are treated in a surgical hospital.
    • Assign strict bed rest for 7-10 days with the elevated position of the diseased limb. Thermal procedures are contraindicated.

case management

    • Bed rest for 1-5 days, then the gradual restoration of normal physical activity with the rejection of prolonged immobilization
    • The first episode of deep phlebothrombosis will need to be treated for 3-6 months, in subsequent episodes – at least a year
    • During the introduction of heparin in / in determine the time of blood clotting.

If after 3 hours after the introduction of 5,000 IU the clotting time exceeds the initial one by 3-4 times, and after 4 hours – by 2-3 times, the administered dose is considered sufficient. If blood clotting has not changed significantly, increase the initial dose by 2500 IU. It is necessary to control blood platelets, if they decrease below 75×109/l, the administration of heparin should be stopped

    • When treating with phenylin, it will be necessary to control PTI every day until the required values ​​\u200b\u200bare reached (limit – 25-30%), then weekly for several weeks, after which (with stabilization) monthly during the entire time of taking the product
    • Consideration should be given to the possibility of significant bleeding (eg, hematuria or gastrointestinal bleeding) because anticoagulant therapy often unmasks cancer, peptic ulcer, or arteriovenous malformations. Conservative therapy
    • Lumbar novocaine blockade according to AV Vishnevsky
    • Ointment compresses
    • Anticoagulants, fibrinolytic products (effective in the earliest, traditionally not often recognized stage of venous thrombosis, in later periods thrombolysis can cause thrombus fragmentation and the occurrence of PE; contraindicated without installing a cava filter in ileofemoral thrombosis), reopoliglyukin, reogluman; with thrombophlebitis – broad-spectrum antibiotics. Doses of products – see Thrombosis of the portal vein.

Surgical treatment – with a floating thrombus, the installation of a cava filter in the inferior vena cava at a level below the renal veins is indicated.

Complications

    • White painful phlegmasia occurs due to spasm of the arteries located next to the thrombosed vein. Clinical picture: severe pain syndrome, pale limb, cold to the touch, peripheral vascular pulsation is absent or sharply weakened. The condition is difficult to differentiate from acute disorders of arterial circulation (with arterial embolism, arterial obstruction occurs immediately, and with thrombophlebitis – by the end of the first day)
    • Blue painful phlegmasia is secondary to white phlegmasia: almost the entire outflow of blood from the limb is blocked as a result of occlusion of the femoral and iliac veins. Clinical picture: cyanosis of the limb with extensive edema and severe pain on palpation, no pulse. The left leg is most commonly affected. Subsequently, gangrene occurs. Shock may occur due to the deposition of a significant amount of blood in the affected limb
    • Purulent fusion of a thrombus – with acute thrombophlebitis with the formation of an abscess, and sometimes phlegmon or septicopyemia. With purulent thrombophlebitis, fluctuation in the area of ​​softening is characteristic
    • PE, characterized by a sharp violation of blood circulation and external respiration, and with the overlap of small branches – symptoms of the formation of hemorrhagic infarcts of the lung. Course and forecast
    • About 20% of untreated proximal (i.e., above the lower leg) deep phlebothrombosis progresses to PE, in 10-20% of cases it is fatal. With aggressive anticoagulant therapy, mortality is reduced by 5-10 times
    • Deep phlebothrombosis of the veins of the leg never leads to clinically significant

thromboembolic complications and therefore do not require anticoagulant therapy. However, thrombi from the deep veins of the lower leg can penetrate into the proximal venous system, therefore, if there is a risk of such penetration, patients are prescribed impedance plethysmography or duplex ultrasound after 3-5 days for 10 days, and if they penetrate, anticoagulant therapy is prescribed. Prevention

    • Early movements after surgery
    • The use of elastic stockings that compress the superficial veins of the leg and increase blood flow in the deep veins
    • Periodic compression of the lower leg with a pneumatic cuff increases blood flow in the lower extremities and helps prevent blood stasis.
    • Venoconstrictors (dihydroergotamine, detralex) also increase blood flow through deep veins
    • Heparin administered in prophylactic doses before and after surgery (2,500-5,000 IU n/k every 6-12 hours) effectively prevents deep vein thrombosis.

Synonyms

  • Deep venous thrombophlebitis
  • Acute deep vein thrombosis
  • Phlebitis of deep veins
  • Thrombophlebitis of deep veins
  • Acute venous insufficiency of the lower extremities Thrombophlebitis superficial, Cemulitis (and\) ICD. 180 Phlebitis and thrombophlebitis

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