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Symptoms blood clot lower leg: Deep vein thrombosis – Symptoms and causes

Deep Vein Thrombosis (DVT) – Heart and Blood Vessel Disorders

Although the risk of deep vein thrombosis cannot be entirely eliminated, it can be reduced in several ways:

  • Intermittent pneumatic compression devices

Preventive measures are selected depending on the person’s risk factors and individual characteristics.

People at low risk of deep vein thrombosis, such as those who must be temporarily inactive for long periods, as during an airplane flight, and those who are undergoing minor surgery but have no other risk factors for deep vein thrombosis, can take simple measures. Such people should elevate their legs, flex and extend their ankles about 10 times every 30 minutes, and walk and stretch every 2 hours while awake during long flights.

People at higher risk of deep vein thrombosis require additional preventive treatment. Such people include

  • People undergoing minor surgery who have specific risk factors for deep vein thrombosis (for example, cancer or excessive blood clotting)

  • People without risk factors undergoing major surgery (especially orthopedic surgery)

  • People who are hospitalized with a serious illness (for example a heart attack or serious injury)

Alternatively, intermittent pneumatic compression (IPC) leggings are an effective way to prevent clots in higher risk people, particularly those who are having surgery associated with a high risk of bleeding or who just had a serious injury and thus should not use an anticoagulant drug. Usually made of plastic, these leggings are automatically pumped up and emptied by an electric pump. They repeatedly squeeze the calves and empty the veins. The leggings are put on before surgery and kept on during and after surgery, until the person can walk again.

Continuously wearing high-compression elastic stockings (support hose) makes the veins narrow slightly and the blood flow more rapidly. As a result, clotting may be less likely. However, elastic stockings are not sufficient protection against developing deep vein thrombosis. Also, they may give a false sense of security and discourage more effective methods of prevention. If not worn correctly, they may bunch up and aggravate the problem by blocking blood flow in the legs.

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Signs and symptoms: Blood clot in the legs

Deep venous thrombosis

Definition

Deep venous thrombosis is a condition in which a blood clot forms in a vein that is deep inside the body.

Alternative Names

DVT; Blood clot in the legs

Causes

Deep venous thrombosis (DVT) mainly affects the veins in the lower leg and thigh. A clot (thrombus) forms in the larger veins of the area. This clot can interfere with blood flow, and it may break off and travel through the bloodstream (embolize). The traveling blood clot (embolus) can lodge in the brain, lungs, heart, or other area, severely damaging that organ.

Risks for DVT include prolonged sitting (such as on long plane or car trips) or bedrest. It also may be caused by recent surgery (especially hip, knee, or female reproductive organ surgery), fractures, childbirth within the last 6 months, and the use of medications such as estrogen and birth control pills.

Risks also include overproduction of red blood cells in bone marrow (polycythemia vera), cancerous (malignant) tumor, and having a condition in which the blood is more likely to clot (hypercoagulability).

Deep venous thrombosis is most common in adults over age 60, but it can occur in any age group.

Symptoms

  • Leg pain in one leg
  • Leg tenderness in one leg
  • Swelling (edema) of one leg
  • Increased warmth in one leg
  • Changes in skin color (redness) in one leg

Exams and Tests

An exam may show a red, swollen, or tender leg.

The presence of deep venous thrombosis may be seen on:

  • X-rays to show veins (venography) in the legs
  • Doppler ultrasound exam of a limb
  • Plethysmography of the legs
  • D-dimer blood test

Many causes of increased clotting (hypercoagulability) can be found by these blood tests:

  • Antithrombin III, protein C, protein S
  • Factor V Leiden
  • Prothrombin 20210a mutation
  • DIC screening
  • Lupus anticoagulant and anticardiolipin antibodies

Treatment

DVT treatment helps prevent a pulmonary embolus from forming and helps prevent another DVT.

For years, the standard treatment has been a medication called heparin to stop blood clots from forming (anticoagulant). Heparin is given through the vein. It results in quick anticoagulation and it treats the clot. A person with DVT also may get an oral medication called warfarin with the heparin.

Warfarin usually takes several days to fully work. Heparin is continued until the warfarin has been fully effective for at least 24 hours. People will take warfarin for about 6 months. Usually warfarin is started after heparin.

Because heparin is given continuously through a vein (IV), it requires a hospital stay. However, newer forms of heparin known as low molecular-weight heparin (usually a drug called enoxaparin) can sometimes be used. This heparin can be given by injection once or twice a day to shorten or avoid the need for a hospital stay.

Warfarin causes an increase in the time it takes blood to clot, known as prothrombin time (PT). A system called the International Normalized Ratio (INR) is used to report the ability of the blood to clot properly. Doctors will adjust warfarin to keep the INR between 2 and 3.

Outlook (Prognosis)

Most DVT’s disappear without a problem, but they can recur. Some people may have chronic pain and swelling in the leg, known as post phlebitic syndrome. Pulmonary embolus is uncommon when DVT’s are treated properly, but it can occur and can be life threatening.

Possible Complications

  • Pulmonary embolus
  • Post-phlebitic syndrome

When to Contact a Medical Professional

Call your health care provider if you have DVT-like symptoms.

Go to the emergency room or call the local emergency number (such as 911) if you have DVT and you develop chest pain, difficulty breathing, fainting, loss of consciousness, or other severe symptoms.

Prevention

Doctors may prescribe anticoagulants to help prevent DVT in high-risk people or those who are undergoing high-risk surgery. To help prevent DVT, move your legs often during long plane trips, car trips, and other situations in which you are sitting or lying down for long periods of time.

Signs and Symptoms DVT | Thrombosis Adviser

In some, there may be no symptoms of DVT, but most common symptoms include:1,2

 

  1. Pain, swelling and tenderness in one leg most commonly in the calf (symptoms in both legs is uncommon)
     
  2. Warm skin around the area of the clot
     
  3. Skin turning to a reddish or bluish colour over the affected area.

Signs and Symptoms of DVT1,2

What is a Pulmonary Embolism? A pulmonary embolism is when a clot that has formed from DVT travels to the lungs and causes a blockage. Read more DVT poses many risks to your long-term health; If the blood clot becomes dislodged it can travel to the lungs and cause pulmonary embolism (PE). Following a DVT you are also at risk of developing post-thrombotic syndrome (PTS) whereby damage to the veins (from the presence of the DVT) leads to permanent disruption to how well the blood flows back up from your feet/lower limbs. Over time this leads to swelling, pain and can cause chronic disability.3

What risk factors increase the risk of DVT?

DVT can develop at any age but is most common in people over the age of 40. Other risk factors for developing DVT include:

 

  • Having a family history of DVT
     
  • Being overweight or obese
     
  • Having damaged blood vessels
     
  • Having certain conditions that cause your blood to clot more easily than usual, such as cancer (including chemotherapy and radiotherapy treatment), heart and lung disease, thrombophilia and Hughes syndrome
     
  • Being inactive or immobile when travelling during long journeys. This can slow blood flow which increases the risk of clots developing
     
  • Pregnancy – Blood clots more easily during pregnancy
     
  • Woman on contraceptive pills and hormone replacement therapy. These can increase the likelihood of blood clotting.

 

Next: How is it diagnosed

 

DVT and venous insufficiency – Vascular Society

When a clot develops in a deep vein of the limb (leg or arm or pelvis) we call it a Deep Vein Thrombosis (DVT).  This causes the leg to swell and become painful. It is important to have this correctly diagnosed since treatment to stop the clot enlarging and moving through the circulation to the heart and lungs (pulmonary embolus) is usually needed. This involves thinning the blood with heparin injections and then an oral anticoagulant (warfarin, rivaroxaban, etc..).  The deep veins of the leg may be damaged by the thrombosis and fail to work normally after a DVT. The swelling and pain in the leg long term after a DVT is sometimes called Post Thrombotic Syndrome (PTS)


What Causes a DVT ?


There are many factors that can cause a DVT to occcur. In the deep veins of the leg, if the blood flow is slow, or the vein wall is damaged / diseased or the blood itself is more prone to clot (thicker blood) then a clot forming in the vein becomes more  likely. This triad of factors (VEIN, BLOOD, FLOW) is the model used to explain why a clot may have occurred. Often referred to as Virchows Triad.


Slower blood flow occurs when people are immobile due to illness or injury, when travelling in restriced positions for many hours, after surgery, with dehydration, increasing age and obesity. The vein wall may be more prone to a clot after injury, limb surgery, previous DVT, infusion with drugs and fluids that damage the vein lining. The blood can be more likely to clot due to medications, (hormones, the pill) in patients with cancer and in conditions where the blood count is raised (polycythaemia, leukaemia). Some patients have inherited conditions with abnormal clotting factors and are more prone to DVT as a result.


With thinning of the blood, the clotting process can usually be controlled. Over 3-6 months the clot in the vein is slowly resorbed and often the vein “recanalises” so that blood can flow through it again. 10-20% of veins may remain blocked. The valves in the veins are often damaged in this process, and the deep veins often do not work as efficiently as normal after a DVT.


There is growing interest in using clot dissolving drugs, and devices within the clotted veins to remove the clot when it first forms. This is called mechanico-lysis. For large extensive clots in the leg and pelvis, there is some evidence that this early removal of the clot can improve the function in the leg veins rather than leaving the clot to slowly be resorbed or leave the vein blocked. On going studies are evaluating this treamtent, to see which patients benefit most from this treatment.


Venous Insufficiency.


If the venous system in the leg fails to work normally the pressure in the leg veins rises. This damages the circulation in the lower leg particularly around the ankle leading to swelling, discomfort, skin changes and eventually it can cause ulceration. Varicose veins, a DVT, or primary failure of the valves in the veins can all contribute to this.  There are  some simple measures  to help the circulation in the leg veins, (elastic stockings, walking, avoiding standing, elevation, weight control) which are all very important in the management of this problem.   Occasionally procedures on the veins may help, particularly if the problem is mainly in the superficial veins.


 


 


 


 


 


 


 


 


 


 


 


Post Thrombotic Syndrome PTS 


PTS refers to the occurrenc of venous insufficiency with the above symptoms of pain, swelling, skin changes etc… in a leg after DVT. This often occurs in the first 1-2 years after the DVT.  Some evidence of symptoms and signs is present in 50% of cases after DVT, but it is only severe in 10-20% of cases. Good anticoagulation after the DVT, keeping mobile, avoiding being overweight, can all help reduce PTS. There is some debate about the effectivenes of wearing support stckings and for how long in order to reduce PTS. They probably help to some extent, especially early on after the DVT when the leg is swollen to improve symptoms. Some suggest wearing them for 2 years, but this may not always be necessary.


For more information go to Circulation Foundation


 


 



History, Physical Examination, Pulmonary Embolism

  • Tapson VF. Acute pulmonary embolism. N Engl J Med. 2008 Mar 6. 358(10):1037-52. [Medline].

  • Haeger K. Problems of acute deep venous thrombosis. I. The interpretation of signs and symptoms. Angiology. 1969 Apr. 20(4):219-23. [Medline].

  • McLachlin J, Richards T, Paterson JC. An evaluation of clinical signs in the diagnosis of venous thrombosis. Arch Surg. 1962 Nov. 85:738-44. [Medline].

  • Meignan M, Rosso J, Gauthier H, et al. Systematic lung scans reveal a high frequency of silent pulmonary embolism in patients with proximal deep venous thrombosis. Arch Intern Med. 2000 Jan 24. 160(2):159-64. [Medline].

  • [Guideline] Snow V, Qaseem A, Barry P, et al. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2007 Feb 6. 146(3):204-10. [Medline].

  • Buller HR, Ten Cate-Hoek AJ, Hoes AW, et al. Safely ruling out deep venous thrombosis in primary care. Ann Intern Med. 2009 Feb 17. 150(4):229-35. [Medline].

  • Bauersachs R, Berkowitz SD, Brenner B, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med. 2010 Dec 23. 363(26):2499-510. [Medline]. [Full Text].

  • Buller HR, Prins MH, Lensin AW, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med. 2012 Apr 5. 366(14):1287-97. [Medline]. [Full Text].

  • Hughes S. Rivaroxaban stands up to standard anticoagulation for VTE treatment. Medscape Medical News. Medscape Heartwire from WebMD. December 13, 2012. Available at http://www.medscape.com/viewarticle/776147. Accessed: March 19, 2013.

  • Jaff MR, McMurtry MS, Archer SL, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011 Apr 26. 123(16):1788-830. [Medline].

  • Silverstein MD, Heit JA, Mohr DN, Petterson TM, O’Fallon WM, Melton LJ 3rd. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med. 1998 Mar 23. 158(6):585-93. [Medline].

  • Useche JN, de Castro AM, Galvis GE, Mantilla RA, Ariza A. Use of US in the evaluation of patients with symptoms of deep venous thrombosis of the lower extremities. Radiographics. 2008 Oct. 28(6):1785-97. [Medline].

  • Chang R, Chen CC, Kam A, Mao E, Shawker TH, Horne MK 3rd. Deep vein thrombosis of lower extremity: direct intraclot injection of alteplase once daily with systemic anticoagulation–results of pilot study. Radiology. 2008 Feb. 246(2):619-29. [Medline].

  • Biuckians A, Meier GH 3rd. Treatment of symptomatic lower extremity acute deep venous thrombosis: role of mechanical thrombectomy. Vascular. 2007 Sep-Oct. 15(5):297-303. [Medline].

  • Li W, Salanitri J, Tutton S, et al. Lower extremity deep venous thrombosis: evaluation with ferumoxytol-enhanced MR imaging and dual-contrast mechanism–preliminary experience. Radiology. 2007 Mar. 242(3):873-81. [Medline].

  • Kakkos SK, Caprini JA, Geroulakos G, Nicolaides AN, Stansby GP, Reddy DJ. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients. Cochrane Database Syst Rev. 2008 Oct 8. CD005258. [Medline].

  • Araki CT, Back TL, Padberg FT, et al. The significance of calf muscle pump function in venous ulceration. J Vasc Surg. 1994 Dec. 20(6):872-7; discussion 878-9. [Medline].

  • Wakefield TW, Strieter RM, Schaub R, et al. Venous thrombosis prophylaxis by inflammatory inhibition without anticoagulation therapy. J Vasc Surg. 2000 Feb. 31(2):309-24. [Medline].

  • Wakefield TW, Proctor MC. Current status of pulmonary embolism and venous thrombosis prophylaxis. Semin Vasc Surg. 2000 Sep. 13(3):171-81. [Medline].

  • Gibbs NM. Venous thrombosis of the lower limbs with particular reference to bed-rest. Br J Surg. 1957 Nov. 45(191):209-36. [Medline].

  • Sevitt S. The structure and growth of valve-pocket thrombi in femoral veins. J Clin Pathol. 1974 Jul. 27(7):517-28. [Medline]. [Full Text].

  • Aronson DL, Thomas DP. Experimental studies on venous thrombosis: effect of coagulants, procoagulants and vessel contusion. Thromb Haemost. 1985 Dec 17. 54(4):866-70. [Medline].

  • Wessler S, Reimer SM, Sheps MC. Biologic assay of a thrombosis-inducing activity in human serum. J Appl Physiol. 1959 Nov. 14:943-6. [Medline].

  • Sevitt S. The mechanisms of canalisation in deep vein thrombosis. J Pathol. 1973 Jun. 110(2):153-65. [Medline].

  • Gandhi RH, Irizarry E, Nackman GB, Halpern VJ, Mulcare RJ, Tilson MD. Analysis of the connective tissue matrix and proteolytic activity of primary varicose veins. J Vasc Surg. 1993 Nov. 18(5):814-20. [Medline].

  • Rizzi A, Quaglio D, Vasquez G, et al. Effects of vasoactive agents in healthy and diseased human saphenous veins. J Vasc Surg. 1998 Nov. 28(5):855-61. [Medline].

  • Monreal M, Martorell A, Callejas JM, et al. Venographic assessment of deep vein thrombosis and risk of developing post-thrombotic syndrome: a prospective study. J Intern Med. 1993 Mar. 233(3):233-8. [Medline].

  • Strandness DE Jr, Langlois Y, Cramer M, Randlett A, Thiele BL. Long-term sequelae of acute venous thrombosis. JAMA. 1983 Sep 9. 250(10):1289-92. [Medline].

  • Prandoni P, Lensing AW, Cogo A, et al. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med. 1996 Jul 1. 125(1):1-7. [Medline].

  • Meissner MH, Caps MT, Zierler BK, Bergelin RO, Manzo RA, Strandness DE Jr. Deep venous thrombosis and superficial venous reflux. J Vasc Surg. 2000 Jul. 32(1):48-56. [Medline].

  • Meissner MH, Caps MT, Zierler BK, et al. Determinants of chronic venous disease after acute deep venous thrombosis. J Vasc Surg. 1998 Nov. 28(5):826-33. [Medline].

  • Meissner MH, Manzo RA, Bergelin RO, Markel A, Strandness DE Jr. Deep venous insufficiency: the relationship between lysis and subsequent reflux. J Vasc Surg. 1993 Oct. 18(4):596-605; discussion 606-8. [Medline].

  • Caps MT, Manzo RA, Bergelin RO, Meissner MH, Strandness DE Jr. Venous valvular reflux in veins not involved at the time of acute deep vein thrombosis. J Vasc Surg. 1995 Nov. 22(5):524-31. [Medline].

  • Johnson BF, Manzo RA, Bergelin RO, Strandness DE Jr. Relationship between changes in the deep venous system and the development of the postthrombotic syndrome after an acute episode of lower limb deep vein thrombosis: a one- to six-year follow-up. J Vasc Surg. 1995 Feb. 21(2):307-12; discussion 313. [Medline].

  • Johnson BF, Manzo RA, Bergelin RO, Strandness DE Jr. The site of residual abnormalities in the leg veins in long-term follow-up after deep vein thrombosis and their relationship to the development of the post-thrombotic syndrome. Int Angiol. 1996 Mar. 15(1):14-9. [Medline].

  • Haenen JH, Wollersheim H, Janssen MC, et al. Evolution of deep venous thrombosis: a 2-year follow-up using duplex ultrasound scan and strain-gauge plethysmography. J Vasc Surg. 2001 Oct. 34(4):649-55. [Medline].

  • Andriopoulos A, Wirsing P, Botticher R. Results of iliofemoral venous thrombectomy after acute thrombosis: report on 165 cases. J Cardiovasc Surg (Torino). 1982 Mar-Apr. 23(2):123-4. [Medline].

  • Zheng Y, Zhou B, Pu X. [Frequency of protein C polymorphisms in Chinese population and thrombotic patients]. Zhonghua Yi Xue Za Zhi. 1998 Mar. 78(3):210-2. [Medline].

  • Juhan C, Alimi Y, Di Mauro P, Hartung O. Surgical venous thrombectomy. Cardiovasc Surg. 1999 Oct. 7(6):586-90. [Medline].

  • Elliott G. Thrombolytic therapy for venous thromboembolism. Curr Opin Hematol. 1999 Sep. 6(5):304-8. [Medline].

  • Baker WF Jr. Diagnosis of deep venous thrombosis and pulmonary embolism. Med Clin North Am. 1998 May. 82(3):459-76. [Medline].

  • Henriksen O, Sejrsen P. Effect of “vein pump” activation upon venous pressure and blood flow in human subcutaneous tissue. Acta Physiol Scand. 1977 May. 100(1):14-21. [Medline].

  • Kearon C. Initial treatment of venous thromboembolism. Thromb Haemost. 1999 Aug. 82(2):887-91. [Medline].

  • Kakkar VV, Howes J, Sharma V, Kadziola Z. A comparative double-blind, randomised trial of a new second generation LMWH (bemiparin) and UFH in the prevention of post-operative venous thromboembolism. The Bemiparin Assessment group. Thromb Haemost. 2000 Apr. 83(4):523-9. [Medline].

  • Heit JA, Mohr DN, Silverstein MD, Petterson TM, O’Fallon WM, Melton LJ 3rd. Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study. Arch Intern Med. 2000 Mar 27. 160(6):761-8. [Medline].

  • Stein PD. Silent pulmonary embolism. Arch Intern Med. 2000 Jan 24. 160(2):145-6. [Medline].

  • Lewandowski A, Syska-Suminska J, Dluzniewski M. [Pulmonary embolism suspicion in a young female patient with the Paget-von Schrötter syndrome]. Kardiol Pol. 2008 Sep. 66(9):969-71. [Medline].

  • Acharya G, Singh K, Hansen JB, Kumar S, Maltau JM. Catheter-directed thrombolysis for the management of postpartum deep venous thrombosis. Acta Obstet Gynecol Scand. 2005 Feb. 84(2):155-8. [Medline].

  • Baarslag HJ, Koopman MM, Hutten BA, et al. Long-term follow-up of patients with suspected deep vein thrombosis of the upper extremity: survival, risk factors and post-thrombotic syndrome. Eur J Intern Med. 2004 Dec. 15(8):503-507. [Medline].

  • Joffe HV, Kucher N, Tapson VF, Goldhaber SZ. Upper-extremity deep vein thrombosis: a prospective registry of 592 patients. Circulation. 2004 Sep 21. 110(12):1605-11. [Medline].

  • Martinelli I, Battaglioli T, Bucciarelli P, Passamonti SM, Mannucci PM. Risk factors and recurrence rate of primary deep vein thrombosis of the upper extremities. Circulation. 2004 Aug 3. 110(5):566-70. [Medline].

  • Beyth RJ, Cohen AM, Landefeld CS. Long-term outcomes of deep-vein thrombosis. Arch Intern Med. 1995 May 22. 155(10):1031-7. [Medline].

  • Kistner RL, Ball JJ, Nordyke RA, Freeman GC. Incidence of pulmonary embolism in the course of thrombophlebitis of the lower extremities. Am J Surg. 1972 Aug. 124(2):169-76. [Medline].

  • Havig O. Deep vein thrombosis and pulmonary embolism. An autopsy study with multiple regression analysis of possible risk factors. Acta Chir Scand Suppl. 1977. 478:1-120. [Medline].

  • Higdon ML, Higdon JA. Treatment of oncologic emergencies. Am Fam Physician. 2006 Dec 1. 74 (11):1873-80. [Medline].

  • Guijarro Escribano JF, Anton RF, Colmenarejo Rubio A, et al. Superior vena cava syndrome with central venous catheter for chemotherapy treated successfully with fibrinolysis. Clin Transl Oncol. 2007 Mar. 9 (3):198-200. [Medline].

  • Baltayiannis N, Magoulas D, Anagnostopoulos D, et al. Percutaneous stent placement in malignant cases of superior vena cava syndrome. J BUON. 2005 Jul-Sep. 10 (3):377-80. [Medline].

  • Urruticoechea A, Mesia R, Dominguez J, et al. Treatment of malignant superior vena cava syndrome by endovascular stent insertion. Experience on 52 patients with lung cancer. Lung Cancer. 2004 Feb. 43 (2):209-14. [Medline].

  • Satoh K, Satoh T, Yaoita N, Shimokawa H. Recent advances in the understanding of thrombosis. Arterioscler Thromb Vasc Biol. 2019 Jun. 39 (6):e159-65. [Medline]. [Full Text].

  • Arfvidsson B, Eklof B, Kistner RL, Masuda EM, Sato DT. Risk factors for venous thromboembolism following prolonged air travel. Coach class thrombosis. Hematol Oncol Clin North Am. 2000 Apr. 14(2):391-400, ix. [Medline].

  • Slipman CW, Lipetz JS, Jackson HB, Vresilovic EJ. Deep venous thrombosis and pulmonary embolism as a complication of bed rest for low back pain. Arch Phys Med Rehabil. 2000 Jan. 81(1):127-9. [Medline].

  • Ruggeri M, Tosetto A, Castaman G, Rodeghiero F. Congenital absence of the inferior vena cava: a rare risk factor for idiopathic deep-vein thrombosis. Lancet. 2001 Feb 10. 357(9254):441. [Medline].

  • Hamoud S, Nitecky S, Engel A, Goldsher D, Hayek T. Hypoplasia of the inferior vena cava with azygous continuation presenting as recurrent leg deep vein thrombosis. Am J Med Sci. 2000 Jun. 319(6):414-6. [Medline].

  • Greenfield LJ, Proctor MC. The percutaneous Greenfield filter: outcomes and practice patterns. J Vasc Surg. 2000 Nov. 32(5):888-93. [Medline].

  • Tsuji Y, Goto A, Hara I, et al. Renal cell carcinoma with extension of tumor thrombus into the vena cava: surgical strategy and prognosis. J Vasc Surg. 2001 Apr. 33(4):789-96. [Medline].

  • Stamatakis JD, Kakkar VV, Sagar S, Lawrence D, Nairn D, Bentley PG. Femoral vein thrombosis and total hip replacement. Br Med J. 1977 Jul 23. 2(6081):223-5. [Medline]. [Full Text].

  • Pullen LC. PICCs may double risk for clots in critically ill patients. Medscape Medical News from WebMD. May 20, 2013. Available at http://www.medscape.com/viewarticle/804428. Accessed: June 4, 2013.

  • Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet. 2013 Jul 27. 382(9889):311-25. [Medline].

  • Alikhan R, Cohen AT, Combe S, et al. Risk factors for venous thromboembolism in hospitalized patients with acute medical illness: analysis of the MEDENOX Study. Arch Intern Med. 2004 May 10. 164(9):963-8. [Medline].

  • Heit JA, Elliott CG, Trowbridge AA, Morrey BF, Gent M, Hirsh J. Ardeparin sodium for extended out-of-hospital prophylaxis against venous thromboembolism after total hip or knee replacement. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2000 Jun 6. 132(11):853-61. [Medline].

  • Chu C, Tokumaru S, Izumi K, Nakagawa K. Obesity increases risk of anticoagulation reversal failure with prothrombin complex concentrate in those with intracranial hemorrhage. Int J Neurosci. 2016 Jan. 126 (1):62-6. [Medline].

  • Nordstrom M, Lindblad B, Bergqvist D, Kjellstrom T. A prospective study of the incidence of deep-vein thrombosis within a defined urban population. J Intern Med. 1992 Aug. 232(2):155-60. [Medline].

  • Dahlback B. Inherited thrombophilia: resistance to activated protein C as a pathogenic factor of venous thromboembolism. Blood. 1995 Feb 1. 85(3):607-14. [Medline].

  • Anderson FA Jr, Wheeler HB, Goldberg RJ, Hosmer DW, Forcier A. The prevalence of risk factors for venous thromboembolism among hospital patients. Arch Intern Med. 1992 Aug. 152(8):1660-4. [Medline].

  • Warlow C, Ogston D, Douglas AS. Deep venous thrombosis of the legs after strokes. Part I–incidence and predisposing factors. Br Med J. 1976 May 15. 1(6019):1178-81. [Medline]. [Full Text].

  • Monreal M, Lafoz E, Casals A, et al. Occult cancer in patients with deep venous thrombosis. A systematic approach. Cancer. 1991 Jan 15. 67(2):541-5. [Medline].

  • Rickles FR, Levine M, Edwards RL. Hemostatic alterations in cancer patients. Cancer Metastasis Rev. 1992 Nov. 11(3-4):237-48. [Medline].

  • Levine MN, Gent M, Hirsh J, et al. The thrombogenic effect of anticancer drug therapy in women with stage II breast cancer. N Engl J Med. 1988 Feb 18. 318(7):404-7. [Medline].

  • Clagett GP, Reisch JS. Prevention of venous thromboembolism in general surgical patients. Results of meta-analysis. Ann Surg. 1988 Aug. 208(2):227-40. [Medline]. [Full Text].

  • Clagett GP, Anderson FA Jr, Heit J, Levine MN, Wheeler HB. Prevention of venous thromboembolism. Chest. 1995 Oct. 108(4 Suppl):312S-334S. [Medline].

  • Coagulation and thromboembolism in orthopaedic surgery. Beaty JH, ed. Orthopaedic Knowledge Update. Rosemont, IL: Amer Academy of Orthopaedic Surgeons; 1999. 6: 63-72.

  • Kakkar VV, Howe CT, Nicolaides AN, Renney JT, Clarke MB. Deep vein thrombosis of the leg. Is there a “high risk” group?. Am J Surg. 1970 Oct. 120(4):527-30. [Medline].

  • Dahlback B. Inherited thrombophilia: resistance to activated protein C as a pathogenic factor of venous thromboembolism. Blood. 1995 Feb 1. 85(3):607-14. [Medline].

  • Motykie GD, Caprini JA, Arcelus JI, et al. Risk factor assessment in the management of patients with suspected deep venous thrombosis. Int Angiol. 2000 Mar. 19(1):47-51. [Medline].

  • Motykie GD, Zebala LP, Caprini JA, et al. A guide to venous thromboembolism risk factor assessment. J Thromb Thrombolysis. 2000 Apr. 9(3):253-62. [Medline].

  • Schafer AI. Hypercoagulable states: molecular genetics to clinical practice. Lancet. 1994 Dec 24-31. 344(8939-8940):1739-42. [Medline].

  • Meissner MH, Strandness E. Pathophysiology and natural history of acute deep venous thrombosis, Rutherford’s Vascular Surgery. 2005. 2124-2142.

  • Ho CH, Chau WK, Hsu HC, Gau JP, Yu TJ. Causes of venous thrombosis in fifty Chinese patients. Am J Hematol. 2000 Feb. 63(2):74-8. [Medline].

  • Vandenbrouke JP, Bloemenkamp KW, Rosendaal FR, Helmerhorst FM. Incidence of venous thromboembolism in users of combined oral contraceptives. Risk is particularly high with first use of oral contraceptives. BMJ. 2000 Jan 1. 320(7226):57-8. [Medline].

  • Cushman M, Tsai AW, White RH, et al. Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology. Am J Med. 2004 Jul 1. 117(1):19-25. [Medline].

  • Bollen L, Vande Casteele N, Ballet V, et al. Thromboembolism as an important complication of inflammatory bowel disease. Eur J Gastroenterol Hepatol. 2016 Jan. 28 (1):1-7. [Medline].

  • Sevitt S, Gallagher N. Venous thrombosis and pulmonary embolism. A clinico-pathological study in injured and burned patients. Br J Surg. 1961 Mar. 48:475-89. [Medline].

  • Gorman WP, Davis KR, Donnelly R. ABC of arterial and venous disease. Swollen lower limb-1: general assessment and deep vein thrombosis. BMJ. 2000 May 27. 320(7247):1453-6. [Medline]. [Full Text].

  • Martinelli I, Lensing AW, Middeldorp S, et al. Recurrent venous thromboembolism and abnormal uterine bleeding with anticoagulant and hormone therapy use. Blood. 2015 Dec 22. [Medline].

  • Kearon C, Crowther M, Hirsh J. Management of patients with hereditary hypercoagulable disorders. Annu Rev Med. 2000. 51:169-85. [Medline].

  • Prandoni P, Mannucci PM. Deep-vein thrombosis of the lower limbs: diagnosis and management. Baillieres Best Pract Res Clin Haematol. 1999 Sep. 12(3):533-54. [Medline].

  • Rathbun SW, Raskob GE, Whitsett TL. Sensitivity and specificity of helical computed tomography in the diagnosis of pulmonary embolism: a systematic review. Ann Intern Med. 2000 Feb 1. 132(3):227-32. [Medline].

  • Goldhaber SZ. Diagnosis of deep venous thrombosis. Clin Cornerstone. 2000. 2(4):29-37. [Medline].

  • Signorelli SS, Valerio F, Davide C, et al. Evaluating the potential of routine blood tests to identify the risk of deep vein thrombosis: a 1-year monocenter cohort study. Angiology. 2017 Aug. 68 (7):592-7. [Medline].

  • Lensing AW. Anticoagulation in acute ischaemic stroke: deep vein thrombosis prevention and long-term stroke outcomes. Blood Coagul Fibrinolysis. 1999 Aug. 10 Suppl 2:S123-7. [Medline].

  • Lensing AW, Prins MH. Recurrent deep vein thrombosis and two coagulation factor gene mutations: quo vadis?. Thromb Haemost. 1999 Dec. 82(6):1564-6. [Medline].

  • Kleinjan A, Di Nisio M, Beyer-Westendorf J, et al. Safety and feasibility of a diagnostic algorithm combining clinical probability, d-dimer testing, and ultrasonography for suspected upper extremity deep venous thrombosis: a prospective management study. Ann Intern Med. 2014 Apr 1. 160(7):451-7. [Medline].

  • Deitelzweig S, Jaff MR. Medical management of venous thromboembolic disease. Tech Vasc Interv Radiol. 2004 Jun. 7(2):63-7. [Medline].

  • McGarry LJ, Stokes ME, Thompson D. Outcomes of thromboprophylaxis with enoxaparin vs. unfractionated heparin in medical inpatients. Thromb J. 2006 Sep 27. 4:17. [Medline].

  • Cosmi B, Palareti G. D-dimer, oral anticoagulation, and venous thromboembolism recurrence. Semin Vasc Med. 2005 Nov. 5(4):365-70. [Medline].

  • Linkins LA, Bates SM, Lang E, et al. Selective D-dimer testing for diagnosis of a first suspected episode of deep venous thrombosis: a randomized trial. Ann Intern Med. 2013 Jan 15. 158(2):93-100. [Medline].

  • Brown T. Selective D-dimer testing best for DVT diagnosis. Medscape Heartwire from WebMD. January 15, 2013. Available at http://www.medscape.com/viewarticle/791417. Accessed: March 19, 2013.

  • Perrier A, Desmarais S, Miron MJ, et al. Non-invasive diagnosis of venous thromboembolism in outpatients. Lancet. 1999 Jan 16. 353(9148):190-5. [Medline].

  • Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003 Sep 25. 349(13):1227-35. [Medline].

  • Nakamura M, Yamada N, Oda E, et al. Predictors of venous thromboembolism recurrence and the bleeding events identified using a Japanese healthcare database. J Cardiol. 2017 Aug. 70 (2):155-62. [Medline].

  • Ita K. Transdermal delivery of heparin: Physical enhancement techniques. Int J Pharm. 2015 Dec 30. 496 (2):240-9. [Medline].

  • [Guideline] Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016 Feb. 149 (2):315-52. [Medline]. [Full Text].

  • Tromeur C, Van Der Pol LM, Couturaud F, Klok FA, Huisman MV. Therapeutic management of acute pulmonary embolism. Expert Rev Respir Med. 2017 Aug. 11 (8):641-8. [Medline].

  • van der Hulle T, Dronkers CE, Klok FA, Huisman MV. Recent developments in the diagnosis and treatment of pulmonary embolism. J Intern Med. 2016 Jan. 279 (1):16-29. [Medline].

  • Park J, Byun Y. Recent advances in anticoagulant drug delivery. Expert Opin Drug Deliv. 2015 Dec 23. 1-14. [Medline].

  • Kabuki T, Nakanishi R, Hisatake S, et al. A treatment strategy using subcutaneous fondaparinux followed by oral rivaroxaban is effective for treating acute venous thromboembolism. J Cardiol. 2017 Aug. 70 (2):163-8. [Medline].

  • Bijsterveld NR, Moons AH, Boekholdt SM, et al. Ability of recombinant factor VIIa to reverse the anticoagulant effect of the pentasaccharide fondaparinux in healthy volunteers. Circulation. 2002 Nov 12. 106(20):2550-4. [Medline].

  • Cohen AT, Dobromirski M. The use of rivaroxaban for short- and long-term treatment of venous thromboembolism. Thromb Haemost. 2012 Jun. 107(6):1035-43. [Medline].

  • Romualdi E, Donadini MP, Ageno W. Oral rivaroxaban after symptomatic venous thromboembolism: the continued treatment study (EINSTEIN-extension study). Expert Rev Cardiovasc Ther. 2011 Jul. 9(7):841-4. [Medline].

  • Raskob GE, Gallus AS, Pineo GF, et al. Apixaban versus enoxaparin for thromboprophylaxis after hip or knee replacement: pooled analysis of major venous thromboembolism and bleeding in 8464 patients from the ADVANCE-2 and ADVANCE-3 trials. J Bone Joint Surg Br. 2012 Feb. 94(2):257-64. [Medline].

  • Lassen MR, Gallus A, Raskob GE, Pineo G, Chen D, Ramirez LM. Apixaban versus enoxaparin for thromboprophylaxis after hip replacement. N Engl J Med. 2010 Dec 23. 363(26):2487-98. [Medline]. [Full Text].

  • Lassen MR, Raskob GE, Gallus A, Pineo G, Chen D, Hornick P. Apixaban versus enoxaparin for thromboprophylaxis after knee replacement (ADVANCE-2): a randomised double-blind trial. Lancet. 2010 Mar 6. 375(9717):807-15. [Medline].

  • US Food and Drug Administration. Supplement approval (apixaban) [letter]. August 19, 2014. Available at http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2014/202155Orig1s006ltr.pdf. Accessed: August 28, 2014.

  • Agnelli G, Buller HR, Cohen A, et al, for the AMPLIFY Investigators. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med. 2013 Aug 29. 369 (9):799-808. [Medline]. [Full Text].

  • Agnelli G, Buller HR, Cohen A, et al, for the AMPLIFY-EXT Investigators. Apixaban for extended treatment of venous thromboembolism. N Engl J Med. 2013 Feb 21. 368 (8):699-708. [Medline]. [Full Text].

  • Liu X, Thompson J, Phatak H, et al. Extended anticoagulation with apixaban reduces hospitalisations in patients with venous thromboembolism. An analysis of the AMPLIFY-EXT trial. Thromb Haemost. 2015 Dec 22. 115 (1):161-8. [Medline].

  • Schulman S, Kearon C, Kakkar AK, et al, for the RE-COVER Study Group. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med. 2009 Dec 10. 361 (24):2342-52. [Medline].

  • Schulman S, Kakkar AK, Goldhaber SZ, et al, for the RE-COVER II Trial Investigators. Treatment of acute venous thromboembolism with dabigatran or warfarin and pooled analysis. Circulation. 2014 Feb 18. 129 (7):764-72. [Medline].

  • Schulman S, Kearon C, Kakkar AK, et al, for the RE-MEDY Trial Investigators, RE-SONATE Trial Investigators. Extended use of dabigatran, warfarin, or placebo in venous thromboembolism. N Engl J Med. 2013 Feb 21. 368 (8):709-18. [Medline].

  • US Food and Drug Administration. FDA approves anti-clotting drug Savaysa [news release]. Available at https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm429523.htm. January 8, 2015; Accessed: July 16, 2015.

  • Buller HR, Decousus H, Grosso MA, for the Hokusai-VTE Investigators. Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med. 2013 Oct 10. 369 (15):1406-15. [Medline].

  • US Food and Drug Administration. FDA approved betrixaban (BEVYXXA, Portola) for the prophylaxis of venous thromboembolism (VTE) in adult patients. Available at https://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm564422.htm. June 23, 2017; Accessed: June 27, 2017.

  • Cohen AT, Harrington RA, Goldhaber SZ, et al, for the APEX Investigators. Extended thromboprophylaxis with betrixaban in acutely Ill medical patients. N Engl J Med. 2016 Aug 11. 375 (6):534-44. [Medline]. [Full Text].

  • Gibson CM, Chi G, Halaby R, et al, for the, APEX Investigators. Extended-duration betrixaban reduces the risk of stroke versus standard-dose enoxaparin among hospitalized medically Ill patients: an APEX trial substudy (acute medically Ill venous thromboembolism prevention with extended duration betrixaban). Circulation. 2017 Feb 14. 135 (7):648-55. [Medline].

  • Prandoni P, Prins MH, Lensing AW, et al. Residual thrombosis on ultrasonography to guide the duration of anticoagulation in patients with deep venous thrombosis: a randomized trial. Ann Intern Med. 2009 May 5. 150(9):577-85. [Medline].

  • Schulman S, Granqvist S, Holmstrom M, et al. The duration of oral anticoagulant therapy after a second episode of venous thromboembolism. The Duration of Anticoagulation Trial Study Group. N Engl J Med. 1997 Feb 6. 336 (6):393-8. [Medline].

  • Lee AY, Levine MN, Baker RI, et al. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med. 2003 Jul 10. 349(2):146-53. [Medline].

  • Hull R, Pineo G, Mah A, et al. A randomized trial evaluating long term low molecular weight heparin therapy for three months verses intravenous heparin followed by warfarin sodium. Blood 100. 2002. 148a.

  • Pettila V, Kaaja R, Leinonen P, Ekblad U, Kataja M, Ikkala E. Thromboprophylaxis with low molecular weight heparin (dalteparin) in pregnancy. Thromb Res. 1999 Nov 15. 96(4):275-82. [Medline].

  • Zidane M, Schram MT, Planken EW, et al. Frequency of major hemorrhage in patients treated with unfractionated intravenous heparin for deep venous thrombosis or pulmonary embolism: a study in routine clinical practice. Arch Intern Med. 2000 Aug 14-28. 160(15):2369-73. [Medline].

  • Vo T, Vazquez S, Rondina MT. Current state of anticoagulants to treat deep venous thrombosis. Curr Cardiol Rep. 2014 Mar. 16(3):463. [Medline].

  • Levi M, Eerenberg E, Kamphuisen PW. Bleeding risk and reversal strategies for old and new anticoagulants and antiplatelet agents. J Thromb Haemost. 2011 Sep. 9 (9):1705-12. [Medline].

  • Hirsh J, Bauer KA, Donati MB, Gould M, Samama MM, Weitz JI. Parenteral anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun. 133 (6 suppl):141S-159S. [Medline].

  • Marshall A, Levine M, Howell ML, et al. Dose-associated pulmonary complication rates after fresh frozen plasma administration for warfarin reversal. J Thromb Haemost. 2015 Dec 8. [Medline].

  • Purrucker JC, Haas K, Rizos T, et al. Early clinical and radiological course, management, and outcome of intracerebral hemorrhage related to new oral anticoagulants. JAMA Neurol. 2015 Dec 14. 1-10. [Medline].

  • Aronis KN, Hylek EM. Who, when, and how to reverse non-vitamin K oral anticoagulants. J Thromb Thrombolysis. 2015 Dec 1. 123 (6):1350-61. [Medline].

  • US Food and Drug Administration. FDA approves Praxbind, the first reversal agent for the anticoagulant Pradaxa [news release]. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm467300.htm. October 16, 2015; Accessed: March 30, 2016.

  • Pollack CV Jr, Reilly PA, Eikelboom J, et al. Idarucizumab for dabigatran reversal. N Engl J Med. 2015 Aug 6. 373 (6):511-20. [Medline].

  • Eikelboom JW, Quinlan DJ, van Ryn J, Weitz JI. Idarucizumab: the antidote for reversal of dabigatran. Circulation. 2015 Dec 22. 132 (25):2412-22. [Medline].

  • Ansell JE. Universal, class-specific and drug-specific reversal agents for the new oral anticoagulants. J Thromb Thrombolysis. 2016 Feb. 41 (2):248-52. [Medline].

  • Ghadimi K, Dombrowski KE, Levy JH, Welsby IJ. Andexanet alfa for the reversal of factor Xa inhibitor related anticoagulation. Expert Rev Hematol. 2015 Dec 21. [Medline].

  • Ansell JE, Bakhru SH, Laulicht BE, et al. Use of PER977 to reverse the anticoagulant effect of edoxaban. N Engl J Med. 2014 Nov 27. 371 (22):2141-2. [Medline].

  • Enden T, Haig Y, Klow NE, et al for CaVenT Study Group. Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet. 2012 Jan 7. 379(9810):31-8. [Medline].

  • [Guideline] Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb. 141 (2 suppl):e419S-e496S. [Medline].

  • Plate G, Akesson H, Einarsson E, Ohlin P, Eklof B. Long-term results of venous thrombectomy combined with a temporary arterio-venous fistula. Eur J Vasc Surg. 1990 Oct. 4(5):483-9. [Medline].

  • Eklof B, Kistner RL. Is there a role for thrombectomy in iliofemoral venous thrombosis?. Semin Vasc Surg. 1996 Mar. 9(1):34-45. [Medline].

  • Mewissen MW, Seabrook GR, Meissner MH, Cynamon J, Labropoulos N, Haughton SH. Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry. Radiology. 1999 Apr. 211(1):39-49. [Medline].

  • Prandoni P, Lensing AW, Prins MH, et al. Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial. Ann Intern Med. 2004 Aug 17. 141(4):249-56. [Medline].

  • [Guideline] Hirsh J, Guyatt G, Albers GW, Harrington R, Schunemann HJ. Antithrombotic and thrombolytic therapy: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008 Jun. 133 (6 suppl):110S-112S. [Medline].

  • Partsch H. Ambulation and compression after deep vein thrombosis: dispelling myths. Semin Vasc Surg. 2005 Sep. 18(3):148-52. [Medline].

  • Kahn SR, Shrier I, Kearon C. Physical activity in patients with deep venous thrombosis: a systematic review. Thromb Res. 2008. 122(6):763-73. [Medline].

  • Ramos R, Salem BI, De Pawlikowski MP, Coordes C, Eisenberg S, Leidenfrost R. The efficacy of pneumatic compression stockings in the prevention of pulmonary embolism after cardiac surgery. Chest. 1996 Jan. 109(1):82-5. [Medline].

  • Skillman JJ, Collins RE, Coe NP, et al. Prevention of deep vein thrombosis in neurosurgical patients: a controlled, randomized trial of external pneumatic compression boots. Surgery. 1978 Mar. 83(3):354-8. [Medline].

  • Kolluri R, Plessa AL, Sanders MC, Singh NK, Lucore C. A randomized study of the safety and efficacy of fondaparinux versus placebo in the prevention of venous thromboembolism after coronary artery bypass graft surgery. Am Heart J. 2016 Jan. 171 (1):1-6. [Medline].

  • [Guideline] Lim W, Le Gal G, Bates SM, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism. Blood Adv. 2018 Nov 27. 2 (22):3226-56. [Medline]. [Full Text].

  • [Guideline] American Academy of Family Physicians. Diagnosis of venous thromboembolism – clinical practice guideline (endorsed March 2019). Available at https://www.aafp.org/patient-care/clinical-recommendations/all/venous-thromboembolism1.html. March 2019; Accessed: June 3, 2019.

  • [Guideline] Witt DM, Nieuwlaat R, Clark NP, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood Adv. 2018 Nov 27. 2 (22):3257-91. [Medline]. [Full Text].

  • Brien L. Anticoagulant medications for the prevention and treatment of thromboembolism. AACN Adv Crit Care. 2019 Summer. 30 (2):126-38. [Medline].

  • Agnelli G, Prandoni P, Santamaria MG, et al. Three months versus one year of oral anticoagulant therapy for idiopathic deep venous thrombosis. Warfarin Optimal Duration Italian Trial Investigators. N Engl J Med. 2001 Jul 19. 345(3):165-9. [Medline].

  • Alkjaersig N, Fletcher AP, Sherry S. The mechanism of clot dissolution by plasmin. J Clin Invest. 1959 Jul. 38(7):1086-95. [Medline]. [Full Text].

  • [Guideline] Qaseem A, Snow V, Barry P, et al for the Joint American Academy of Family Physicians/American College of Physicians Panel on Deep Venous Thrombosis/Pulmonary Embolism. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Fam Med. 2007 Jan-Feb. 5(1):57-62. [Medline]. [Full Text].

  • Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS. Does this patient have deep vein thrombosis?. JAMA. 1998 Apr 8. 279(14):1094-9. [Medline].

  • Bauer KA, Eriksson BI, Lassen MR, Turpie AG. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after elective major knee surgery. N Engl J Med. 2001 Nov 1. 345(18):1305-10. [Medline].

  • Berend KR, Lombardi AV Jr. Multimodal venous thromboembolic disease prevention for patients undergoing primary or revision total joint arthroplasty: the role of aspirin. Am J Orthop (Belle Mead NJ). 2006 Jan. 35(1):24-9. [Medline].

  • Bergmann JF, Neuhart E. A multicenter randomized double-blind study of enoxaparin compared with unfractionated heparin in the prevention of venous thromboembolic disease in elderly in-patients bedridden for an acute medical illness. The Enoxaparin in Medicine Study Group. Thromb Haemost. 1996 Oct. 76(4):529-34. [Medline].

  • Bjarnason H, Kruse JR, Asinger DA, et al. Iliofemoral deep venous thrombosis: safety and efficacy outcome during 5 years of catheter-directed thrombolytic therapy. J Vasc Interv Radiol. 1997 May-Jun. 8(3):405-18. [Medline].

  • Boudes PF. The challenges of new drugs benefits and risks analysis: lessons from the ximelagatran FDA Cardiovascular Advisory Committee. Contemp Clin Trials. 2006 Oct. 27(5):432-40. [Medline].

  • Breddin HK. Low molecular weight heparins in the prevention of deep-vein thrombosis in general surgery. Semin Thromb Hemost. 1999. 25 Suppl 3:83-9. [Medline].

  • Bristol-Myers Squibb. US FDA approves Eliquis (apixaban) to reduce the risk of blood clots following hip or knee replacement surgery [press release]. Available at http://news.bms.com/press-release/us-fda-approves-eliquis-apixaban-reduce-risk-blood-clots-following-hip-or-knee-replace. Accessed: March 25, 2014.

  • Bulger CM, Jacobs C, Patel NH. Epidemiology of acute deep vein thrombosis. Tech Vasc Interv Radiol. 2004 Jun. 7(2):50-4. [Medline].

  • Burke DT. Prevention of deep venous thrombosis: overview of available therapy options for rehabilitation patients. Am J Phys Med Rehabil. 2000 Sep-Oct. 79(5 Suppl):S3-8. [Medline].

  • Buller HR, Agnelli G, Hull RD, Hyers TM, Prins MH, Raskob GE. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep. 126(3 Suppl):401S-428S. [Medline].

  • Camporese G, Bernardi E, Prandoni P, et al. Low-molecular-weight heparin versus compression stockings for thromboprophylaxis after knee arthroscopy: a randomized trial. Ann Intern Med. 2008 Jul 15. 149(2):73-82. [Medline].

  • Caprini JA, Arcelus JI, Maksimovic D, Glase CJ, Sarayba JG, Hathaway K. Thrombosis prophylaxis in orthopedic surgery: current clinical considerations. J South Orthop Assoc. 2002 Winter. 11(4):190-6. [Medline].

  • Cham MD, Yankelevitz DF, Shaham D, et al. Deep venous thrombosis: detection by using indirect CT venography. The Pulmonary Angiography-Indirect CT Venography Cooperative Group. Radiology. 2000 Sep. 216(3):744-51. [Medline].

  • Chan WS, Spencer FA, Lee AY, et al. Safety of withholding anticoagulation in pregnant women with suspected deep vein thrombosis following negative serial compression ultrasound and iliac vein imaging. CMAJ. 2013 Mar 5. 185(4):E194-200. [Medline]. [Full Text].

  • Cho JS, Martelli E, Mozes G, Miller VM, Gloviczki P. Effects of thrombolysis and venous thrombectomy on valvular competence, thrombogenicity, venous wall morphology, and function. J Vasc Surg. 1998 Nov. 28(5):787-99. [Medline].

  • Coche EE, Hamoir XL, Hammer FD, Hainaut P, Goffette PP. Using dual-detector helical CT angiography to detect deep venous thrombosis in patients with suspicion of pulmonary embolism: diagnostic value and additional findings. AJR Am J Roentgenol. 2001 Apr. 176(4):1035-9. [Medline].

  • Colwell C, Mouret P. Ximelagatran for the prevention of venous thromboembolism following elective hip or knee replacement surgery. Semin Vasc Med. 2005 Aug. 5(3):266-75. [Medline].

  • Comerota AJ, Throm RC, Mathias SD, Haughton S, Mewissen M. Catheter-directed thrombolysis for iliofemoral deep venous thrombosis improves health-related quality of life. J Vasc Surg. 2000 Jul. 32(1):130-7. [Medline].

  • Comp PC, Spiro TE, Friedman RJ, et al. Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. Enoxaparin Clinical Trial Group. J Bone Joint Surg Am. 2001 Mar. 83-A(3):336-45. [Medline].

  • Deitelzweig S, Jaff MR. Medical management of venous thromboembolic disease. Tech Vasc Interv Radiol. 2004 Jun. 7(2):63-7. [Medline].

  • DOULBLE REF141.

  • Dranitsaris G, Stumpo C, Smith R, Bartle W. Extended dalteparin prophylaxis for venous thromboembolic events: cost-utility analysis in patients undergoing major orthopedic surgery. Am J Cardiovasc Drugs. 2009. 9(1):45-58. [Medline].

  • Dennis M, Sandercock P, Reid J, Graham C, Forbes J, Murray G. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. CLOTS (Clots in Legs Or sTockings after Stroke) Trials Collaboration. Lancet. 2013 Aug 10. 382(9891):516-24. [Medline].

  • Eklof B, Arfvidsson B, Kistner RL, Masuda EM. Indications for surgical treatment of iliofemoral vein thrombosis. Hematol Oncol Clin North Am. 2000 Apr. 14(2):471-82. [Medline].

  • Epstein NE. Efficacy of pneumatic compression stocking prophylaxis in the prevention of deep venous thrombosis and pulmonary embolism following 139 lumbar laminectomies with instrumented fusions. J Spinal Disord Tech. 2006 Feb. 19(1):28-31. [Medline].

  • Eriksson BI, Borris LC, Friedman RJ, et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med. 2008 Jun 26. 358(26):2765-75. [Medline].

  • Eskeland G, Solheim K, Skjorten F. Anticoagulant prophylaxis, thromboembolism and mortality in elderly patients with hip fractures. A controlled clinical trial. Acta Chir Scand. 1966 Jan-Feb. 131(1):16-29. [Medline].

  • Fisher CG, Blachut PA, Salvian AJ, Meek RN, O’Brien PJ. Effectiveness of pneumatic leg compression devices for the prevention of thromboembolic disease in orthopaedic trauma patients: a prospective, randomized study of compression alone versus no prophylaxis. J Orthop Trauma. 1995 Feb. 9(1):1-7. [Medline].

  • Francis CW, Berkowitz SD, Comp PC, et al. Comparison of ximelagatran with warfarin for the prevention of venous thromboembolism after total knee replacement. N Engl J Med. 2003 Oct 30. 349(18):1703-12. [Medline].

  • Gaffney PJ, Creighton LJ, Callus M, Thorpe R. Monoclonal antibodies to crosslinked fibrin degradation products (XL-FDP). II. Evaluation in a variety of clinical conditions. Br J Haematol. 1988 Jan. 68(1):91-6. [Medline].

  • Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest. 2001 Jan. 119(1 Suppl):132S-175S. [Medline].

  • Gerotziafas GT, Samama MM. Heterogeneity of synthetic factor Xa inhibitors. Curr Pharm Des. 2005. 11(30):3855-76. [Medline].

  • Gillies TE, Ruckley CV, Nixon SJ. Still missing the boat with fatal pulmonary embolism. Br J Surg. 1996 Oct. 83(10):1394-5. [Medline].

  • Ginsberg JS, Turkstra F, Buller HR, MacKinnon B, Magier D, Hirsh J. Postthrombotic syndrome after hip or knee arthroplasty: a cross-sectional study. Arch Intern Med. 2000 Mar 13. 160(5):669-72. [Medline].

  • Grossman C, McPherson S. Safety and efficacy of catheter-directed thrombolysis for iliofemoral venous thrombosis. AJR Am J Roentgenol. 1999 Mar. 172(3):667-72. [Medline].

  • Heit JA, Silverstein MD, Mohr DN, Petterson TM, O’Fallon WM, Melton LJ 3rd. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Arch Intern Med. 2000 Mar 27. 160(6):809-15. [Medline].

  • Henderson D. DVT in pregnancy ruled out by serial Doppler ultrasound. Medscape Medical News from WebMD. January 14, 2013. Available at http://www.medscape.com/viewarticle/777659. Accessed: March 25, 2014.

  • Horellou MH, Conrad J, Samama MM. Hull RD, Raskob GE, Pineo GF, eds. Venous Thromboembolism: An Evidence-Based Atlas. Armonk, NY: Futura; 1996.

  • Hull RD, Pineo GF. Prophylaxis of deep venous thrombosis and pulmonary embolism. Current recommendations. Med Clin North Am. 1998 May. 82(3):477-93. [Medline].

  • Hull RD, Pineo GF, Francis C, et al. Low-molecular-weight heparin prophylaxis using dalteparin extended out-of-hospital vs in-hospital warfarin/out-of-hospital placebo in hip arthroplasty patients: a double-blind, randomized comparison. North American Fragmin Trial Investigators. Arch Intern Med. 2000 Jul 24. 160(14):2208-15. [Medline].

  • Hull RD, Pineo GF, Stein PD, et al. Timing of initial administration of low-molecular-weight heparin prophylaxis against deep vein thrombosis in patients following elective hip arthroplasty: a systematic review. Arch Intern Med. 2001 Sep 10. 161(16):1952-60. [Medline].

  • Hull RD, Raskob GE, Brant RF, Pineo GF, Valentine KA. Relation between the time to achieve the lower limit of the APTT therapeutic range and recurrent venous thromboembolism during heparin treatment for deep vein thrombosis. Arch Intern Med. 1997 Dec 8-22. 157(22):2562-8. [Medline].

  • Hull RD, Raskob GE, Brant RF, Pineo GF, Valentine KA. The importance of initial heparin treatment on long-term clinical outcomes of antithrombotic therapy. The emerging theme of delayed recurrence. Arch Intern Med. 1997 Nov 10. 157(20):2317-21. [Medline].

  • Iskander GA, Nelson RS, Morehouse DL, Tenquist JE, Szlabick RE. Incidence and propagation of infrageniculate deep venous thrombosis in trauma patients. J Trauma. 2006 Sep. 61(3):695-700. [Medline].

  • Kakkar AK, Brenner B, Dahl OE, et al. Extended duration rivaroxaban versus short-term enoxaparin for the prevention of venous thromboembolism after total hip arthroplasty: a double-blind, randomised controlled trial. Lancet. 2008 Jul 5. 372(9632):31-9. [Medline].

  • Kakkar VV, Adams PC. Preventive and therapeutic approach to venous thromboembolic disease and pulmonary embolism–can death from pulmonary embolism be prevented?. J Am Coll Cardiol. 1986 Dec. 8(6 Suppl B):146B-158B. [Medline].

  • Katz DS, Hon M. Current DVT imaging. Tech Vasc Interv Radiol. 2004 Jun. 7(2):55-62. [Medline].

  • Kearon C. Epidemiology of venous thromboembolism. Semin Vasc Med. 2001. 1(1):7-26. [Medline].

  • Kearon C, Ginsberg JS, Julian JA, et al. Comparison of fixed-dose weight-adjusted unfractionated heparin and low-molecular-weight heparin for acute treatment of venous thromboembolism. JAMA. 2006 Aug 23. 296(8):935-42. [Medline].

  • Kearon C, Ginsberg JS, Kovacs MJ, et al. Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thromboembolism. N Engl J Med. 2003 Aug 14. 349(7):631-9. [Medline].

  • Kearon C, Julian JA, Newman TE, Ginsberg JS. Noninvasive diagnosis of deep venous thrombosis. McMaster Diagnostic Imaging Practice Guidelines Initiative. Ann Intern Med. 1998 Apr 15. 128(8):663-77. [Medline].

  • Keeney JA, Clohisy JC, Curry MC, Maloney WJ. Efficacy of combined modality prophylaxis including short-duration warfarin to prevent venous thromboembolism after total hip arthroplasty. J Arthroplasty. 2006 Jun. 21(4):469-75. [Medline].

  • Knight LC, Baidoo KE, Romano JE, Gabriel JL, Maurer AH. Imaging pulmonary emboli and deep venous thrombi with 99mTc-bitistatin, a platelet-binding polypeptide from viper venom. J Nucl Med. 2000 Jun. 41(6):1056-64. [Medline].

  • Korelitz BI, Sommers SC. Responses to drug therapy in ulcerative colitis. Evaluation by rectal biopsy and histopathological changes. Am J Gastroenterol. 1975 Nov. 64(5):365-70. [Medline].

  • Lachiewicz PF, Kelley SS, Haden LR. Two mechanical devices for prophylaxis of thromboembolism after total knee arthroplasty. A prospective, randomised study. J Bone Joint Surg Br. 2004 Nov. 86(8):1137-41. [Medline].

  • Lassen MR, Ageno W, Borris LC, et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty. N Engl J Med. 2008 Jun 26. 358(26):2776-86. [Medline].

  • Lassen MR, Bauer KA, Eriksson BI, Turpie AG. Postoperative fondaparinux versus preoperative enoxaparin for prevention of venous thromboembolism in elective hip-replacement surgery: a randomised double-blind comparison. Lancet. 2002 May 18. 359(9319):1715-20. [Medline].

  • Leizorovicz A, Haugh MC, Chapuis FR, Samama MM, Boissel JP. Low molecular weight heparin in prevention of perioperative thrombosis. BMJ. 1992 Oct 17. 305(6859):913-20. [Medline]. [Full Text].

  • Leonardi MJ, McGory ML, Ko CY. The rate of bleeding complications after pharmacologic deep venous thrombosis prophylaxis: a systematic review of 33 randomized controlled trials. Arch Surg. 2006 Aug. 141(8):790-7; discussion 797-9. [Medline].

  • Levine MN, Hirsh J, Gent M, et al. Prevention of deep vein thrombosis after elective hip surgery. A randomized trial comparing low molecular weight heparin with standard unfractionated heparin. Ann Intern Med. 1991 Apr 1. 114(7):545-51. [Medline].

  • Linkins LA, Choi PT, Douketis JD. Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis. Ann Intern Med. 2003 Dec 2. 139(11):893-900. [Medline].

  • Lotke PA, Lonner JH. The benefit of aspirin chemoprophylaxis for thromboembolism after total knee arthroplasty. Clin Orthop Relat Res. 2006 Nov. 452:175-80. [Medline].

  • Loud PA, Katz DS, Bruce DA, Klippenstein DL, Grossman ZD. Deep venous thrombosis with suspected pulmonary embolism: detection with combined CT venography and pulmonary angiography. Radiology. 2001 May. 219(2):498-502. [Medline].

  • Loud PA, Katz DS, Klippenstein DL, Shah RD, Grossman ZD. Combined CT venography and pulmonary angiography in suspected thromboembolic disease: diagnostic accuracy for deep venous evaluation. AJR Am J Roentgenol. 2000 Jan. 174(1):61-5. [Medline].

  • Meissner MH, Manzo RA, Bergelin RO, Markel A, Strandness DE Jr. Deep venous insufficiency: the relationship between lysis and subsequent reflux. J Vasc Surg. 1993 Oct. 18(4):596-605; discussion 606-8. [Medline].

  • Merli GJ. Prophylaxis for deep venous thrombosis and pulmonary embolism in the surgical patient. Clin Cornerstone. 2000. 2(4):15-28. [Medline].

  • Mewissen MW, Seabrook GR, Meissner MH, Cynamon J, Labropoulos N, Haughton SH. Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry. Radiology. 1999 Apr. 211(1):39-49. [Medline].

  • Michiels JJ, Oortwijn WJ, Naaborg R. Exclusion and diagnosis of deep vein thrombosis by a rapid ELISA D-dimer test, compression ultrasonography, and a simple clinical model. Clin Appl Thromb Hemost. 1999 Jul. 5(3):171-80. [Medline].

  • Michota F, Merli G. Anticoagulation in special patient populations: are special dosing considerations required?. Cleve Clin J Med. 2005 Apr. 72 Suppl 1:S37-42. [Medline].

  • Mismetti P, Quenet S, Levine M, et al. Enoxaparin in the treatment of deep vein thrombosis with or without pulmonary embolism: an individual patient data meta-analysis. Chest. 2005 Oct. 128(4):2203-10. [Medline].

  • Muntz JE, Friedman RJ, eds. Case Vignettes: Thromboprophylaxis in Arthroscopic Surgery. Elsevier Excerpta Medica. 2006.

  • Nawaz S, Chan P, Ireland S. Suspected deep vein thrombosis: a management algorithm for the accident and emergency department. J Accid Emerg Med. 1999 Nov. 16(6):440-2. [Medline]. [Full Text].

  • O’Brien SH, Haley K, Kelleher KJ, Wang W, McKenna C, Gaines BA. Variation in DVT prophylaxis for adolescent trauma patients: a survey of the Society of Trauma Nurses. J Trauma Nurs. 2008 Apr-Jun. 15(2):53-7. [Medline].

  • Prevention of fatal postoperative pulmonary embolism by low doses of heparin. An international multicentre trial. Lancet. 1975 Jul 12. 2(7924):45-51. [Medline].

  • Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet. 2000 Apr 15. 355(9212):1295-302. [Medline].

  • Prevention of thromboembolism in spinal cord injury. Consortium for Spinal Cord Medicine. J Spinal Cord Med. 1997 Jul. 20(3):259-83. [Medline].

  • Quinlan DJ, McQuillan A, Eikelboom JW. Low-molecular-weight heparin compared with intravenous unfractionated heparin for treatment of pulmonary embolism: a meta-analysis of randomized, controlled trials. Ann Intern Med. 2004 Feb 3. 140(3):175-83. [Medline].

  • Ramzi DW, Leeper KV. DVT and pulmonary embolism: Part II. Treatment and prevention. Am Fam Physician. 2004 Jun 15. 69(12):2841-8. [Medline].

  • Rhodes JM, Cho JS, Gloviczki P, Mozes G, Rolle R, Miller VM. Thrombolysis for experimental deep venous thrombosis maintains valvular competence and vasoreactivity. J Vasc Surg. 2000 Jun. 31(6):1193-205. [Medline].

  • Ridker PM, Goldhaber SZ, Danielson E, et al. Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism. N Engl J Med. 2003 Apr 10. 348(15):1425-34. [Medline].

  • Rosendaal FR. Venous thrombosis: a multicausal disease. Lancet. 1999 Apr 3. 353(9159):1167-73. [Medline].

  • Salvati EA, Pellegrini VD Jr, Sharrock NE, et al. Recent advances in venous thromboembolic prophylaxis during and after total hip replacement. J Bone Joint Surg Am. 2000 Feb. 82(2):252-70. [Medline].

  • Schiff RL, Kahn SR, Shrier I, et al. Identifying orthopedic patients at high risk for venous thromboembolism despite thromboprophylaxis. Chest. 2005 Nov. 128(5):3364-71. [Medline].

  • Schweizer J, Kirch W, Koch R, et al. Short- and long-term results after thrombolytic treatment of deep venous thrombosis. J Am Coll Cardiol. 2000 Oct. 36(4):1336-43. [Medline].

  • Shepard RM Jr, White HA, Shirkey AL. Anticoagulant prophylaxis of thromboembolism in postsurgical patients. Am J Surg. 1966 Nov. 112(5):698-702. [Medline].

  • Snyder BK. Venous thromboembolic prophylaxis: the use of aspirin. Orthop Nurs. 2008 Jul-Aug. 27(4):225-30; quiz 231-2. [Medline].

  • Sors H, Meyer G. Place of aspirin in prophylaxis of venous thromboembolism. Lancet. 2000 Apr 15. 355(9212):1288-9. [Medline].

  • Taillefer R, Edell S, Innes G, Lister-James J. Acute thromboscintigraphy with (99m)Tc-apcitide: results of the phase 3 multicenter clinical trial comparing 99mTc-apcitide scintigraphy with contrast venography for imaging acute DVT. Multicenter Trial Investigators. J Nucl Med. 2000 Jul. 41(7):1214-23. [Medline].

  • Turpie AG, Bauer KA, Eriksson BI, Lassen MR. Fondaparinux vs enoxaparin for the prevention of venous thromboembolism in major orthopedic surgery: a meta-analysis of 4 randomized double-blind studies. Arch Intern Med. 2002 Sep 9. 162(16):1833-40. [Medline].

  • Turpie AG, Gallus AS, Hoek JA. A synthetic pentasaccharide for the prevention of deep-vein thrombosis after total hip replacement. N Engl J Med. 2001 Mar 1. 344(9):619-25. [Medline].

  • Turpie AG, Lassen MR, Davidson BL, et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty (RECORD4): a randomised trial. Lancet. 2009 May 16. 373(9676):1673-80. [Medline].

  • Communication about an ongoing safety review: Innohep (tinzaparin sodium injection). U.S. Food and Drug Administration. December 2, 2008. Available at http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/ucm136254.htm. Accessed: March 12, 2009.

  • van Dongen CJ, MacGillavry MR, Prins MH. Once versus twice daily LMWH for the initial treatment of venous thromboembolism. Cochrane Database Syst Rev. 2005 Jul 20. CD003074. [Medline].

  • Vedantham S, Millward SF, Cardella JF, et al. Society of Interventional Radiology position statement: treatment of acute iliofemoral deep vein thrombosis with use of adjunctive catheter-directed intrathrombus thrombolysis. J Vasc Interv Radiol. 2006 Apr. 17(4):613-6. [Medline].

  • Verstraete M. Direct thrombin inhibitors: appraisal of the antithrombotic/hemorrhagic balance. Thromb Haemost. 1997 Jul. 78(1):357-63. [Medline].

  • Weitz JI, Middeldorp S, Geerts W, Heit JA. Thrombophilia and new anticoagulant drugs. Hematology Am Soc Hematol Educ Program. 2004. 424-38. [Medline].

  • Wells PS, Anderson DR, Rodger MA, et al. A randomized trial comparing 2 low-molecular-weight heparins for the outpatient treatment of deep vein thrombosis and pulmonary embolism. Arch Intern Med. 2005 Apr 11. 165(7):733-8. [Medline].

  • Wood S. Apixaban (Eliquis) approved for DVT/PE prophylaxis post-hip or knee replacement. Medscape Medical News from WebMD. March 14, 2014. Available at http://www.medscape.com/viewarticle/821991. Accessed: March 25, 2014.

  • Sundboll J, Hovath-Puho E, Adelborg K, et al. Risk of arterial and venous thromboembolism in patients with atrial fibrillation or flutter: a nationwide population-based cohort study. Int J Cardiol. 2017 Aug 15. 241:182-7. [Medline].

  • Wijarnpreecha K, Thongprayoon C, Panjawatanan P, Ungprasert P. Hepatitis C virus infection and risk of venous thromboembolism: a systematic review and meta-analysis. Ann Hepatol. 2017 Aug 1. 16 (4):514-20. [Medline].

  • Mityul M, Kim DJ, Salter A, Yano M. CT IVC venogram: normalized quantitative criteria for patency and thrombosis. Abdom Radiol (NY). 2019 Jun. 44 (6):2262-7. [Medline].

  • Deep Vein Thrombosis – Early Symptoms, Signs, Causes & Treatments

    Blood returns to the heart through veins. When the blood clumps together and turns into solid material, it is called a blood clot. When the clot is in the deep vein it is called deep vein thrombosis (DVT). Deep vein thrombosis (DVT) usually occurs in the leg veins.

    If the clot breaks off and travels to the lungs, it can cause a pulmonary embolism (PE) – a clot that blocks blood flow to the lungs, which can be deadly.

    DVT causes symptoms in only about half the people who develop this condition. Symptoms may include:

    • Swelling of the leg
    • Pain or tenderness in the leg
    • Increased warmth in the swollen or painful area
    • Red or discolored skin in the swollen or painful area of the leg

    Some people may not know they have a DVT until it breaks off and travels to the lungs, causing a pulmonary embolism. PE is an emergency situation requiring immediate medical help.
    PE symptoms include:

    • Sharp chest pain when taking a deep breath
    • Shortness of breath
    • Bloody cough
    • A rapid or irregular heartbeat
    • Feeling of anxiety
    • Feeling faint or passing out

    DVT causes symptoms in only about half the people who develop this condition

    Causes

    Blood normally flows continuously in arteries and veins. In certain situations the cells in blood may clump together to form a plug (blood clot) and fail to flow properly. This is triggered whenever flowing blood is exposed to certain substances after the vein’s inner lining is damaged as a result of surgery, serious injuries, inflammation or immune responses.
    Inactivity is a major cause of DVTs. Extended periods of lying down can lead to sluggish, improper flow of blood in your legs. Some of the leading causes of DVT are surgery, injuries or illnesses requiring prolonged period of bedrest.
    Other possible causes include cancer, hormone therapy and inherited conditions that make blood cells clump together and form clot more easily. Birth control pills can also increase the risk of clotting.

    Risk Factors

    • A previous episode of DVT
    • Immobility, such bed rest during hospitalization
    • Pregnancy and the first few weeks after giving birth
    • A catheter (large IV tube) in the deep veins used for medical treatment
    • Age – DVT can occur at any age, but risk increases with age
    • Overweight or obesity
    • Cancer and cancer treatment
    • Smoking
    • Hormone therapy or birth control pills
    • Injury to blood vessels, broken bones or other trauma
    • Some inherited blood disorders

    Evaluation

    To determine if DVT is present, your doctor will obtain your medical history and perform an examination. Your diagnostic tests may include:

    Duplex ultrasound: Noninvasive test uses high-frequency sound waves to measure blood flows through your veins and evaluate the presence of clot.

    D-dimer test: Measures a substance in the blood that when elevated may indicate underlying blood clot.

    CT Venogram: Imaging test that uses IV contrast and specialized CT scan to create detailed pictures of the veins in your abdomen and legs.

    Venography: Dye is injected into a vein in the affected leg. The dye makes the vein visible on an x-ray image. The x-ray shows whether blood flow is slow in the vein, which may suggest a blood clot.

    Complications

    Pulmonary embolism (PE): Most of the time with a DVT the clot is in the veins of the lower or upper extremities and attached to the vein wall. When the clot dislodges from the vein it will travel to another part of the body, this is called an embolus. With PE, the clot travels to the lungs and blocks blood flow. As a result, the lungs can be damaged by lack of blood flow, and other organs can be damaged by a lack of oxygen supplied by the lungs. PE is a dangerous, potentially fatal occurrence requiring immediate medical attention.

    Post-thrombotic syndrome (PTS): Is a condition that may develop one to two years following an episode of DVT. Following a DVT the veins involved may be damaged and there be underlying blockage or reversal of blood flow. Both of these situations can lead to increased venous blood pressure in the legs. The symptoms associated with this condition, known as PTS, may include chronic leg pain and chronic swelling. Advanced stages of the condition include skin damage with discoloration and/or ulceration (wound) in the affected leg.

    For Deep Vein Thrombosis treatment options and prevention visit our page:
    https://www.advancedheartandvein.com/deep-vein-thrombosis

    Are You at Risk for a Blood Clot?

    Venous thromboembolism (VTE) is a condition used to describe two related conditions, which involve blood clots, most often called deep vein thrombosis (DVT) and pulmonary embolism (PE). It’s easy enough to understand, right? Let’s break down the words. “Venous” means “in the veins,” and “thrombus” is the word for a non-moving “blood clot”. An “embolus” is an abnormal particle such as a clot or air bubble that moves around the body via your blood stream. When an embolus blocks blood flow in a blood vessel it is called an “embolism”.

    Simply speaking, DVT is when a blood clot forms in a deep vein usually in the thigh or lower leg, and a PE is when a part of the clot breaks off in the veins and travel to the lungs. It’s important to understand these conditions because DVT/PE can be a serious life-threatening condition that can happen to anyone.

    What’s So Important about Blood Clots?

    When blood clots that form in the leg or thigh become loose and travel to the lungs, they can block blood flow causing serious problems or even death.

    DVT and PE affect many people in the U.S. and worldwide. In fact, there are over 900,000 VTE events in the U.S. every year. That’s more than the number of heart attacks or the number of strokes that occur each year. It is predicted the number of DVT and PE will continue to increase and by the year 2050, they are predicted to affect approximately 1.8 million Americans.

    If you have a thrombus (or blood clot), your doctor will start treatment quickly to reduce the chances of it traveling in the blood stream and blocking blood flow to an artery in the lungs. Treatment may also reduce the chances of the blood clot happening again. DVTs are usually treated with medicines that are commonly called blood thinners. Less often, other treatments for DVTs including surgery or medicines called thrombolytics that break the clot up may be used. Treatment for PE requires either thrombolytics or surgery in addition to blood thinners.

    Why Do Blood Clots Happen?

    Three main categories of factors that lead to an increased risk for blood clots are known in the medical community as Virchow’s Triad, named after a Prussian doctor who worked in this area. The factors are:

    • Blood stasis: This is when the blood flow slows down or pools. This can happen for a number of reasons including immobility for prolonged periods, certain types of surgery, or chronic heart disease.
    • Hypercoagulability: This state occurs when the blood coagulates, or sticks together more easily than normal. It may happen because of specific genetic causes, cancer, smoking, oral contraceptive use, and pregnancy among others.
    • Vascular injury: This is injury or trauma to the walls of the veins. Injuries may occur, from things like surgery, bone fractures, placement of a venous catheter,or injection drug use.

    Risk Factors

    As you might imagine, DVT and PE may occur in patients who may have a combination of the factors listed above in Virchow’s triad. Some conditions putting people at a higher risk for these blood clots are if they have:

    • Had knee or hip surgery.
    • Had trauma and/or bone fractures.
    • An age older than 40 years.
    • Been on prolonged bed rest.
    • Suffered a serious medical illness, infection, heart attack, or stroke.
    • Cancer.
    • Cancer and are receiving chemotherapy.
    • Had a previous DVT or PE.

    Symptoms and Signs

    DVT may have no symptoms at all or may include different combinations of pain, tenderness, discoloration, and leg swelling (that leaves an indentation when pressed). PE may include symptoms of shortness of breath, coughing (with or without blood in the phlegm), chest pain, a fast pulse (>100 beats per minute), and a low-grade fever. If blood clots in the lung cause the blood in the heart to back up it may cause low blood pressure and shock. If you experience any of these symptoms of DVT or PE, contact your health care professional right away.

    Prompt treatment for DVT and PE can reduce the chance that another event will occur. It is important to discuss the treatment plan with your health care team and learn what to expect while on that treatment plan. It’s also important to stick with the plan you agreed upon and follow up with your health care team regularly.

    Prevention

    If you haven’t had a DVT or PE, but think you may be at an increased risk due to the factors described above, there are some ways to reduce the risk of DVT and PE from occurring. Talk with your health care professional about your risks and for help to:

    • Stop smoking (if you smoke).
    • Lose weight– obesity is risk factor for VTE and can also enhance the risk of other risk factors for VTE.
    • Get active– to help keep your blood moving.

    It is important to be aware of this condition for you and your loved ones to reduce the risk of blood clots, when possible. If you suspect a DVT or PE, seek medical attention quickly.

    George H. Sands, M.D. is a Senior Medical Director at Pfizer.

    [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16]

    90,000 disease, symptoms, treatment, causes, diagnosis

    Deep vein thrombosis of the lower extremities often develops in elderly patients suffering from cardiovascular diseases, diabetes mellitus, obesity, in the elderly and oncological patients. Thrombosis often occurs in severe trauma, traumatic and prolonged operations, in pregnant women before and after childbirth.

    In the development of venous thrombosis, an important role is played by changes in the vascular endothelium on the affected limb, which acquires increased thrombogenicity and adhesiveness.These factors lead to the formation of blood clots.

    In most cases (89%), the thrombus originates in the sural venous sinuses – relatively large, blindly ending cavities in the calf muscles that open into the deep veins of the lower leg. The sural sinuses are passively filled with blood when the calf muscles are relaxed and emptied when they contract (muscle-venous pump).

    The clinical picture of deep vein thrombosis of the lower leg within 1-2 days is often erased.The general condition of the patients remains satisfactory, there are minor pains in the calf muscles, aggravated by movement, a slight swelling of the lower third of the leg, soreness of the calf muscles on palpation. One of the characteristic signs of deep vein thrombosis of the lower leg is pain in the calf muscles during dorsiflexion of the foot. Patients with deep vein thrombosis begin to experience sharp pain in the calf muscles even with a slight increase in pressure.

    Diagnosis of acute thrombosis of the main veins of the lower extremities is based on the data of the clinical picture of the disease.The simplest and safest method for detecting phlebothrombosis is ultrasound duplex scanning. If you find symptoms, make an appointment with a phlebologist.

    Treatment of thrombosis is usually conservative, much less often – operative. With inadequate treatment of deep vein thrombosis, almost 50% of patients may experience pulmonary embolism over a three-month period. Adequate treatment of acute deep vein thrombosis of the lower extremities with anticoagulants reduces the risk of thrombus spread and pulmonary embolism to 5% or less.

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    Deep vein thrombosis of the lower extremities

    Added: 07.03.2016

    Life story: On the way home from work, a woman stumbled and fell. At the hospital, she was diagnosed with a fracture, put in a plaster cast, and a couple of days later sent home to recover. During the week everything went well … Sudden death made everyone who knew her shudder, and first of all her relatives and friends. An autopsy revealed that the cause was a detached blood clot that blocked the pulmonary artery. It was just that the woman had deep vein thrombosis in the legs, which did not cause her much inconvenience and therefore remained unattended.Very sorry. But a woman could still live and please her relatives and loved ones.

    There are a million such stories. Very few people are serious about the health of veins and the first time they go to a phlebologist only when spider veins and “grape bunches” of unhealthy veins appear. Few pay attention to signs of thrombosis such as rare pain, stiffness, a feeling of heaviness and discomfort in the leg muscles. Such a frivolous attitude to one’s own health leads to bad consequences.

    Unfortunately, it is often impossible to determine in time the initial symptoms of thrombosis of the vessels of the legs and many do not know that this type of thrombosis is almost asymptomatic, and therefore it is very dangerous , however, if the skin changes color, and where the blood clot is located, swelling occurs – these are signs of vascular disease. In a healthy person, venous blood moves from the bottom up: from the legs – to the organs located higher: lungs, heart, etc. If a blood clot blocks the lumen of a vein, then blood will hardly flow from the lower extremities, and edema appears.Since a blood clot can be located in different places, edema can also occur on the lower leg, ankle, and thigh. Sometimes the entire leg swells. When thrombosis of the lower extremities progresses, its symptoms are more pronounced. Sharp pain appears and heaviness in the legs increases. These symptoms are triggered by venous congestion below the site of thrombosis. As a result of the complete closure of the lumen of the vein, edema increases, metabolism in soft tissues is disrupted. This can lead to gangrene.Swelling and pain in the legs can be not only signs of vascular insufficiency, but also many other diseases. Sometimes acute thrombosis occurs. A person who moved normally today may not get out of bed tomorrow due to huge swelling. It is extremely serious if, due to the latent form of the course of thrombosis, a patient suddenly has pulmonary embolism. It occurs because a blood clot breaks off and migrates from the affected vessels of the legs into the artery of the lungs, where it is blocked.It only seems that the legs are far from the heart and lungs. But in fact, a vein is a direct road for a blood clot. If it breaks off, it literally flies up in seconds and enters the pulmonary artery, which is very dangerous. At the same time, it is not possible to save everyone … Therefore, do not risk it. For the successful treatment of deep vein thrombosis, its timely diagnosis is necessary. Today there is an accurate way to diagnose the condition of the veins – ultrasound. If you have something wrong with your legs, you have varicose veins, see a specialist.An experienced surgeon with a specialization in phlebology, Vladimir Sorokin, accepts at the Latgale Medical Center, who will diagnose the vessels of the legs and give valuable recommendations, and, if necessary, prescribe treatment. In order to prescribe the correct course of treatment, whether it is drug therapy or surgery, it is necessary to accurately diagnose the disease and comprehensively study the parameters of the thrombus (size, localization and the possibility of separation). If your doctor detects a deep vein clot during an ultrasound scan, he or she may refer you to a hospital for further treatment.Do not refuse hospitalization or postpone it for later: a blood clot can come off at any time. So, if you observe swelling of the extremities, a feeling of heaviness in the lower extremities, sharp pains, blue skin, fever and chills, then immediately consult a specialist.

    It is also worth remembering that the risk of serious problems is exacerbated by:

    • Smoking.
    • Trauma contributes to the development of acute thrombosis. It leads to the fact that the vascular wall is affected and the process of hemostasis is activated.As a result, a blood clot forms.
    • Overweight.
    • Pregnancy contributes to the compression of the iliac veins, and sometimes the inferior vena cava. This leads to an increase in vascular pressure in the veins below.
    • During childbirth, the fetus, which moves through the birth canal, has many opportunities for squeezing the iliac veins.
    • Very high risk of clogged veins after caesarean section.
    • Infection causes blockage of blood vessels in men.This is due to the activation of blood clotting factors in response to the vascular walls being affected.
    • Long trips and flights.
    • Advanced age.
    • Taking medications that increase blood clotting.
    • Joint operations, abdominal operations. The high prevalence of venous thrombosis is due to the fact that the number of operations using general anesthesia is increasing every year, as well as the increase in the number of operated elderly people with severe concomitant diseases.
    • Complicated bone fractures.
    • Cancer.
    • The occurrence of vascular thrombosis is facilitated by bed rest (for a long time). The reason is the lack of muscle contraction, slowing blood flow and venous stasis.
    • Healthy people also get sick if they sit or stand for a long time (traveling by car, working at a computer).

    Recommendations of the surgeon Vladimir Sorokin:

    • Periodic visits to a specialist will help you detect thrombosis in time and begin timely and effective treatment.
    • Gels, creams, ointments available in pharmacies improve venous blood flow and relieve fatigue and heaviness in the legs. But such remedies are only good as an aid, they bring temporary relief, but do not solve the problem.
    • Elastic compression methods that are prescribed for a long time are effective. Elastic stockings act on the superficial veins of the lower extremities, increasing blood flow in the deep veins.
    • When sedentary work, you need to walk more often, walk at least within your office every 15–20 minutes.
    • When you go to bed, place a pillow under your feet so that they have an elevated position and there would be no swelling.
    • Do special exercises and diet. Do not be afraid to change your usual way of life! This will benefit not only the veins, but the entire body.

    You can make an appointment with Vladimir Sorokin at the Latgale Medical Center (20 Rigas Street, Daugavpils) or by calling 25251010. The cost of a phlebologist consultation is 35EUR.

    In Latgale Medical Center, phlebologist consultation includes:

    – Doppler ultrasonography of the veins and arteries of the lower extremities;
    – phlebologist consultation, drawing up a treatment plan and specialist recommendations;
    – conclusion of a phlebologist;
    – help in choosing compression products.

    We will be glad to help you quickly, efficiently and confidentially!

    90,000 External symptoms in patients with pulmonary embolism

    Pulmonary embolism (PE) is an acute blockage of the trunk or branches of the arterial system of the lungs by a thrombus formed in the veins of the systemic circulation or in the right half of the heart [1, 2, 6].

    In 95% of cases, PE is a consequence of deep vein thrombosis (DVT); therefore, in the modern literature, the term “pulmonary embolism” is most often replaced by the term “venous thromboembolism” [1, 4, 5, 8, 9].

    PE is the third most common type of pathology of the cardiovascular system after coronary heart disease (CHD) and stroke. Annually causes death of 300-500 thousand people [1, 8, 9].

    Thrombophlebitis is the most common source of thrombus formation [1, 2, 5, 6, 8, 9].

    Distinguish between superficial thrombophlebitis (mainly varicose veins) and deep vein thrombophlebitis of the lower extremities. More rare forms of thrombophlebitis include Paget-Schrötter disease (thrombosis of the axillary and subclavian veins), Mondor’s disease (thrombophlebitis of the saphenous veins of the anterolateral surface of the chest) (Fig. 1) and Buerger’s migratory thrombophlebitis (thromboangiitis obliterans) [1, 4, 6].

    Acute thrombophlebitis of the superficial veins of the lower extremities develops, as a rule, in a varicose vein.The greater saphenous vein is more often affected. In the course of the affected vein, skin hyperemia and a dense painful cord are determined (Fig. 2).

    In some cases, ascending thrombophlebitis of the great saphenous vein develops with the spread of the process to the saphenofemoral anastomosis and the threat of pulmonary embolism.

    Most often, embologenous thrombi are localized in the great veins of the lower extremities, the veins of the pelvis and the inferior vena cava.

    The greatest danger of PE is thrombophlebitis of the deep veins of the leg.The disease usually begins acutely, with pain in the calf muscles, a feeling of fullness, an increase in body temperature. External signs of this disease: edema in the distal parts of the leg, cyanotic edema of the skin, after 2-3 days a network of dilated superficial veins appears on the legs, thighs, abdomen, then – if all veins are affected – diffuse cyanosis (Fig. 3).

    Unilateral edema, unilateral pain in the lower extremities and tachycardia in the so-called revised Geneva account as signs of a possible PE have the most points in total (tab.1) [1, 2, 4, 5].

    The clinical probability of pulmonary embolism is determined: with a total of 0–3 points – low; 4-10 points – intermediate; ³ 11 points – high.

    A number of symptoms are characteristic of deep vein thrombophlebitis of the lower leg.

    1. Homann’s symptom – with dorsiflexion of the foot, a sharp pain appears in the gastrocnemius muscle (Fig. 4).

    2. Symptom Moses – pain when squeezing the leg in the anteroposterior direction in the absence of pain after compression from the sides (Fig.5).

    3. Symptom Opitz – Ramines – sharp pain along the veins of the lower leg after increasing pressure to 40–45 mm Hg. in the sphygmomanometer cuff placed above the knee joint; after lowering the pressure, the pain disappears (Fig. 6).

    4. Lovenberg’s symptom – a sharp pain in the calf muscles at a pressure of 60-150 mm Hg. in the cuff overlaid on the middle third of the lower leg (Fig. 7).

    The development of thrombophlebitis in the femoral vein before the deep vein flows into it is characterized by pain in the adductor muscles of the thigh.On examination, slight edema and dilatation of the saphenous veins are found, on palpation – pain in the region of the Gunter’s canal.

    Thrombophlebitis of the common femoral vein is accompanied by sharp pain in the limb, expressed by its edema and cyanosis. The increase in body temperature is accompanied by chills. In the upper third of the thigh, groin and pubic regions, dilated superficial veins appear.

    In acute thrombosis of the main veins of the pelvis and thigh, white or blue phlegmas may develop.White phlegmasia is characterized by edema of the entire limb and milky-white color of the skin, blue phlegmosis is characterized by more common edema, cyanosis of the skin, and the formation of purple-cyanotic spots (Fig. 8).

    Factors predisposing to PE are: operations on the pelvic organs and lower extremities, especially in old age, injuries of the lower extremities, malignant diseases, prolonged venous catheterization (including subclavian), varicose veins of the lower extremities, prolonged bed rest, cardiac insufficiency and disturbance of the rhythm of the heart, post-thrombophlebitic syndrome, etc.

    When examining a patient with PE in the acute period, acrocyanosis, less often cyanosis, especially of the upper half of the body, can be detected.

    The outcome of acute deep vein thrombosis in most patients is post-thrombophlebitic syndrome, the external signs of which are lymphostasis and trophic ulcers (Fig. 9).

    Distinguish between acute, subacute and recurrent pulmonary embolism.

    The most persistent clinical symptoms are shortness of breath, pleural pain, hemoptysis, tachycardia, fever.

    For differential diagnosis of PE, the following methods are currently used: D-dimer determination, electrocardiography, echocardiography, multispiral computed tomography, ventilation perfusion scintigraphy, angiopulmonography, ultrasound examination of the veins of the lower extremities [1, 2, 4, 5].

    An increase in the concentration of D-dimer in the blood> 0.5 μg / ml is one of the most reliable markers of DVT, the sensitivity of which reaches 100% [1, 2, 4, 5].

    The X-ray picture of PE is diverse. A symptom of increased transparency of the pulmonary field, unilateral expansion of the lung root as a result of expansion of the main branch of the pulmonary artery, pulmonary infarction with perifocal pneumonia, areas of depletion of the pulmonary pattern, high standing of the dome of the diaphragm are distinguished. Subpleural localization of thrombosis determines a high frequency of reactive pleurisy, including interlobar. As the fluid resorbs, the appearance of multiple pleural adhesions, moorings is noted, obliteration of the pleural cavities develops.

    With purulent thrombophlebitis, microbes multiply in the thrombotic masses and the vein wall, which leads to the development of a purulent process in the paravasal tissue. Septic thrombophlebitis can be a source of generalization of infection and the formation of abscesses in various organs, including the lungs. Septic thrombophlebitis often develops in injection drug users.

    The most characteristic changes on the ECG are the appearance of Q waves and a negative T wave in the III chest lead.

    The basis of therapy is made up of anticoagulant and fibrinolytic agents, as well as drugs aimed at preventing infection.Low molecular weight heparins are considered the most effective and safe.

    Clinical examples

    Patient J., 45 years old, was hit by a car – left leg injury with hematoma. The lower leg was swollen, severe pain, the patient could not walk. After 2 weeks, there was a sudden sharp pain in the left side of the chest, palpitations, body temperature rose to 40 ° C. I went to a doctor and was sent to a hospital.

    On examination, the left shin is edematous, dense to the touch (Fig.ten).

    Positive symptoms of Hohmann and Moses.

    The plain chest X-ray (CT) shows an effusion in the left pleural cavity (Fig. 11).

    A pleural puncture was performed, 450 ml of hemorrhagic fluid was aspirated. Analysis of pleural fluid: beats. weight – 1.023 kg / l, Rivalta reaction – positive, protein – 35 g / l, leukocytes (neutrophils – 60%, lymphocytes – 20%, eosinophils – 20%), erythrocytes – 1/2 of the field of view, mesothelium cells – a lot …

    Two courses of treatment with antibacterial drugs of a broad spectrum of action for 5 days, repeated punctures were carried out.

    Control X-ray of the chest organs – the level of fluid in the left external sinus continues to be determined (Fig. 12).

    Computed tomography of the lungs – in S 9 of the left lung focal shadow 75 ´ 25 ´ 45 mm of a heterogeneous structure with clear uneven contours: there is a small amount of fluid in the left pleural cavity (Fig.13).

    Ultrasound of the vessels of the lower extremities – post-traumatic phlebitis and venous thrombosis of the left leg, hematoma.

    Final diagnosis: PE: infarction pneumonia S 9 left lung, left-sided pleural effusion; post-traumatic phlebitis and venous thrombosis of the left leg.

    Patient G., 47 years old. About 15 years ago, I began to notice heaviness in the left leg, the leg seemed to “hang”, especially after physical exertion. Swelling of the left leg was periodically noted; used troxevasin.

    During a walk in the park, suddenly there was a lack of air, a feeling of fear, a rapid heartbeat, then there was severe pain in the left side of the chest, the inability to take a deep breath. The next day, the body temperature increased to 38 about 90 238 C, on the 4th day hemoptysis appeared.

    The patient was admitted to the therapeutic department.

    On examination – on the left lower leg, in the popliteal fossa and partly on the thigh – the vascular mesh, the area of ​​skin hyperemia, varicose veins (Fig.fourteen).

    Palpation showed pain along the deep veins of the left leg, especially in the popliteal fossa, positive symptoms of Hohmann, Moses, Opitz-Ramines and Lovenberg on the left leg (Fig. 15).

    On the roentgenogram of the chest organs to the left of the IV rib downwards, an inhomogeneous darkening (Fig. 16).

    In the clinical analysis of blood: leukocytes – 13 ´ 10 9 / l, ESR – 47 mm / hour.

    In the coagulogram, an increased level of fibrinogen.

    A pleural puncture was performed, 350 ml of hemorrhagic fluid was aspirated.Analysis of pleural fluid: beats. weight – 1.026 kg / l, Rivalta reaction – positive, protein – 45 g / l, leukocytes (neutrophils – 70%, lymphocytes – 20%, eosinophils – 10%), erythrocytes – in the entire field of view, mesothelium cells – a lot.

    Clinical diagnosis: PE: infarction, pneumonia of the lower lobe of the left lung, left-sided exudative pleurisy; deep vein thrombophlebitis of the left leg.

    Treatment with enoxaparin, clopidogrel hydrogen sulfate, aspirin cardio, vazoket was carried out.

    After the treatment, the plain chest X-ray shows positive dynamics in the form of resorption of infiltration in the lower left sections; the left costodiaphragmatic sinus is sealed (Fig. 17).

    Patient M., 69 years old. Varicose veins of the superficial veins and deep vein thrombophlebitis of the left lower leg were detected at the age of 50 (Fig. 18).

    Hohmann, Moses and cuff symptoms are positive.

    History of infiltrative tuberculosis of the upper lobes of the lungs with disintegration and mycobacterial excretion with an outcome after effective treatment in fibrous focal changes in the upper lobes of the lungs.

    Suffering from ischemic heart disease and hypertension, periodically exacerbated by deep vein thrombophlebitis of the legs.

    At the age of 67, he suffered a minor stroke.

    During the last five years – recurrent right-sided interlobar pleurisy (Fig. 19).

    Pleural puncture was not performed.

    Presumptive tuberculous and metastatic interlobar pleurisy were excluded.

    Ultrasound examination of the vessels of the lower extremities: right leg – no signs of vascular lesions were detected; left leg – the popliteal vein partially collapses during compression tests, a recanalized organized thrombus is determined in it.

    Clinical diagnosis: recurrent PE of small branches of the pulmonary artery with interlobar right-sided pleural effusion. Varicose veins and deep vein thrombophlebitis of the left lower leg.

    About varicose veins

    Chronic venous insufficiency is a disease that leads to long-term, sometimes lifelong, impairment of venous outflow from the lower extremities.

    The most common causes of CVI are varicose veins and deep vein thrombosis.

    The main cause of chronic venous insufficiency and varicose veins is disruption of the normal functioning of the valves of the veins.

    The blood flow becomes chaotic, and in the veins, especially the subcutaneous ones, the pressure increases so much that the walls of the vessel cannot withstand and begin, like a balloon, to expand varicosely. In addition to varicose veins, other symptoms of the disease appear.

    Risk factors for varicose veins and CVI

    Female (women suffer from varicose veins 4-6 times more often than men)

    Features of labor (varicose veins usually occur in persons whose work is associated with prolonged standing on their feet: sellers, hairdressers, surgeons).

    Overweight

    Multiple pregnancies

    Hereditary predisposition The presence of varicose veins in close relatives increases the likelihood of its development

    Heavy physical work (strength sports, chronic respiratory diseases)

    Permanent leg injuries (among athletes, workers)

    Constipation

    Hormonal contraception

    Symptoms of varicose veins and venous insufficiency

    • Swelling of the leg and foot by the end of the day;
    • Feeling of heaviness and fullness in the calves during prolonged sitting or standing;
    • Bursting pains in calves, hot legs and night cramps in calves;
    • Shoes, comfortable in the morning, begin to press in the evening; socks leave deep marks on the skin.These symptoms are ameliorated by walking and after a night’s rest;
    • Vascular stars on thighs and calves, dark blue intradermal veins and convoluted varicose veins;
    • The skin of the lower leg becomes dry, sensitive to various injuries, trophic ulcers may develop.

    How dangerous are chronic venous insufficiency and varicose veins?

    It is believed that chronic venous insufficiency and varicose veins are not very dangerous diseases that cause only cosmetic inconvenience.This is not true. Violation of venous outflow can provoke the formation of blood clots in deep (thrombosis) or varicose saphenous (thrombophlebitis) veins.

    Deep vein thrombosis is manifested by a sharp dense swelling of the leg. In this case, the skin acquires a bluish tint, and any movement causes pain. With thrombophlebitis along the saphenous varicose veins, painful induration and redness appear.

    Thrombosis and thrombophlebitis are extremely insidious diseases.Having torn off, a thrombus can cause a serious complication – pulmonary embolism, often resulting in the death of the patient.

    Acute thrombosis and thrombophlebitis must be treated in a phlebological hospital, as in some cases an emergency operation may be required.

    Drug treatment

    Venotonic

    The safest and most effective are produced from plants containing substances that strengthen the venous wall.These are the so-called bioflavonoids (diosmin, hesperidin, etc.). The effect of drugs, as a rule, begins immediately after the start of treatment and reaches a maximum after 1.5–2 months of daily administration. With non-started varicose veins, taking medications is necessary at least 2 times a year. In severe cases of varicose veins, they must be taken continuously.

    Local treatment

    One of the most proven and effective remedies is “Heparin-gel”, which is successfully used in cases of edema, pain, heaviness in the legs.

    To keep your veins healthy

    Be active

    Avoid heavy physical activity

    Do not abuse the sun and hot baths

    Do not wear tight underwear, tight belts or waistbands

    Watch your posture.Do not cross your legs while sitting

    Do not abuse alcohol or smoke

    Eat right

    A large amount of raw vegetables and fruits should be present in the daily diet.