The case of James a 48 year old male is a case of a patient with DVT but with little information. This man is a lawn tennis player with some issues that made him visit the emergency room and had the boot placed on him for 4 weeks duration. It was after that episode of medical management that he noticed a form of ankle to calf swelling on one of the legs. The swelling was really abnormal in terms of size hence he needs to see the doctor urgently. Despite swelling and the test such as ultrasound done, the extent of severity to him was still yet to be fully understood. It was after a doctor explained the related consequences and associated related issues such as pulmonary embolism that he now understands that it is an emergency situation that needs critical management to prevent the movement of clots to the lungs. Taking a look at this case, we can see that DVT is an urgent condition that needs to be properly managed to prevent various forms of associated complications. It is very important for people to be aware of this condition and complications especially in patients that are usually at risk of developing the DVT.
Deep Vein Thrombosis is a serious, but preventable medical condition which results from the accumulation of blood clots inside the vein. Most times, affected individual are usually less informed about the severity. It is a condition that can happen to anyone at any age thus causing serious illness or disability. It can also lead to death in some cases if not managed properly on time. These condition most times are found affecting the deep leg veins especially the calf, femoral and popliteal veins (Kesieme et al., 2011). It is a dangerous condition that could be associated with serious morbidity and mortality. Those that are really affected most are the adult. It is associated with situations where the blood clot break off, and travel to other parts of the body to cause another problem such as a pulmonary embolism. Symptoms in most situations are edema, leg pain, tenderness, and warmth. The signs are related to calf pain, tender segment and variable discoloration of the region.
Etiology/causes
Contributing factors are acquired or congenital factors. Acquired factors are either medication or illnesses while congenital factors are the anatomic variant, enzyme deficiency and mutation. Etiology can also be classified as acute provoking condition or chronic conditions.
When we describe the causes of DVT, we need to talk about the issue of venous stasis that is related to the immobilization and central venous obstruction. The increased blood viscosity may then affects the venous blood flow hence causing the venous stasis. All these changes are usually due to an increase in the cellular component of the blood. The increasing in cellular component is a situation found in cases of polycythemia rubra vera or thrombocytosis or in cases where the patient is dehydrated. Those other conditions that can also contribute to the venous stasis are those related to increased central venous pressure, or congenital anomaly increases outflow resistance.
Anatomic variants contributing to venous stasis
Venous stasis that usually results from anatomic variation are related to diminution or absence of veins such as the inferior vena cava or iliac veins. The best-known anomaly is compression of left common iliac vein at the anatomic crossing of the right common iliac artery. These anomalies usually affects the blood flow hence contributes to the venous blood stasis. This anatomic variation are noted in some individuals to cause a form of compression of the left iliac vein which later caused web formation that precedes the stasis that usually lead to the left leg deep vein thrombosis. The reason this occurs is still yet to be well understood.
The compression that affects the iliac vein is normally called the May-Thurner syndrome. It is some situations that there are the variants of the inferior vena cava. These noted variations thus contribute to increasing in risk of the symptoms simply because of the small-caliber vessels causing obstruction.
Mechanical injury to vein
This is another problem affecting the vein especially the vein walls thus contributing to an increased risk of venous thrombosis simply because of the damage to the vein walls which cause a reduction in the speed of the blood flow. This problem is commonly seen in patients that have undergone surgery such as the arthroplasty patients (simply because of an association with femoral vein manipulation). The contribution of the injured wall to the increased risk is simply because of the fact that the endothelium that is injured can result in antithrombogenic endothelium, and this subsequently lead to prothrombotic simply because of production of the agents such as the tissue factor, von Willebrand factor, and the fibronectin. The post-operative issues are not the only aspect where there can be injury to the vein. Other areas may be in the areas of the trauma, surgical intervention and iatrogenic injury. These factors are usually more pronounced especially in patients that are at high risk of the DVT or has previous episode of DVT.
Research has also shown that the peripherally inserted central catheter (PICC) is a factor that cans double the risk of a deep vein thrombosis especially when compared to central venous catheters (Kaushal et al., 2014). This case was more noted in patients that had cancer or critically ill. However, the event of pulmonary embolism complication is yet to be linked together.
Common risk factors for deep venous thrombosis
- History of prior VTE; This remain the single most powerful risk factor of all listed factors associated with the DVT. This is related to about 25 percent of patient found with deep venous thrombosis (Kaushal et al., 2014). The major reason for this is simply because of the remaining remnants of the clots found in the previous episode. In another situation, it might be as a result of recurrent thrombosis causing the new hypercoagulable state.
- Age; is another factor that has been well studied in DVT patients. It has now been found to be an independent risk factor for the condition. Patients between the ages of 30-80 are liable for about 30 fold increase in risk of having the condition. This is especially commoner when such patients are under some other risk factors that contribute to the condition.
- Cancer; another factor relating to the DVT is that of the presence of malignancy. This has been noted in about 30 % of patients with the condition (Kaushal et al., 2014). What is found to be responsible is the abnormal coagulation factor affecting the thrombogenic mechanism. Patients undergoing chemotherapy for the cancer management are also liable to DVT because of the increased risk caused by venous thrombosis resulting from a problem with the vascular endothelium.
- Obesity
- Immobility
- Surgery
- Presence of an acute infectious disease
Genetic factors
- Commonly seen in patients with a mutation with their blood’s coagulation factors or cascade.
- Patients with such are always at high risk of DVT.
- Some of the factors affected are the primary deficiencies of coagulation inhibitors antithrombin, protein C, and protein S (Kaushal et al., 2014).
- Procoagulant enzyme proteins problems are seen to affects factor V, factor VIII, factor IX, factor XI, and prothrombin (Kaushal et al., 2014).
Other conditions that can induce hypercoagulability
There are several other factors that can lead to hypercoagulability. Those factors are risk factors an individual need to avoid. Such factors include; Immobilization longer than 3 days, major surgery in previous 4 weeks, Long plane or car trips (> 4 hours) in previous 4 weeks and now having another long trip greater than 4 weeks. Stroke, acute myocardial infarction (AMI), Congestive heart failure (CHF), Sepsis, Nephrotic syndrome, Ulcerative colitis, Multiple trauma
CNS/spinal cord injury, Burns, lower extremity fractures, systemic lupus erythematosus (SLE) and the lupus anticoagulant all contribute to increased risk of having hypercoagulability state. The following disease state also contribute to an increased risk; Behçet syndrome, Homocystinuria, Polycythemia rubra vera, Thrombocytosis, Inherited disorders of coagulation/fibrinolysis, Antithrombin III deficiency, Protein C deficiency, Protein S deficiency
Prothrombin 20210A mutation, Factor V Leiden, Dysfibrinogenemias and disorders of plasminogen activation (Kaushal et al., 2014).
Lower-extremity venogram shows outlining of an acute deep venous thrombosis in the popliteal vein with contrast enhancement.
Incidence
DVT has been found to has an estimated incidence of 0.1 percent annual incidence within the subpopulation. This is estimated to be travel related condition. Studied by two different researchers has been found to have an incidence of 1 in 4,656 flight and 1 in 6000 flights for flight greater than 4 hours. In another study involving five prospective studied, the incidence o among traveler of greater than 8 hours are found to be 0.5%..
Symptoms and signs
The symptoms are the swelling of the leg, pain in the leg, warmth over the area and changes in the color. The signs are unexplained shortness of breath, chest pain, dizziness or fainting, rapid pulse, sweat and cough.
Treatment
The management is divided into two main parts which are the main management and nursing management. The main management are the use of anti-coagulation therapy, heparin (monitor, PIT, INR), thrombolytic therapy ( is very good in helping to dissolve clot of especially in patient with clot issues), surgical management (this is done especially in situations where clots can't be dissolved by the use of the thrombolytic therapy). Those surgical methods that are used mainly for such treatment are the thrombectomy which is the removal of thrombosis. Another method that can be done is that which involves the placement of a thrombi filter after the thrombectomy to sift the emboli and thrombus
Prevention
Take the prescribed medications as directed, reduce vitamin K, exercise of lower calf muscles, movement and eating right.
References
Bates, S.M. & Ginsberg, J.S. (2004). Treatment of Deep-Vein Thrombosis. Clinical Practice. The New England Journal of Medicine.
Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMcp031676
Kesieme et al., (2011). Deep Vein Thrombosis: A clinical review. Journal of Bone Metabolism.
Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3262341/
Kaushal et al., (2014). Deep Venous Thrombosis Clinical Presentation. Medscape.
Retrieved from http://emedicine.medscape.com/article/1911303-clinical
Reyes, N., Grosse, S.,& Grant,A. (2014). Deep Vein Thrombosis & Pulmonary Embolism. Medical Tourism. Chapter 2.
Retrieved from http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-2-the-pre-travel-consultation/deep-vein-thrombosis-and-pulmonary-embolism
