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Deep vein thrombosis (DVT, also called venous thrombosis) is a blood clot that develops in a vein deep in the body. The clot may partially or completely block blood flow through the vein. Most DVTs occur in the lower leg, thigh or pelvis, although they also can occur in other parts of the body including the arm, brain, intestines, liver or kidney.
Deep vein thrombosis (DVT) is the formation of blood clots (thrombi) in the deep veins. It commonly affects the deep leg veins (such as the calf veins, femoral vein, or popliteal vein) or the deep veins of the pelvis. It is a potentially dangerous condition that can lead to preventable morbidity and mortality.
A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins usually of the leg but can occur in the veins of the arms and the mesenteric and cerebral veins. Deep-vein thrombosis is a common and important disease. It is part of the venous thromboembolism disorders which represent the third most common cause of death from cardiovascular disease after heart attacks and stroke. Even in patients who do not get pulmonary emboli, recurrent thrombosis and “post-thrombotic syndrome” are a major cause of morbidity.[rx][rx][rx]
The severity of the disease is classified as
Provoked – Due to acquired states (surgery, oral contraceptives, trauma, immobility, obesity, cancer)
Unprovoked – Due to idiopathic or endogenous reasons; more likely to suffer recurrence if anticoagulation is discontinued
Proximal – Above the knee; affecting the femoral or iliofemoral veins; much more likely to lead to complications such as pulmonary emboli
Distal –Below the kneeRisk Factors
- Incidence and prevalence – Deep-vein thrombosis and pulmonary emboli are common and often “silent” and thus go undiagnosed or are only picked up at autopsy. Therefore, the incidence and prevalence are often underestimated. It is thought the annual incidence of DVT is 80 cases per 100,000 with a prevalence of lower limb DVT of 1 case per 1000 population. Annually in the United States, more than 200,000 people develop venous thrombosis; of those, 50,000 cases are complicated by pulmonary embolism.[rx][rx][rx]
- Age – Deep-vein thrombosis is rare in children and the risk increases with age, most occurring in the over 40s.
- Gender – There is no consensus about whether there is a sexual bias in the incidence of DVT.
- Ethnicity – There is evidence from the USA that there is an increased incidence of DVT and an increased risk of complications in African Americans and white people when compared to Hispanics and Asians.
- Associated diseases – In the hospital, the most commonly associated conditions are a malignancy, congestive heart failure, obstructive airways disease and patients undergoing surgery.
Causes of Deep Vein Thrombosis
Immobility which causes blood flow in the veins to be slow. Slow-flowing blood is more likely to clot than normal-flowing blood.
After longer periods of bed rest – for instance in hospital, after a bone fracture or injury. Staying in bed for a long time and not moving much can lead to poor blood circulation in your legs.
Blood clotting disorders – Some people are born with a disease that makes their blood clot too much.
More major operation – More major surgical procedures and serious injuries cause damage to blood vessels and activate the blood clotting (coagulation) system.
There are also various other factors that can increase someone’s risk of developing DVT
Being older than 60 years
Family history (parents or siblings had a DVT)
Certain types of cancer
Being severely overweight (obese)
Taking the contraceptive pill
Hormone therapy for menopause
Very noticeable varicose veins
Certain inflammatory diseases
Regular long-haul journeys where you spend a lot of time sitting.
A surgical operation where you are asleep for over 1-1.5 hours – is the most common cause of a DVT. Your legs are still when you are under anesthetic because the muscles in your body are temporarily paralyzed. Blood flow in the leg veins can become very slow, making a lot more likely to occur. Certain types of surgery (particularly operations on the pelvis or legs) increase the risk of DVT even more.
Any illness or injury that causes immobility – increases the risk. This includes having a leg in a hard plaster cast after a fracture. People who are admitted to intensive care units are at an increased risk of DVT. This is due to a number of reasons but partly because they are very ill and also because they are immobile (they may even be kept asleep by anesthetic medications).
Long journeys by plane, train or coach/car – may cause a slightly increased risk. This is because you are mostly sitting still and not moving around very much.
Damage to the inside lining of the vein – increases the risk of a blood clot forming. For example, a DVT may damage the lining of the vein. So, if you have a DVT, then you have an increased risk of having another one in the future. Some conditions such as inflammation of the vein wall (vasculitis) and some medicines (for example, some chemotherapy medicines) can damage the vein and increase the risk of having a DVT.
Conditions that cause the blood to clot more easily than normal – (thrombophilia) can increase the risk. Some conditions can cause the blood to clot more easily than usual. Examples include nephrotic syndrome and antiphospholipid syndrome. See separate leaflets called Nephrotic Syndrome, Antiphospholipid syndrome and Thrombophilia for more details. Some rare inherited conditions can also cause the blood to clot more easily than normal.
The contraceptive pill and hormone replacement therapy (HRT) – which contain estrogen can cause the blood to clot slightly more easily. Women taking the pill or HRT have a small increased risk of DVT.
People with cancer or heart failure – have an increased risk. Sometimes a DVT happens in a person who has not yet been diagnosed with cancer. Investigations looking for the cause of a DVT may show cancer to be the underlying cause.
Older people (over 60 years of age) – are more likely to have a DVT, particularly if you have poor mobility or have a serious illness such as cancer.
Pregnancy – increases the risk. About 1 in 1,000 pregnant women have a DVT while they are pregnant, or within about six months after they give birth.
Obesity – also increases the risk. If your body mass index (BMI) is more than 30 kg/m2, you are more at risk of DVT.
Being male – Men tend to develop a DVT more often than women.
Lack of fluid in the body (dehydration) – can make a DVT more likely to happen.
Injury to a vein, often caused by
- Severe muscle injury, or
- Major surgery (particularly involving the abdomen, pelvis, hip, or legs).
Slow blood flow, often caused by
- Confinement to bed
(e.g., due to a medical condition or after surgery);
- Limited movement (e.g., a cast on a leg to help heal an injured bone);
- Sitting for a long time, especially with crossed legs; or
Increased estrogen, often caused by
- Birth control pills
- Hormone replacement therapy, sometimes used after menopause
- Pregnancy, for up to 6 weeks after giving birth
Certain chronic medical illnesses, such as
- Heart disease
- Lung disease
- Cancer and its treatment
- Inflammatory bowel disease (Crohn’s disease or ulcerative colitis)
Other factors that increase the risk of DVT include
- Previous DVT or PE
- The family history of DVT or PE
- Age (risk increases as age increases)
- A catheter located in a central vein
- Inherited clotting disorders
Symptoms of Deep Vein Thrombosis
Symptoms of deep venous thrombosis (DVT) may include the following
Edema – a Most specific symptom
Leg pain – occurs in 50% of patients but is nonspecific
Tenderness – Occurs in 75% of patients
Warmth or erythema of the skin over the area of thrombosis
Clinical symptoms of pulmonary embolism (PE) as the primary manifestation
Calf pain on dorsiflexion of the foot (Homans sign)
A palpable, indurated, cordlike, tender subcutaneous venous segment
Variable discoloration of the lower extremity
The blanched appearance of the leg because of edema (relatively rare)
Potential complications of DVT include the following
As many as 40% of patients have silent PE when symptomatic DVT is diagnosed
Paradoxical emboli (rare)
Postthrombotic syndrome (PTS)
PE symptoms include
- Sudden shortness of breath
- Chest pain that’s worsened by breathing deeply, moving or coughing
- Back pain
- Light-headedness, dizziness, fainting
- Rapid pulse
- Coughing (some people, but not all, cough up blood)
As many as 46% with patients with classic symptoms have negative venograms, and as many as 50% of those with image-documented venous thrombosis lack specific symptoms.
Clinical probability scoring
The Wells’ score is commonly used to evaluate the probability of DVT based on a patient’s medical history and physical examination. Clinical judgment plays a critical role because certain DVT risk factors and markers are evident early in the diagnostic process.
|Activecancer (treatment ongoing or within previous 6 months or palliative)||1|
|Paralysis, paresis or recent plaster immobilization of lower extremities||1|
|Recently bedridden for more than 3 days or major surgery within 4 weeks||1|
|Localized tenderness along the distribution of the deep vein system||1|
|The entire leg has swollen||1|
|Calf swelling by more than 3 cm when compared with asymptomatic leg||1|
|Collateral superficial veins||1|
|Alternative diagnosis as likely or greater than that of DVT||–2|
Although a high Wells’ score indicates a clinical probability of DVT, an objective imaging technique such
Diagnosis of Deep Vein Thrombosis
As per the NICE guidelines following investigations are done
D-dimers (very sensitive but not very specific)
Proximal leg vein ultrasound, which when positive, indicates that the patient should be treated as having a DVT
Deciding how to investigate is determined by the risk of DVT. The first step is to assess the clinical probability of a DVT using the Wells scoring system.
For patients with a score of 0 to 1, the clinical probability is low, but for those with 2 or above the clinical probability is high.
If a patient scores 2 or above, either a proximal leg vein ultrasound scan should be done within 4 hours, and if the result is negative, a D-dimer test should be done. If imaging is not possible within 4 hours, a D-dimer test should be undertaken, and an interim 24-hour dose of a parenteral anticoagulant should be given. A proximal leg vein ultrasound scan should be carried out within 24 hours of being requested.
In the case of a positive D-dimer test and a negative proximal leg vein ultrasound scan, the proximal leg vein ultrasound scan should be repeated 6 to 8 days later for all patients.
If the patient does not score 2 on the DVT Wells score, but the D-dimer test is positive, the patient should have a proximal leg vein ultrasound scan within 4 hours, or if this is not possible, the patient should receive an interim 24-hour dose of a parenteral anticoagulant. A proximal leg vein ultrasound scan should then be carried out within 24 hours of being requested.
The American Academy of Family Physicians (AAFP)/American College of Physicians (ACP) recommendations for workup of patients with probable DVT are as follows
Validated clinical prediction rules (eg Wells) – should be used to estimate the pretest probability of venous thromboembolism (VTE) and interpret test results
In appropriately selected patients with a low pretest probability of DVT or PE – it is reasonable to obtain a high-sensitivity D-dimer
In patients with intermediate to high pretest probability of lower-extremity DVT – ultrasonography is recommended
In patients with the intermediate or high pretest probability of PE – diagnostic imaging studies (eg, ventilation-perfusion scan, multidetector helical CT, and pulmonary angiography) are required
Doppler ultrasound – Using high-frequency sound waves, this system can visualize the large, proximal veins and detect a clot if one is present. Painless and without complications, this is the most commonly used method to diagnose deep vein thrombosis. However, sometimes the test can miss a lot, especially in the smaller veins.
Venography – A liquid dye is injected into the veins for imaging studies. It highlights blockage of blood flow by a clot. This is the most accurate test, but also the most uncomfortable and invasive. It is rarely done today because of the availability of improved ultrasound technology.
Impedance plethysmography – Electrodes are used to measure volume changes within veins. Because this test does not detect clots better than ultrasound and is harder to perform, it is rarely used.
CT scan – This is a type of X-ray that gives a very detailed look at the leg veins in cross section and can detect clots. It is rarely used for this purpose as it is more difficult to interpret and is time-consuming. The CT scan is more useful for identification of blood clots in the lung.
Magnetic resonance imaging (MRI) – This test uses radio frequency waves and a strong magnetic field to create detailed images of the inside of your body. You lie still on a sliding table while the test takes place. Expect to hear loud tapping or knocking sounds. If needed, you may get a fluid injected into your vein to enhance the images of your blood vessels. This imaging test is effective at finding DVT in the pelvis, as well as in the thigh. It also allows your doctor to examine both legs at once.
Contrast venography – Venography is the definitive diagnostic test for DVT, but it is rarely done because the noninvasive tests (D-dimer and venous ultrasound) are more appropriate and accurate to perform in acute DVT episodes. It involves cannulation of a pedal vein with an injection of a contrast medium, usually noniodinated, eg, Omnipaque. A large volume of Omnipaque diluted with normal saline results in the better deep venous filling and improved image quality.[rx]
Impedance plethysmography – The technique is based on measurement of the rate of change in impedance between two electrodes on the calf when a venous occlusion cuff is deflated. The free outflow of venous blood produces a rapid change in impedance while the delay in the outflow, in the presence of a DVT, leads to a more gradual change.[rx] It is portable, safe, and noninvasive but its main drawback remains an apparent insensitivity to calf thrombi and small, nonobstructing proximal vein thrombi.
Venous ultrasonography – Venous ultrasonography is the investigation of choice in patients stratified as DVT likely.[rx] It is noninvasive, safe, available, and relatively inexpensive. There are three types of venous ultrasonography: compression ultrasound (B-mode imaging only), duplex ultrasound (B-mode imaging and Doppler waveform analysis), and color Doppler imaging alone. In duplex ultrasonography, blood flow in the normal vein is spontaneous, phasic with respiration, and can be augmented by manual pressure. In color flow sonography, pulsed Doppler signal is used to produce images.[rx] Compression ultrasound is typically performed on the proximal deep veins, specifically the common femoral, femoral, and popliteal veins, whereas a combination of duplex ultrasound and color duplex is more often used to investigate the calf and iliac veins.[rx]
The main laboratory studies to be considered include the following
Coagulation studies (eg, prothrombin time and activated partial thromboplastin time) to evaluate for a hypercoagulable state
- Bleeding and Clotting time
- Activated protein C resistant
- Anti-prothrombin ||| level
- Screening for disseminated intravenous coagulation (DIC)
Treatment of Deep Vein Thrombosis
Treatment of DVT aims to prevent pulmonary embolism, reduce morbidity, and prevent or minimize the risk of developing the post-thrombotic syndrome.
The cornerstone of treatment is anticoagulation. NICE guidelines only recommend treating proximal DVT (not distal) and those with pulmonary emboli. In each patient, the risks of anticoagulation need to be weighed against the benefits.[rx][rx][rx]
Low-molecular-weight heparin or fondaparinux for 5 days or until INR is greater than 2 for 24 hours (unfractionated heparin for patients with renal failure and increased risk of bleeding)
Vitamin K analogs for 3 months
In patients with cancer, consider anticoagulation for 6 months with low-molecular-weight heparin
In patients with unprovoked DVT consider vitamin K analogs beyond 3 months
Rivaroxaban is an oral factor Xa inhibitor which has recently been approved by the FDA and NICE and is attractive because there is no need for regular INR monitoring
- Warfarin remains the drug of choice for long-term therapy to prevent clot formation once acute anticoagulation is achieved. LMWH is, however, preferred after long-term therapy of DVT in pregnancy as warfarin therapy is contraindicated,[rx] and in patients with cancer. Long-term anticoagulant therapy with LMWH is more effective than warfarin at preventing recurrent venous thrombosis in cancer patients without a statistically significant bleeding risk.[rx]
Symptomatic iliofemoral DVT
Symptoms of less than 14 days duration
Good functional status
Life expectancy of 1 year or more
Low risk of bleeding
Compression hosiery – Below-knee graduated compression stockings with an ankle pressure greater than 23 mm Hg for 2 years (if there are no contraindications)
Inferior vena cava filters – If anticoagulation is contraindicated or if emboli are occurring despite adequate anticoagulation
Treatment options for DVT include the following
Anticoagulation (a mainstay of therapy) – Heparins, warfarin, factor Xa inhibitors, and various emerging anticoagulants
Endovascular and surgical interventions
Physical measures (eg, elastic compression stockings and ambulation)
Heparin products used in the treatment of DVT include the following
Low-molecular-weight heparin (LMWH; eg, enoxaparin)
Unfractionated heparin (UFH)
Factor Xa inhibitors used in the treatment of DVT include the following
Fondaparinux – This agent appears to be comparable to enoxaparin with respect to efficacy and safety
Rivaroxaban – This agent appears to prevent VTE recurrence as effectively as enoxaparin followed by a vitamin K antagonist and may be associated with less bleeding, in addition, it appears to be usable in high-risk groups
Endovascular therapy is performed to reduce the severity and duration of lower-extremity symptoms, prevent PE, diminish the risk of recurrent VTE, and prevent PTS. Percutaneous transcatheter treatment of DVT includes the following
Thrombus removal with catheter-directed thrombolysis – American College of Chest Physicians (ACCP) recommends thrombolytic therapy only for patients with massive iliofemoral vein thrombosis associated with limb ischemia or vascular compromise
Stenting of venous obstructions
American Heart Association (AHA) recommendations for inferior vena cava filters include the following
Confirmed acute proximal DVT or acute PE in patients contraindicated for anticoagulation
Recurrent thromboembolism while on anticoagulation
Active bleeding complications requiring termination of anticoagulation therapy
These agents prevent recurrent or ongoing thrombolytic occlusion of the vertebrobasilar circulation.
- Rivaroxaban is an oral factor Xa inhibitor that inhibits platelet activation by selectively blocking the active site of factor Xa without requiring a cofactor (eg, antithrombin III) for activity. It is indicated for the treatment of DVT or PE, and to reduce the risk of recurrent DVT and PE following initial treatment. It is also indicated for prophylaxis of DVT in patients undergoing knee or hip replacement surgery.
- Apixaban is an oral factor Xa inhibitor that inhibits platelet activation by selectively and reversibly blocking the active site of factor Xa without requiring a cofactor (eg, antithrombin III) for activity.
- It inhibits free and clot-bound factor Xa, and prothrombinase activity; no direct effect on platelet aggregation, but indirectly inhibits platelet aggregation induced by thrombin.
- It is indicated for prophylaxis of DVT or PE in adults undergoing knee or hip replacement surgery. It is also indicated for the treatment of DVT and PE and for prevention of recurrence (following the initial 6 months of the initial treatment).
- Dabigatran is a new oral univalent direct thrombin inhibitor. Dabigatran etexilate is the prodrug of dabigatran. It is rapidly absorbed from the gastrointestinal tract with a bioavailability of 5% to 6%. It has a half-life of 8 hours after single-dose administration and up to 17 hours after multiple doses with plasma levels that peak at 2 hours.[rx] The drug is excreted largely unchanged via the kidneys. It has a low bioavailability (6%), produces a predictable anticoagulant effect, and requires no coagulation monitoring.[rx] Dabigatran has been approved in Canada and Europe for VTE prevention after orthopedic surgery.
- Fondaparinux, a synthetic pentasaccharide, has been approved for prophylaxis of DVT. It is an indirect selective inhibitor of factor Xa which binds to antithrombin with high affinity in a reversible manner. Heparin-induced thrombocytopenia has not been reported with fondaparinux as it does not interact with platelet function and aggregation and has a predictable response.80 Monitoring of prothrombin time or partial thromboplastin time is also not required. In summary, it has an equal or better effectiveness than currently available agents, a low bleeding risk, no need for laboratory monitoring, and once daily administration.
- Fondaparinux sodium is a synthetic anticoagulant that works by inhibiting factor Xa, a key component involved in blood clotting. It provides a highly predictable response and has a bioavailability of 100%. The drug has a rapid onset of action and a half-life of 14-16 hours, allowing for sustained antithrombotic activity over a 24-hour period. Fondaparinux sodium does not affect prothrombin time or activated partial thromboplastin time, nor does it affect platelet function or aggregation.
- Heparin augments the activity of antithrombin III and prevents the conversion of fibrinogen to fibrin. It does not actively lyse but is able to inhibit further thrombogenesis. Heparin prevents reaccumulation of a clot after spontaneous fibrinolysis.
- These medicines interfere with the blood clotting process. They’re used to treat blood clots in patients who can’t take heparin.
- Doctors prescribe these medicines to quickly dissolve large blood clots that cause severe symptoms. Because thrombolytics can cause sudden bleeding, they’re used only in life-threatening situations.
Vena Cava Filter
- If you can’t take blood thinners or they’re not working well, your doctor may recommend a vena cava filter. The filter is inserted inside a large vein called the vena cava. The filter catches blood clots before they travel to the lungs, which prevents pulmonary embolism. However, the filter doesn’t stop new blood clots from forming.
- Your healthcare team will usually advise you to walk regularly once compression stockings have been prescribed. This can help prevent symptoms of DVT returning and may help to improve or prevent complications of DVT, such as post-thrombotic syndrome.
Raising your leg
- As well as wearing compression stockings, you might be advised to raise your leg whenever you’re resting. This helps to relieve the pressure in the veins of the calf and stops blood and fluid pooling in the calf itself.
- When raising your leg, make sure your foot is higher than your hip. This will help the returning blood flow from your calf. Putting a cushion underneath your leg while you’re lying down should help raise your leg above the level of your hip.
Graduated Compression Stockings
- Graduated compression stockings can reduce leg swelling caused by a blood clot. These stockings are worn on the legs from the arch of the foot to just above or below the knee.
- Compression stockings are tight at the ankle and become looser as they go up the leg. This creates gentle pressure up the leg. The pressure keeps blood from pooling and clotting.
- This is rarely indicated. The risk of major bleeding, including intracranial hemorrhage, should be weighed against the benefits of complete and rapid lysis of thrombi. It is indicated in massive DVT which leads to phlegmasia cerulean dolens and threatened limb loss. The available thrombolytic agents include tissue plasminogen activator, streptokinase, and urokinase.
- Endovascular thrombolytic methods have evolved considerably in recent years. Catheter-directed thrombolysis (CDT) can be used to treat DVTs as an adjunct to medical therapy.[rx] Current evidence suggests that CDT can reduce clot burden and DVT recurrence and consequently prevent the formation of post-thrombotic syndrome compared with systemic anticoagulation.[rx] Pharmacomechanical CDT is now routinely used in some centers for the treatment of acute iliofemoral DVT.[rx]
- Appropriate indications may include younger individuals with acute proximal thromboses, a long life expectancy, and relatively few comorbidities. Limb-threatening thromboses may also be treated with CDT, although the subsequent mortality remains high.[rx] A number of randomized controlled trials are currently underway comparing the longer-term outcomes of CDT compared with anticoagulation alone.
Vena cava filters
- Vena cava filters are indicated in very few circumstances. They include absolute contraindication to anticoagulation, life-threatening hemorrhage on anticoagulation, and failure of adequate anticoagulation.[rx] Absolute contraindications to anticoagulation include central nervous system (CNS) hemorrhage, overt gastrointestinal bleeding, retroperitoneal hemorrhage, massive hemoptysis, cerebral metastases, massive cerebrovascular accident, CNS trauma, and significant thrombocytopenia (<50,000/μL).[rx] They may be retrievable or nonretrievable, most of the newly developed ones being retrievable.
For the majority of patients with DVT, oral therapy with vitamin K antagonists (e.g., warfarin) is very effective for long-term prevention of recurrent thrombosis.rx Although the initial treatment of DVT is similar for most patients, the duration of long-term treatment varies depending on the perceived risk of recurrent DVT. The risk can be classified into the following 5 categories:
- First proximal DVT occurs in the context of a transient risk factor (e.g., surgery or trauma). In this situation, the risk of recurrence is very low and a limited duration of therapy (3 months) is adequate.rx,Rx
- First DVT occurs in the context of active malignant disease, which is an ongoing risk factor. Patients with malignant disease have a higher incidence of recurrent thrombosis and bleeding complications while receiving oral anticoagulation therapy following a first thrombotic event.rx,Rx This is likely due to the prothrombotic state associated with cancer and to the difficulty of managing oral anticoagulant therapy with concomitant drugs, erratic oral intake and liver dysfunction. Researchers with the CLOT trial have shown that long-term anticoagulation therapy with LMW heparin is more effective than warfarin at preventing recurrent venous thrombosis without a statistically significant increase in bleeding risk.
- It is our practice to give all patients who have active malignant disease LMW heparin for at least 6 months if there is an adequate renal function. Not only will it lead to lower risks of recurrent thrombosis in many patients, but it facilitates the management of patients who need to undergo multiple procedures (e.g., biopsy, line insertion) and who have periodic thrombocytopenia due to chemotherapy. Since the risk of recurrence is high (2–3 fold higher among patients with cancer than among those without cancer),rx treatment with anticoagulation drugs is recommended as long as the cancer is felt to be active. We wait 6 months after cure or complete remission before stopping therapy.
- First DVT occurs in the context of a thrombophilic defect. These defects include factor V Leiden, prothrombin gene mutation, deficiencies in protein C, protein S and antithrombin, increased factor VIII levels, hyperhomocysteinemia, and elevated antiphospholipid antibody levels. Many of these defects are associated with an increased risk of a first DVT. Patients with persistently elevated antiphospholipid antibody levels determined by either ELISA or clotting assays have a 2-fold higher relative risk of recurrence within 4 years after stopping anticoagulation therapy for a first DVT than those without this thrombophilia.rx
- It has been reported that patients with an elevated factor VIII level (above the 90th percentile of normal) have a 2-year risk of recurrence of 37% after stopping anticoagulant agents, compared with 5% among those with normal levels.rx However, this study included a lower risk of calf vein thrombosis, which may explain the wide difference. In general, the risk of recurrence after a first idiopathic DVT is not influenced by the presence or absence of most thrombophilic defectsrx and, with the exception of patients with elevated antiphospholipid antibody levels and combined or homozygous genetic defects, we do not routinely recommend prolonged anticoagulation therapy in these populations after a first idiopathic DVT.
- Recurrent DVT – After the second recurrence of DVT, the risk of further thromboembolic events following the discontinuation of anticoagulation therapy is felt to be excessive if only 6 months of oral anticoagulation therapy is administered.rx Therefore, we generally recommend that anticoagulation therapy be continued in this situation. During yearly visits bleeding risk can be assessed, which will enable a risk-benefit evaluation to determine if anticoagulation therapy should continue. However, no study has looked at the risk of recurrent DVT if both events occurred during a transient risk period. In this situation, a shorter duration of anticoagulation therapy may be adequate (3–6 months), but other factors may influence this decision.
- First DVT occurs in the absence of temporary or identifiable ongoing risk factors for thrombosis (idiopathic) – Six months is considered a minimum duration for anticoagulation therapy in these patients while continuing for longer is effective in preventing thrombosis. However, the risk of recurrent venous thromboembolism in the first year after stopping anticoagulation therapy is about 10%, regardless of when the therapy is stopped after 6 months.rx When considering prolonging anticoagulation therapy after 6 months, the risks of bleeding with long-term anticoagulation therapy must be individualized and weighed against the potential benefits of preventing recurrence of thrombosis.
The intensity of anticoagulation therapy
- The standard intensity of oral anticoagulation therapy is an international normalized ratio (INR) of 2 to 3. In patients who have antiphospholipid antibody-related thrombosis, it has long been felt that higher intensity anticoagulation therapy is needed to prevent recurrence.rx
- However, the results of 2 randomized controlled trials showed that standard anticoagulation therapy is as effective as a high-intensity treatment, even in this subgroup of patients.rx Therefore, high-intensity anticoagulation therapy is not recommended in any patient with DVT.
- Maintaining good INR control will decrease the risk of postphlebitic syndrome.rx There has also been a debate on the usefulness of long-term low-intensity anticoagulation therapy (INR 1.5–1.9) to prevent recurrent thrombosis while reducing the risk of bleeding.
- A large randomized trial has shown that low-intensity anticoagulation therapy is less effective than standard anticoagulation therapy at preventing recurrent thrombosis and does not lower the risk of bleeding.rx Therefore, low-intensity therapy is not recommended.
- Upper-extremity DVTs can be subdivided into catheter-and noncatheter-related thrombosis. There is a risk of pulmonary embolism with this condition, and therefore treatment with anticoagulation therapy is generally recommended.
- Initial treatment with thrombolytic therapy for acute upper-extremity DVT has been used with some success, but no randomized controlled trials comparing thrombolytic therapy with anticoagulation therapy alone have been performed. A more detailed discussion of upper-extremity DVT is beyond the scope of this article, and we would refer the reader to a review addressing this topic.rx
Special patient populations
- The treatment of DVT during pregnancy deserves special mention since oral anticoagulation therapy is generally avoided during pregnancy because of the teratogenic effects in the first trimester and the risk of fetal intracranial bleeding in the third trimester.
- LMW heparin is the treatment of choice for DVT during pregnancy. If acute DVT occurs near term, interrupting anticoagulation therapy may be hazardous because of the risk of pulmonary embolism. In this situation, placement of a retrievable inferior vena cava filter must be considered. However, there is no consensus as to what the appropriate dose should be and whether anti-Xa levels need to be monitored. This topic is well discussed in a recent review.rx
- For obese patients with DVT, results of a registry study suggest that they have similar outcomes as nonobese patients with DVT.rx The dose of LMW heparin does not need to be capped, and monitoring is not required, except perhaps in people who are morbidly obese, since fewer data are available for these patients.rx
Preventing a first deep vein thrombosis (DVT)
A DVT is often just a one-off event after a major operation.
However, some people who develop a DVT have an ongoing risk of a further DVT – for example, if you have a blood clotting problem or continued immobility. As mentioned above, you may be advised to take anticoagulation medicine long-term. Your doctor will advise you about this.
Other things that may help to prevent a first or recurrent DVT include the following:
- If possible avoid long periods of immobility – such as sitting in a chair for many hours. If you are able to, get up and walk around now and then. A daily brisk walk for 30-60 minutes is even better if you can do this. The aim is to stop the blood pooling and to get the circulation in the legs moving. Regular exercise of the calf muscles also helps. You can do some calf exercises even when you are sitting.
- Major operations are a risk for a DVT – particularly operations to the hip, lower tummy (abdomen) and leg. There are a number of methods to help reduce this risk:
- To help prevent a DVT – you may be given an anticoagulant such as a heparin injection just before an operation. This is called prophylaxis. Enoxaparin and dalteparin are the most common types of heparin given for prophylaxis against blood clots. The new drug, fondaparinux sodium, can also be given by injection in some circumstances to prevent DVT in surgical patients or immobile medical patients in the hospital.
- The newer anticoagulant medicines – discussed above can be used to prevent DVT or PE after hip or knee replacement surgery. Rivaroxaban, apixaban, and dabigatran are used in these situations and can be given by mouth as a tablet, rather than injection.
- An inflatable sleeve connected to a pump to compress the legs during a long operation may also be used.
- You may also be given compression stockings to wear whilst you are in the hospital.
- It is now common practice to get you up and walking as soon as possible after an operation.
- When you travel on a long plane, train, car or coach journeys, you should have little walks up and down the aisle every now and then. Try to exercise your calf muscles whilst sitting in your seat. (You can do this by circling your ankles, getting into a ‘tiptoe’ position and lifting your toes off the floor whilst keeping your heels on the ground.) You should aim to stay well-hydrated and avoid alcohol and sleeping medications.
- People who are overweight have an increased risk of DVT. Therefore, to reduce your risk, you should try to lose weight.
Risk factors for Deep Vein Thrombosis
Anyone can develop DVT and PE. Many factors can contribute, but having multiple factors at once can increase the likelihood that a blood clot will occur. Some common factors that may increase the risk of DVT and PE include
- Injury to a vein caused by a fracture, muscle injury or major surgery
- Sluggish blood flow or lack of blood flow due to bed rest, limited movement, sitting, and crossing legs for a long time, and paralysis
- Increased estrogen from birth control pills hormone replacement therapy, or pregnancy
- Cancer and cancer treatments
- A personal or family history of DVT and PE or clotting disorder
- Central venous catheters
- Varicose veins
- Venous insufficiency in the lower extremities.
The more common risk factors are
- Prolonged sitting, such as during a long plane flight or car ride
- Prolonged bed rest or immobility, such as after injury or during illness (for example stroke)
- Recent surgery, particularly orthopedic (especially hip, leg, or, knee such as knee or hip replacement), gynecologic, heart, or abdominal surgery
- Recent trauma to the lower body, such as fractures of the bones of the hip, thigh, or lower leg
- Heart attack or heart failure
- Pregnancy or recent childbirth
- Being at very high altitude, greater than 14,000 feet
- Use of estrogen therapy or birth control pills
- Rare inherited genetic conditions that lead to changes in certain blood clotting factors
- Certain heart or respiratory conditions
- Advanced age
- Medical conditions that affect the veins such as vasculitis (inflammation of the vein walls), varicose veins
- Superficial venous thrombosis (SVT) occurs when a blood clot forms in a superficial vein near the surface of the body. While not the same as DVT (which occurs in deep veins) it can be a risk factor for DVT/PE
- Disseminated intravascular coagulation (DIC), a medical condition in which blood clotting occurs inappropriately, usually is caused by overwhelming infection or organ failure.
Prevention of Deep Vein Thrombosis
If you have had DVT, then you will need to prevent further clots from developing by
- Taking your medications to prevent or treat blood clots as prescribed by your doctor.
- Keeping your follow-up appointments with your doctor and, if taking warfarin, with the laboratory so that your response to medications and other treatments can be evaluated.
If you have never had a deep vein clot, but have an increased risk for developing one, be sure to
- Exercise your lower leg muscles if you will be sitting still for long periods of time. Stand up and walk at least every half hour if you are on a long flight. Or get out of the car every hour if you are on a long road trip.
- Get out of bed and move around as soon as you are able after surgery or being ill. The sooner you move around, the less chance you have to develop a clot.
- Take medications or use intermittent compression garments to prevent clots after some types of surgery, as directed by your doctor.
- Follow-up with your doctor as recommended to evaluate your risk and follow your doctor’s recommendations for reducing your risk.
Natural Home Remedies for Deep Vein Thrombosis (DVT)
There are no specific Deep Vein Thrombosis home remedies for the removal of a blood clot, but DVT should not be overlooked merely as a blood clot as in worst cases of PE (Pulmonary Embolism) the situation becomes life-threatening.
For the first 15 – 20 days you have to depend upon the treatment given by doctors.
- Usually, the first drug given to the patient is HEPARIN.
- If heparin is given through a vein (IV), you must stay in the hospital.
- Newer forms of heparin can be given by injection once or twice a day. You may not need to stay in the hospital as long, or at all if you are prescribed this newer form of heparin.
- Another drug called Warfarin (Coumadin) or any anticoagulant (as suggested by the physician) is also started along with heparin. These anticoagulants keep more clots from forming or old ones from getting bigger. Generally, these drugs do not dissolve clots.
- Most likely warfarin is administered for a minimum of 3 months but in some cases, people have to take it for the rest of their lives.
Although no natural remedies are there which can cure DVT, some can help in the process of blood thinning and prevention of the disease. Here our primary goal is to prevent the disease from reoccurring.
Ginger is one of the most powerful tips on how to get rid of deep vein thrombosis. It can improve the flow of blood in your arteries and veins. In addition, ginger can stop your cholesterol level from increasing too much and prevent the accumulation of plaque that limits the circulation.
- Cut a ginger into slices and get some slices in hot water.
- Continue to boil the mixture in some minutes and then, have it simmered in about 10 minutes.
- After that, it should be strained.
- You can pour a bit honey to make it taste better.
- Consume the mixture several times per day.
In addition, you should increase the frequency of using ginger in daily cooking.
In the deep vein thrombosis treatment, you should choose home remedies that are good for the blood circulation. And undeniably, rosemary is a great choice and therefore, it is a great tip on how to get rid of deep vein thrombosis. The presence of flavonoid in rosemary can enhance the flow of blood and help you escape from bruises and sprains. Furthermore, its richness of vitamin B6 is good for bringing more oxygen to tissues.
Fibrin, one of the direct causes for deep vein thrombosis, can be broken down if you use ginger regularly. In fact, ginger is one of the best tips on how to get rid of deep vein thrombosis. It has positive effects on the flow of blood as well .
- Take 2-3 garlic cloves into your mouth and chew them raw.
- Drink a cup of water after that.
You ought to follow this remedy in the morning every day to get the best result.
One of the most outstanding advantages of turmeric is to thin the blood effectively. Another is to enhance your flow of blood. The amount of curcumin found in turmeric can reduce the possibility of clot formation in your arteries and veins. Moreover, the anti-inflammatory quality of turmeric can help you overcome the painful feeling and swelling easily. To sum up, turmeric is a wonderful tip on how to get rid of deep vein thrombosis .
- Get powdered turmeric combined with warm milk.
- Before consuming it, you can pour a bit raw honey if you like..
Cayenne pepper is a popular natural blood thinner and a great tip on how to get rid of deep vein thrombosis. With a high content of capsaicin, cayenne pepper can help enhance the circulation of blood and reduce the formation of blood clots. It is commonly seen that cayenne pepper is used in normalizing the blood pressure and putting the level of cholesterol under control.
- Pour half a spoon of powdered cayenne pepper in the fresh spinach juice.
- You can pour some salt to maximize the benefits.
- Consume the mixture 2-3 times on a daily basis.
Nevertheless, cayenne pepper is forbidden for pregnant women.
Foods that contain a considerable amount of vitamin E are strongly recommended in the attempts to get rid of deep vein thrombosis. And almond is one of the best choices for you. In 2007, the Circulation journal revealed that when the body gets vitamin E, the possibility of blood clot formation is much lower and this remedy is extremely suitable for those who suffer from this problem due to genetics
- Take almonds to dip in the water before you go to bed.
- In the next morning, you can chew them raw to get as much vitamin E as possible.
Another abundant source of vitamin E and many other essential nutrients is avocado. With anticoagulant quality, it can prevent the formation of blood clots as much as possible. You should include avocado in salad to consume every day or make the juice from it
With a high number of antioxidant nutrients in its content, hawthorn is one of the most effective tips on how to get rid of deep vein thrombosis. It can protect your body in general and your heart in particular from many toxins. It increases the flow of blood to support every part of your body efficiently.
Apple Cider Vinegar
Another tip on how to get rid of deep vein thrombosis that has been used for years is apple cider vinegar. It can bring a quick relief for the painful feeling and swollen parts in your body. When you use this vinegar, the blood circulation will be improved significantly.
- 1-2 spoons of apple cider vinegar should be poured in a cup of water.
- You can supplement raw honey to make it taste better before consuming it twice per day.
It is worth noting that blackstrap molasses is such a great tip on how to get rid of deep vein thrombosis at home. A lot of nutrients can be found in blackstrap molasses, such as iron, calcium and potassium and all of them contribute to prevent blood clots.
- Get 1-2 spoons of blackstrap molasses and pour it into warm milk.
- Consume the mixture 2-3 times on a daily basis.
Smoking has been traditionally known to be harmful to the lungs and respiratory system at first. However, during a long period of time, smoking can even have extreme impacts on the arteries and your blood circulation. Therefore, if you want to get rid of deep vein thrombosis as soon as possible, you’d better stop smoking and stay away from smokers immediately.
The abundance of omega-3 fatty acids is the most outstanding feature of fish oil in the deep vein thrombosis treatment. These acids are antiplatelet and fibrinolytic, which means that they can limit the blood clots. Fish oil also provides you with a lot of benefits, especially in the efforts to lower the level of blood pressure and cholesterol
Some of the home remedies for DVT prevention from reoccurrence are
- Regular intake of a glass of water with 1 tbsp lemon juice and chopped slices of ginger is the easiest solution for blood clot problem.
- Lemon and ginger is blood circulation improver.
- Have one garlic clove daily as it has favorable effects on cardiac factors.
- Keep your body hydrated with the intake of lots of water.
- Cold water fish should be preferred over other animal proteins.
- Most useful herb for improving the circulation of blood is ashwagandha. Hence, it works as one of the most effective home remedies for Deep Vein Thrombosis (DVT) natural treatment.
- Broccoli is rich in fiber content is considered good for cardiovascular patients.
- An aggravated stress hormone narrows down the blood vessels. Celery is an active compound and helps in reducing the stress hormone and should be included in the diet.
- The proper vascular state is maintained with the proper amount of Vitamin C in the body.
- Banana, apricot, spinach juice help in keeping the blood pressure normal.
- Skimmed milk should be used, as non skimmed milk offers extra fat which deposits on the walls of blood vessels thereby thinning their diameter.
- Capsicum and pepper help in preventing the platelets to stick together, so you can also include them in your diet.
- Prepare a juice of leaves of spinach and one part each of pepper, garlic, and clove. This is one of the best herbal remedies for Deep Vein Thrombosis (DVT).
- Use mustard oil, canola oil instead of high-fat cooking oils.
Dos and Don’ts for DVT
- Avoid food rich in high Vitamin K.
- Avoid smoking.
- Avoid the intake of alcohol, as it dehydrates you.
- Lose weight if overweight.
- Control your blood pressure.
- Wear compression stockings if advised by your doctor.
- Avoid drinking too much coffee or tea.
- A daily walk for 15 – 20 min.
- Cut down your daily dose of margarine, processed foods.
- Avoid long duration flights, it cannot then try walking on the aisle after every 2 hours or so.
- Don’t sit with an obstruction to the thigh muscle.
- Elevate your leg up to 6 inches while sleeping.
- Don’t sit idle for a long time, move your legs.
- Exercise your lower calf muscles, only after consulting your doctor.
- Avoid doing risky things which may cause bleeding.
- Stretch your legs and feet while you are sitting to keep blood moving steadily in your calves. While sitting, avoid crossing your legs as this can limit blood flow.
- Avoid wearing tight clothes that can restrict blood flow.
- If traveling a long distance by car, stop every hour or so and walk around. While traveling on a plane or bus, try to stand or walk occasionally in the aisle.
- If you are overweight, take the necessary steps to lose weight.
- Strive to keep your blood pressure and cholesterol levels under control.
- Quit smoking as it can have a harmful effect on your arteries.
- Avoid foods high in vitamin K, which can affect how prescribed medicines are working.
- Limit alcohol consumption to one serving per day or avoid it entirely. Alcohol contributes to dehydration.
- Do not forget to take the prescribed medications as directed by your doctor.
- Get regular medical check-ups so your doctor can assess your condition.