PRECEPTOR:
Dr. Haris Munirwan, Sp.JP
Deep Vein Thrombosis :
Pathogenesis, Diagnosis, and
Medical management
Muhammad Riza Qadafi .R
18174091
FACULTY OF MEDICINE ABULYATAMA
UNIVERSITY
MEURAXA HOSPITAL
INTRODUCTION
The Incidence of VTE
estimated to be 1 per 1000
Deep Vein Thrombosis, a people annualy
subset of VTE
Pulmonary embolism
occurs in >1/3 cases as
Anticoagulant is the complication of DVT and
mainstay of therapy for DVT the primary contributor to
mortality
The 30 day mortality rate
exceeds 3 % in patient with
DVT who are not
coagulated
ANATOMY
RISK FACTOR
• A decresase Cell surface to blood volume ratio favor Procoagulants
• Familial Variants that predispose to thrombus formation by increasing the
levels of factor VII,VIII, IX, von Willebrand Factor, and Prothrombin
• Other risk factor for Clot Formation include cancer, oral contraceptives,
obesity, and advancing age.
PATHOGENESIS
• Virchow’s Triad, implicates three contributing factors in
the formation of thrombosis
– Venous stasis The Most consequential
– Vascular Injury
– Hypercoagulability
• The clinical Conditions most closely associated with DVT
are:
- Varicose Veins
– Surgery or Trauma
- Obesity
– Malignancy - Advancing Age
– Prolonged Immobility - A History of DVT
– Pregnancy
– Congestive Heart Failure
The hypercoagulable
micro-environment
that ensues may
down regulate certain
antithrombotic
including
thrombomodulin and
endhotelial protein C
Reseptor
Hypoxia drives the expression of procoagulant ( P-selectin )
and tissue factor
• A Venous thrombus has essentially two components
– An Inner platelet rich white Thrombus forming so called Lines of
Zahn
– An outer red cell dense fibrin clot
Fibrin Clot
Lines of zahn
DIAGNOSIS
• The Clinical Presentation of DVT
– Asymmetrical swelling
– Warmth
– Pain in an extremity
– A high Index of suspicion should be present in patients
with aforementioned risk factor
DIAGNOSTIC IMAGING
First line Imaging
Ultrasound modality
Gold standard for
lower extremity DVT, Contrast
but is limited by a Venography
number of factors
CT Venography
MR Venography The disadvantages
are intolerability,
increased cost, &
imcompatible
hardware
MEDICAL MANAGEMET
• Anti Coagulant os an Essensial component of therapy for DVT
• In case of extensive thrombus burden involving proximal deep
veins. Mechanical- and catheter-directed thrombolysis (CDT)
may be indicated in the acute phase
The hypercoagulable
micro-environment
that ensues may
down regulate certain
antithrombotic
including
thrombomodulin and
endhotelial protein C
The hypercoagulable micro-environment that ensues may
down regulate certain antithrombotic including
thrombomodulin and endhotelial protein C
• History of habits
Patient smoked since senior high school as 18
cigarettes everyday. Patient taking traditional
herbal medicine. All this time, the patient has
habits of eating padang food and innards.
Physical examination
General condition Vital sign
• Ill impression : moderete • Blood pressure: 90/60
• Nutritional status : good mmHg
• Awareness : Compos • Pulse: 90x/m
mentis • Temperature: 36ᴼC
• RR: 18x/m
Physical examination
General status
Head : Normocephal
Eye : clear cornea, blackish brown iris color, pupil isokor, direct light reflex +/+,
indirect light reflex +/+, conjunctival pallor -/-, sclera jaundice -/-
Nose : normal, no discharge, no blood
Mouth : OH good
Ear : Normotia, no discharge and blood
Neck : Thyroid and lymph nodes no enlarged
Thorax
Lung : Symmetrical, breath sound Vesikuler +/+, Wh -/-, Rh -/-
hearth : hearth sound I &II reguler, gallop (-), murmur (-)
chest and breasts : there are stitches in the sternum after CABG.
Abdomen : flat,noisy bowel (+), Timpani, tenderness (-)
Physical examination
Urogenital : Normal
Limb : There are gangrens on digiti left toes
I,II,III,IV,V
View before amputation
Clinical diagnostic
Buerger disease
Treatment
FOLLOW UP
January, S : No complain
12nd2016 O : Compos mentis, mild pain
TD : 100/70 mmHg S: 36,2 ᴼC N: 82 RR= 18x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
A: Pro amputation digiti left toes I,II,III,IV,V
P: Ceftriaxon 2 gr
January, S : breathless
13th2016 O : Compos mentis, mild pain
TD : 110/70 mmHg S: 36,4 ᴼC N: 80 RR= 18x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
A: Pro amputation digiti left toes I,II,III,IV,V
P: Injection RL 20 tpm
Inj ceftriaxon 2x1
Inj ketorolac 3x1
Bedrest
Changing bandages every 2 days
January, S : cough, breathless
O : Compos mentis, mild pain
14th2016 TD : 100/70 mmHg S: 36,3 ᴼC N: 90x/m RR= 16x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
Location status:
-attached bandages on pedis sinistra
-attached kassa on inguinal dextra
A: Pro amputation digiti left toes I,II,III,IV,V
P: Injection lasix 1 amp
ISDN 5 mg sublingual
January, S : cough, breathless
15th2016 O : Compos mentis, mild pain
TD : 100/70 mmHg S: 36,5 ᴼC N: 80x/m RR= 28x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
Location status:
-attached bandages on pedis sinistra
-attached kassa on inguinal dextra, blood seeped
A: Pro amputation digiti left toes I,II,III,IV,V
P: ceftriaxon 2x1 gr , Ketorolac 2x1 amp , RL
Consul cardiologist (dr.Stephani), EKG every morning , Injection lasix 1 amp
IPG 1x75 mg , Letonal 1x25 mg , Bisoprolol 1x25 mg , Avesco 1x1 tab , ISDN 5 mg
sublingual
January, S : breathless
16th2016 O : Compos mentis, mild pain
TD : 110/80 mmHg S: 36,5 ᴼC N: 88x/m RR= 26x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
Location status:
-attached bandages on pedis sinistra
-attached kassa on inguinal dextra
A: Pro amputation digiti left toes I,II,III,IV,V
P: ketorolac 2x1 amp, Ceftriaxon 2x1 amp, Injection lasix 1 amp
IPG 1x75 mg , Letonal 1x25 mg, Bisoprolol 1x25 mg, Avesco 1x1 tab , ISDN 5 mg
sublingual
January, S : breathless
18th2016 O : Compos mentis, mild pain
TD : 120/80 mmHg S: 36,5 ᴼC N: 80x/m RR= 28x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
Location status:
-attached bandages on pedis sinistra
-attached kassa on inguinal dextra
A: Pro amputation digiti I-V pedis sinistra
P: Cefixime 2x100 gr , Nadiclop 2x25 gr , Lasix 2x1 amp, Neurodex 2x1 gr,
Lantoprazol 2x1 Impepsa 3x1
Surgery report (january 13th 2016)
• Types of surgery : Pro amputation digiti left toes I,II,III,IV,V
• Position : Supine
• Anesthesia : SAB
• Operation time : Wednesday, January 13th 2016 12.00-14.00 o’clock
• Duration : 2 hours
• Surgery report:
Position of supine with SAB
Asepsis and antisepsis location operating
Incision edge of the wound necroting
Spin of area necroting digiti I-V pedis sinistra
Do amputation and necroting
Followed with skin graft ( FTSG)
Drain in inguinal
Doing suture
Thick bandage
View after amputation
Literature review
Anatomy
Artery
Thigh and gluteal region : femoral artery and
obturator artery
Leg : anterior leg (anterior tibial artery), posterior
leg (dorsalis pedis artery)
Foot : dorsalis pedis artery and posterior tibial
artery
Venous
•Deep vein
gluteal : inferior and superior gluteal vein
thigh : external iliac vein and femoral vein
Foot and leg : anterior tibial vein, posterior and fibular vein, popliteal
vein, plantar vein
•Superficial vein
great saphenous vein
small saphenous vein
Histology
The intima
The media
The adventitia
TAO
• Definition :
Thromboangiitis obliterans (TAO) is an inflammatory,
nonatherosclerotic, occlusive disease of small and medium-
sized arteries and veins that involves distal vessels of the
extremities
Cause and risk factor
• tobacco exposure of any kind, including smoking, chewing or
snuff.
• Aged (predominately 20 to 40 years old)
• more common in men
• Genetics
• Hypercoagulability
• endothelial dysfunction
• immunologic mechanism
• high cholesterol
• high blood pressure
• diabetes
Pathogenesis
Pathology
Clinical description
Two or more limbs being affected
Discoloration of the affected limb
Pain which may increase with activity such as walking and
decrease with rest
Numbness and tingling in the limbs
Raynaud's phenomenon
Skin ulcerations and gangrene of the digits, which are
common
Pulses which may be decreased or absent in the affected
extremity
Later symptoms which include enlarged, red, tender cord-like
veins
Diagnostic method
Non-invasive vascular Angiography
evaluation •The most important diagnostic criterion
is the smooth and regular, non-
•used to check for a lack of atherosclerotic nature of the artery
atherosclerotic lesions and can wall both at the site of, and also
identify the distal sites of proxmally to arterial occlusions.
•In the legs, infrapopliteal lesions
symptomatic arterial occlusion predominate
and other sites of lesions •In the arms, the lesions primarily
concern the radial and cubital arteries
Laboratory
Treatment
• Drug
- vasodilator
- spinal cords stimulators
• Surgical
- sympathectomy
- distal limb amputation
Skin graft and flaps
Example for flap regional
Thank you
