Management of Deep Vein Thrombosis--Below the knee vs above the knee

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Management of DVT treatment wise as well as workup for this fairly common issue....

Submitted: May 29, 2010

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Submitted: May 29, 2010



As a clinician, I see DVT's rather frequently. There are many etiologies that can be attributed to it such as bedridden patients, S/P recent surgical procedures (especially orthopedics), etc. The management is somewhat controversial as the location of the DVT guides clinicians on how to diagnosis and perform the workup/medical management of these patients.

For the sake of keeping things relatively basic, I'll be analyzing below the knee vs above the knee medical management of DVT's. It should be noted that DVT's can occur anywhere in the body. Plenty of cases have been reported as the etiology of them can potentially rise from the Subclavian and Internal Jugular Veins (these are usually due to prolonged IV catheter usages at these sites respectively.)

Below the knee DVT's are thought to be the less \"fatal\" of the 2 major DVT types. It's estimated approximately 1/3rd of these cases can result in Pulmonary Thromboembolic events- aka a P.E. Patients are either monitored carefully with Serial Ultrasounds or can be given a 3 month anticoagulation preparation centered around Low Molecular Weight Heparin such as Enoxaparin (Lovanox) used in combination with Warfarin (Coumadin.)

Above the knee DVT's are treated more aggressively after being confirmed on Spiral CT, Pulmonary angiogram, elevated D-dimers and an abnormal Ventilation/Perfusion scan (V/Q mismatch.) Patients are usually given 6 (or 9 if high risk) months of anticoagulation, and if they happen to have a coexisting thrombophilia disorder such as Factor 5 Leiden or Protein C/S deficiency, the clinician should consider possibly giving warfarin for life.

It should also be noted that recurrent DVT's/thromboembolisms in patients who are on anticoagulants should raise the suspicion of possible Heparin Induced Thrombocytopenia (HIT) which will show with a drastic decrease in platelet counts (as they're being used up in the clotting cascade process.) These patients should be considered for a Greenfield Filter (also known as an IVC filter) for prophylaxis of future thromboembolic events. Ironically though, IVC filters can form clots proximally around the filter site, and can potentially cause a PE!

As you can see, diagnosing Deep Vein Thrombosis and Pulmonary Embolisms aren't too difficult. The challenge lies in the medical management of these patients......

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