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Deep vein thrombosis - Management
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What are the risk factors for deep vein thrombosis?
- Deep vein thrombosis (DVT) is more likely to occur in people with continuing or intrinsic risk factors, such as:
- Previous venous thromboembolism.
- Cancer (known or undiagnosed).
- Increasing age, being overweight or obese, and male sex.
- Heart failure.
- Acquired or familial thrombophilia.
- Chronic low-grade injury to the vascular wall (for example, vasculitis, hypoxia from venous stasis, or chemotherapy).
- Risk factors that temporarily raise the likelihood of DVT include:
- Immobility (for example, following a stroke, operation, plaster cast, hospitalization, or during long-distance travel).
- Significant trauma or direct trauma to a vein (for example, intravenous catheter).
- Hormone treatment (for example, oestrogen-containing contraception or hormone replacement therapy).
- Pregnancy and the postpartum period.
- Dehydration.
Basis for recommendation
- The risk factors for deep vein thrombosis have known biochemical and physiological mechanisms and have been documented by observational studies [Lopez et al, 2004].
When should I suspect deep vein thrombosis?
- Consider the possibility of deep vein thrombosis (DVT) if typical symptoms and signs are present, especially if the person has risk factors:
- Pain and swelling developing in one leg, although both legs may be affected.
- Tenderness, changes to skin colour and temperature, and vein distension.
- Also consider an alternative cause for the symptoms and signs.
- Use the Wells Clinical Prediction Rule to assess the likelihood of DVT and inform further management (see Management of DVT).
Basis for recommendation
- Recommendations for suspecting deep vein thrombosis (DVT), and possible differential diagnoses, are based on expert opinion in narrative reviews [Anand et al, 1998; Gorman et al, 2000; Tovey and Wyatt, 2003].
- Individual symptoms and signs are, on their own, poorly predictive of the presence or absence of DVT [Goodacre et al, 2005].
- Therefore, the diagnosis of DVT should be made using a clinical prediction guide such as the Wells Clinical Prediction Rule, which is scored using the sum of the most sensitive and specific risk factors and signs (see Management of DVT).
- Homans' sign (pain in the calf or popliteal region on passive, abrupt, forceful dorsiflexion of the ankle with the knee in a flexed position) is not now used in the assessment of DVT, as it is insensitive and nonspecific, can be painful, and there is a theoretical possibility of dislodging a thrombus.
What else might it be?
- Only about a third of people with clinical suspicion of deep vein thrombosis (DVT) have the condition. Other conditions which may present with similar signs and symptoms include:
- Physical trauma, for example:
- Calf muscle tear or strain.
- Haematoma (collection of blood) in the muscle.
- Sprain or rupture of a leg tendon.
- Fracture.
- Cardiovascular disorders, for example:
- Superficial thrombophlebitis — see the CKS topic on Thrombophlebitis - superficial.
- Post-thrombotic syndrome — see the CKS topic on Leg ulcer - venous.
- Venous obstruction or insufficiency, or external compression of major veins (for example, by fetus, cancer).
- Arteriovenous fistula and congenital vascular abnormalities.
- Vasculitis.
- Heart failure.
- Other conditions include:
- Ruptured Baker's cyst (a Baker's cyst forms behind the knee from an out-pouching of the synovial membrane of the knee joint, and is a common complication of arthritis).
- Cellulitis (commonly mistaken as DVT).
- Dependent (stasis) oedema.
- Lymphatic obstruction.
- Septic arthritis.
- Cirrhosis.
- Nephrotic syndrome.
Basis for recommendation
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