Pulmonary Embolism Is it the Greatest Danger in Deep Vein Thrombosis?

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Milton Hutchinson
5 years ago
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1 Difficult issues in Deep Vein Thrombosis: Pulmonary Embolism Is it the Greatest Danger in Deep Vein Thrombosis? Raluca Dulgheru; C Gherghinescu; B Dorobat; H Muresan; R Darabont; M Cinteza; D Vinereanu University of Medicine and Pharmacy Carol Davila Emergency and University Hospital Bucharest, Romania

2 Conflict of Interest Disclosure None

3 Woman, 51 years - DAY 1 Obesity, hypertension, type 2 diabetes mellitus, smoker, sedentary No other significant medical history 2 days history of right inferior limb edema and pain - acute onset Clinical examination: Mild fever (37.4ºC); BP 110/60 mmhg, HR 100 bpm, no dyspnea, SaO2 100% Normal heart and lung auscultation Edema and cyanosis of right inferior limb, diminished right retromaleolar arterial pulse;

4 Blood tests: Hb = 10 g/dl WBC = /mm³ N = /mm³ Plt = /mm³ Glucose = 232 mg/dl Serum creatinine = 0.85 mg/dl Fibrinogen = 652 mg/dl D dimer +++ Other tests: DAY 1 Normal ECG Normal chest X-ray No direct/indirect signs of PE on TTE

Clinical diagnosis: Confirmation: DAY 1 right iliofemoral DVT duplex ultrasonography Occlusive thrombosis of the right external iliac vein, common and superficial right

5 Clinical diagnosis: Confirmation: DAY 1 right iliofemoral DVT duplex ultrasonography Occlusive thrombosis of the right external iliac vein, common and superficial right femoral vein No color Doppler signal in the IVC - high probability of IVC thrombosis Normal color Doppler signal in the left iliac and femoral veins Treatment: LMWH (enoxaparin)

6 Change in clinical status: DAY 2 Change in biological status: Sudden dyspnoea Hypothension (90/60 mmhg) Tachycardia (120bpm) Worsening of edema and cyanosis of the inferior right limb Anuria Acute renal failure (creatinine 4 mg/dl; K + 6 meq/l) Anemia (Hb 7 mg/dl) Inflammatory syndrome (WBC /mm³; fibrinogen 900 mg/dl) Rhabodmyolysis (CK 4602 U/L) Clinical diagnosis: acute pulmonary embolism with haemodynamic deterioration

abdominal CT scan: rules out massive PE and identifies the cause of hemodynamic

7 DAY 2 Emergency echocardiography rules out massive PE: normal RV diameter and normal RV systolic longitudinal function (TAPSE 24mm); TTG 24mmHg; Contrast thoracic and abdominal CT scan: rules out massive PE and identifies the cause of hemodynamic deterioration IVC thrombosis Right pulmonary Right RV thrombosis inferior lobar artery thrombosis

8 DAY 2 Change of diagnosis: IVC thrombosis Right RV thrombosis Extensive right iliofemoral thrombosis Minor PE Acute RF (postrenal cause) Severe anemia (erythrocyte entrapment) Rhabdomyolysis (compartment syndrome) Change of strategy: UFH continuous IV, aptt guided Catheter directed thrombolysis (t-pa 5 mg bolus; 2mg/h) Hemodialysis

9 DAY 2 Confirmation by venography with left femoral vein approach and intrathrombus placement of the catheter for CDT

10 DAY 3 (24h after starting CDT+UFH) Control venography with intermediate result Balloon angioplasty of IVC

11 DAY 3 (24h after starting CDT+UFH) Catheter placement at the level of right RV and continuous CDT

12 DAY 4 (48h after starting CDT+UFH) Hemodynamically stable No embolic events CDT continued for 4 days UFH continued for 10 days Hemodialysis (5 sessions), until recovery of diuresis Antibiotics Insulin Venography: patency of right RV and IVC

13 What causes of IVC thrombosis to rule out? Occult cancer Nephrotic syndrome Thrombophilic disorders Abdominal compression syndrome Hormonal substitution therapy Systemic lupus Thyroid disorders Ruled out Obesity Diabetes mellitus Smoking Sedentarism +/-hyperviscosity Present

14 Complications Right thigh hematoma with mild compartment syndrome and secondary anemia HIT Transient bacteriemia with Acinetobacter Intestinal dysmicromism Paroxysmal atrial fibrilation Bedsore of the sacral region

15 Patient discharged on OAC treatment 8 months after treatment: No clinical signs of post thrombotic syndrome No evidence of PHT on echocardiography Patency of IVC and right iliac and femoral veins on duplex US No recurrent thrombosis Normal renal function

16 Take home messages 1. Pulmonary embolism is not the only life-threatening complication of DVT; 2. Extensive iliocaval thrombosis can extend to renal veins and precipitate acute renal failure; 3. Aggressive treatment with mechanical endovascular methods and CDT can improve prognosis for the renal function and the post thrombotic syndrome; this requires a multidisciplinary approach. 4. Current guidelines recommend in cases of endovascular procedures addition of lytic therapy, but no standard regimens are established;

17 Always trust your clinical judgment and.. on your patient!

Venous Thrombosis. Magnitude of the Problem. DVT 2 Million PE 600,000. Death 60,000. Estimated Cost of VTE Care $1.5 Billion/year.

Venous Thrombosis. Magnitude of the Problem. DVT 2 Million PE 600,000. Death 60,000. Estimated Cost of VTE Care $1.5 Billion/year. Venous Thrombosis Magnitude of the Problem DVT 2 Million Postthrombotic Syndrome 800,000 PE 600,000 Death 60,000 Silent PE 1 Million Pulmonary Hypertension 30,000 Estimated Cost of VTE Care $1.5 Billion/year