Deep Venous Thrombosis
and its Complications
M.A.Kubtan M.D-F.R.C.S.(U.K)
Dept of General Surgery
Al Mouasat University Hospital
Damascus
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The Role of Clotting
In the blood vascular system
the clotting mechanism guards
against the danger of
haemorrhage
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Thrombosis
Is the formation of a solid mass
( Thrombus ) in the circulation from
the constituents of streaming blood
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Causes of Phlebothrombosis
Changes in the vessel Wall .
 Changes in the Blood flow .
 Changes in the composition of the
Blood .

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Changes in the Vessel Wall
Pressure on the veins by the heavy
calf tissues when the patient is
immobilised in bed .
 Local hypoxia due to pressure on
the vessles associated with
immobility .
 Direct trauma by a fracture edges .
 Ill applied tourniquets and plaster
of Paris .

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The Blood Flow
Stasis (The usual cause of venous thrombosis)
 Increased viscosity of blood
 In polycythaemia Vera
 Dehydration
 Eddy Current

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The Composition of Blood
Platelets ( Thrombocytosis ).
 Clotting Factors .

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Platelets
Thrombocytosis
Transient ( after Parturition, Trauma,
Sever Haemorrhage, and
after Splenectomy ).
Persistent ( Polycythaemia Vera ).
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Platelets Function
Platelet Aggregation .
 Platelet Adhesiveness .

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The Role of Clotting Mechanism
The Clotting Time Is shortened after
 Sever Haemorrhage .
 Trauma .
 Sever Infections ( Typhoid Fever ).
 Administration of Corticosteroids .
 Oral Contraceptive .
 Lipaemia shortens the clotting time and
inhibits fibrinolysis .
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Venous Thrombosis
Thrombophlebitis .
 Phlebothrombosis .

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Thrombophlebitis
is a condition in which there is
both inflammation and a blood
clot in a vein.
Thrombophlebitis can occur in
either superficial or deep
veins.
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Phlebothrombosis



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It is essentially due to Stasis .
It may be caused by local injury to the
venous endothelium .
There is no obvious local infective
element.
It is common postoperative compliction
Frequently encountered in Heart
disease .
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A DVT is a condition
where in a blood ,clot
(thrombus) forms in a
vein of the deep system.
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Pathogenesis of Phlebothrombosis
1.
2.
3.
4.
5.
Primary platelet Thrombus .
The Coralline Thrombus .
Occluding Thrombus .
Consecutive Clot .
Propagated Clot .
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Primary Platelet Thrombosis
‫خثرة الصفيحات البدئية الشاحبة‬



Platelet adhere to the vein wall and aggregate
to form a pale thrombus .
This allows clotting factors to accumulate in
the area .
Promote an increase in the fibrin element .
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Coralline Thrombus
‫الخثرة المرجانية اللون‬
A mixed thrombus

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Due to fibrin deposition on the primary
platelet thrombus .
Leads to further platelet deposition
Consist of alternate layers of fused platelets
and fibrin with entrapped blood cells .
They are bent in the direction of blood flow .
Ripple appearance (Line of Zahn ) .
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Occluding Thrombs
‫الخثرة السادة‬
The growth of coralline thrombus
progressively occludes the vein .
 Composed of blood clot with
smaller platelet element.
 It is red.

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Consecutive Clot
‫الخثرة المتعاقبة‬

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Once the vein is occluded
The stationary column of blood undergoes
coagulation forming a Consecutive clot .
When consecutive clot extend to the next
venous tributary it may become
endothelialised , or there is the development
of more thrombus or clot.
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Propagated Clot
‫الخثرة المتمادية‬


When clot reaches to the entrance of venous
tributary , it may lead to formation of another
consecutive clot .
Stagnation of column of blood above the
consecutive clot may produce propagated clot
en mass .
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A thrombosis in a deep vein is a
much more serious problem than
one in a superficial vein. The
reason for this is that a piece of
the clot in DVT may break off and
travel through the deep veins
back to the heart, and eventually
be pumped by the heart into the
arteries of the lung.
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DVTs can occur anywhere in
the body but are most
frequently found in the deep
veins of the legs, thighs, and
pelvis.
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DVT is a common condition that
affects almost 2 million
Americans each year. Among
patients with DVT, pulmonary
embolism will occur in 30%.
Pulmonary embolism causes
600,000 deaths each year.
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What Are The Symptoms of a
DVT
In the affected leg
swelling
 Pain
 no symptoms at all unless the
clot dislodges

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Common Sites Affected by
Thrombosis

Deep Veins of the Calf .

It may extend to PTV or the POPV.

At the beginning of Femoral Vein .

Commonly in Lt CIV due to
pressure from the Rt CIA .

Following Pelvic Operation .
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Plsmatic D-dimers
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Fibrin is the main constituent of a thrombus.
Its formation is rapidly followed by activation
of fibrionlytic system leading to lysis of fibrin
clot.
Dissolution of stabilized fibrin releases specific
breakdown products D-dimers (DD).
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DD assay as a useful first stage
diagnostic tool
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Negative result can rule out
thromboembolic event.
False positive ( Specificity 40% ).
Test used
1. ELISA (Enzyme-linked
immunosorbant assays ).
2. Latex tests less sensitive .
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Venography
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MR
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Special Clinical Types
Phlegmasia alba dolens.
 Phlegmasia Coerulea dolens.
 Trousseu,s Syndrome.
 Pregnancy-related thrombosis.

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Iliac Femoral Vein Thrombosis
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Isotope Scan
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
Local Causes
i ) lack of Muscular Activity .
ii ) Incompetent Valves .
iii ) Pressure from outside ( Tumours, Ascites ,
Plasters and Bandages .)
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Predisposing Factors
1. Fatal complication of D.V.T.
2. Secondary to non surgical disorders.

Congestive Heart Failure.

Cerebrovascular Accidents.

Chronic Pulmonary Diseases.

Systemic Infection.

Disseminated Carcinomatosis.

Miscellaneous.
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Size
An emboli prove fatal if it measures
1.5 cm in diameter and 50 cm or more
in length.
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Areas are commonly affected
Rt pulmonary artery is more commonly
affected than the left.
 Lower lobes are more commonly affected
than the upper lobes.

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Origin of PE
80% originated from iliac and
femoral veins.
20% originated from I.V.C. ,
Subclavien, Axillary, Internal jagular,
Cavernous Sinuses of the Brain, and
Cardiac Tumors arising in the Rt
Atrium or Rt Ventricle.

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Prevention of PE
Preventing the occurrence of D.V.T.
 Early ambulation.
 Elevation of lower extremities.
 Elastic stockings.
 Mechanical compression.
 Anti platelets agents (Aspirin, Dipyridamol).
 S/C LMWH
 Insertion of stainless steel Umbrella
( Greenfield).
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Complications of Umbrella
Migration.
Protrusion
of struts through the
 caval wall.
Formation of thrombus.
Misplacement of the umbrella.
Retroperitoneal haemorhage.
Perforation of duodenum and
 ureter.
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The Massage
As a precaution installation of the
Greenfield umbrella should be the
treatment of choice to combat the
risk of fatal pulmonary embolus
whenever possible
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