|Year : 2013 | Volume
| Issue : 1 | Page : 10-14
Clinical profile and management of deep vein thrombosis of lower limb
L Chinglensana1, Santhosh Rudrappa1, K Anupama2, T Gojendra1, Kala K Singh1, Sudhir T Chandra1
1 Department of Surgery, Regional Institute of Medical Sciences, Imphal, India
2 Department of Anatomy, Regional Institute of Medical Sciences, Imphal, India
|Date of Web Publication||17-Aug-2013|
Department of General Surgery, Regional Institute of Medical Sciences, Imphal, Manipur - 795 004
Source of Support: None, Conflict of Interest: None
Background: In India, the incidence of deep vein thrombosis (DVT) is not well highlighted and literature survey shows scanty works in this field. Most of the literature available in India is from the orthopaedic departments, overall incidence of DVT in general population is largely unknown. Materials and Methods: A 2 year prospective study to analyze the clinical profile and management of DVT of lower limb was conducted at Regional Institute of Medical Sciences, Imphal. Patients having limb pain, swelling with or without skin changes suspected of DVT were subjected to Doppler examination. Thirty-one patients with Positive test were admitted and treated with standard regimens of low molecular weight heparins (LMWH), oral warfarin, compressive stockings and supportive care. The risk factors, response to treatment, clinical course were documented using physical examination and relevant laboratory tests at regular intervals. The data was prospectively analyzed. Results: Majority of patients were less than 45 years old with no sex preponderance. No risk factors were identified in 45%, 26% had lower limb fractures, Seven percent were pregnancy related and cellulitis, electric burns, antecedent blunt Trauma, Systemic lupus erythematosis were observed in three percent of patients each. Ten percent of patients had history of immobilization due to medical illness. There was excellent response to LMWH in 93.54% of patients with two poorly responding patients requiring mechanical thrombectomy using Fogarty venous thrombectomy balloon catheter. No significant hemorrhagic complication or pulmonary embolism encountered clinically. No recurrent thrombosis or Malignancy noted during 6-16 months. Conclusion: Most of the DVTs are idiopathic and occur in less than 45 years age group. Irrespective of the etiology, LMWH and Warfarins are efficient, safety is well demonstrated, and domiciliary treatment is advisable with surveillance. Idiopathic DVTs require long term follow up to watch for recurrent thrombosis. Owing to small sample size the data cannot be extrapolated to general population to conclude the incidence. Further studies are necessary to stratify risks, and incidence in our Indian population.
Keywords: Deep Vein Thrombosis, India, Low molecular weight heparins
|How to cite this article:|
Chinglensana L, Rudrappa S, Anupama K, Gojendra T, Singh KK, Chandra ST. Clinical profile and management of deep vein thrombosis of lower limb. J Med Soc 2013;27:10-4
|How to cite this URL:|
Chinglensana L, Rudrappa S, Anupama K, Gojendra T, Singh KK, Chandra ST. Clinical profile and management of deep vein thrombosis of lower limb. J Med Soc [serial online] 2013 [cited 2020 Apr 6];27:10-4. Available from: http://www.jmedsoc.org/text.asp?2013/27/1/10/116623
| Introduction|| |
Venous thromboembolism commonly manifests as deep vein thrombosis of the leg, but it may also occur in other veins like cerebral sinus, veins of the arm, retina and mesentery.  According to American Heart Association, more people suffer from deep vein thrombosis (DVT) annually than heart attack or stroke. The incidence of DVT in the general population has been estimated to be 80-100 per 1,00,000 annually in the western societies,  4-75 per 1,00,000 in South-Asia  . In India, the incidence of DVT is not well highlighted and literature survey shows scanty works in this field. Most of the literature available in India is from the orthopaedic departments, overall incidence of DVT in general population is largely unknown. ,,,,, The routine applicability of prophylactic anticoagulation  in our patients is also not well defined.
This is a prospective study to document the patient profile of DVT, study the effectiveness and safety of treatment modalities at our center.
| Materials and Methods|| |
The study was conducted from September 2009 to September 2011. It was a prospective study and approved by the Institutional Ethical Committee.
Doppler sonography confirmed deep vein thrombosis of lower limb with patient not on anticoagulant medications before diagnosis for other causes were included for the study.
All patients with symptoms and signs were screened with Doppler and if found positive were admitted. Consent for participation in the study was obtained. Detailed history was taken to assess risk factors. Level of Immobility if present was graded after Sharma et al. Initial treatment of acute DVT of the lower limb was done by body weight-adjusted dose of Low molecular weight heparin (LMWH), Dalteparin sodium, (100 IU/kg) administered subcutaneously in the gluteal region twice daily for 10-14 days under monitoring of PT-INR (Prothrombin Time and International Normalised Ratio). Ambulation, as tolerated, was advised along with elastic compression stockings. Warfarin sodium (0.2 mg/kg) was started the following day; modification was done depending upon the individual variation and INR, and continued for at least 3 months. Limb elevation was advised for at least 8 hours in a day during treatment. The patients were examined daily and clinical features recorded. Doppler ultrasonography was repeated after first and second weeks of initial treatment bilaterally.
In patients with femoropopliteal DVT of recent onset, who despite appropriate LMWH therapy were at risk of limb gangrene secondary to venous obstruction were treated with surgical thrombectomy. Systemic antibiotics, tissue enzyme Serratiopeptidase, analgesics were used as necessary.
Statistical tests were applied wherever necessary with P < 0.05 as significant level.
| Results and Observations|| |
The patient profile, risk factors associated, DVT characteristics and response to treatment are summarised in [Table 1], [Figure 1], [Table 2] and [Table 3] respectively.
|Table 1: Summary of patient particulars, DVT characteristics and management strategy used |
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|Table 2: Age and sex distribution of patients with deep vein thrombosis |
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| Discussion|| |
Thirty-one patients with lower limb DVT were included in the study and treated in the Cardiovascular and Thoracic Surgery Unit of the Department of Surgery, Regional Institute of Medical Sciences (RIMS) Hospital, Imphal and analyzed.
Prevalence and Incidence of Deep Vein Thrombosis
The life-time prevalence of DVT is 3.1% and tends to rise towards older age groups, and it is higher in women (3.5%) compared with men (2.4%)  . The age of the patients with DVT ranged from 16 years to 75 years (mean 41 years). In contrast to other studies, most of our patients were <45 years (72.97%). Differences in study designs may be the main reason behind this variability. There were 16 (51.61%) male patients and 15 (48.39%) female patients. The difference in sex was not found to be significant (Calculated Value (C.V.)=0.80; IZI < 1.96; P < 0.05) in our study. However, we observed an increasing trend with age only in females. Swollen, painful limb was the commonest presentation.
Twenty-one patients (67.74%) belonged to middle-class family and majority of them were sedentary workers.
Risk Associations of Deep Vein Thrombosis
Patients undergoing surgical procedures are known to be at risk of post-operative DVT, the incidence being highest for major orthopaedic surgeries, also frequently in surgeries involving urogenital and abdominal cancers. ,,,,,, Though none of our patients had abdominal or pelvic surgery as antecedent factor, majority had lower limb fractures (26%), more common in the elderly age group, immobilization due to other causes like chronic obstructive pulmonary disease with pneumonia (3%), electrical burns (3%), cellulitis (3%), blunt injury to ipsilateral limb (3%) were associated. DVT occurred in the 1 st fortnight of postpartum in two females (6%) without any signs of cortical vein thrombosis which is more common in pregnancy and post partum. Antiphospholipid antibody in systemic lupus erythematosis (SLE) was noted in (3%).
Electrical burns are reported to cause DVT in 6.5%-7.2% patients, with highest risk in patients with high Caprini scores, high total body surface area burns and the patients needing fasciotomy. , However, our patient suffered DVT 20 days after electric burns with no other high-risk Caprini events. DVT is still rare in our experience with thermal burns irrespective of TBSA with no reported DVT case in our centre (personal communication) during the study period at least, doubting its temporal rather than causative association.
Though apparently DVT following leg trauma is more common in our sample, we feel that the Caprini score predicting a 40% risk in such patients is a overestimation for our Indian population considering the overall DVT being around 8/450 leg fractures in our experience. Ramesh K Sen, et al.  reports 14.49% (40/276) incidence of DVT in patients of trauma excluding spinal fractures. Based on the available Indian orthopaedic literature To date, the authors summarises that many advocate prophylactic anticoagulation in major orthopaedic trauma at least in high risk patients after ascertaining the absence of contraindications, or mechanical prophylaxis if any contraindication exist.
None of the patients had known malignancy at diagnosis or during our short follow-up (6-16 months). Though mostly associated with superficial vein thrombosis, occult carcinoma especially genitourinary, pancreatic, intra-thoracic malignancy are reported to be diagnosed within 2 years of follow up in some studies.  In contrast to increased postoperative risks especially following colorectal cancer surgeries in the West, we found no such association in our patients similar to Tata Memorial Institute's experience. 
Interestingly fourteen patients (45%) were apparently healthy similar to study by Pilger et al.  No proven risk factor could be associated with them though history of long haul air travel of 4.5 hours in one patient did not qualify to be a risk factor in light of few studies associating risk with more than 8 hours.  These cases probably represent the genetic factors risking DVT and may also be a first sign of occult malignancy which some studies have reported. 
The most commonly reported risk factor in the younger age group by Kreidy et al.  were inherited thrombophilia (46.9% compared with 13.8% in the control group; P < 0.001), pregnancy (18.2% compared with 0.5%; P < 0.001). The risk factors  like oral contraceptive pills, inflammatory bowel disease, nephritic syndrome, obesity, sepsis, stroke, family history of DVT were absent in our patients.
Routine genetic testing was not done for coagulation abnormalities due to lack of essential services and cost factors. Majority were calf DVTs (83.84%) irrespective of aetiology similar to few studies but in contradistinction to caucasoids. ,[ 7]
| Treatment|| |
Pharmacotherapy and Physical Measures
Our therapeutic anticoagulation level seems optimal as evidenced by the satisfactory resolution of signs and symptomatic relief in general [Table 4]. All the patients enrolled in our study were in-patients, which enabled us to monitor the daily progress and observe any possible bleeding complications though there is an increasing trend towards home treatment with new preparations of LMWH.  Haemorrhage and recurrent venous thromboembolism were less likely to occur with twice daily dosing consistent with our results.  Two of females, had minor episodes of nasal bleeding that subsided spontaneously.
|Table 4: Minimum LMWH injections needed for improvement in clinical signs |
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Our study analysis did not show any alarming fluctuation in the INR values during the whole treatment duration and in follow-up period, as with Tovey, et al.
Two of our patients who poorly responded to anticoagulation underwent thrombectomy under spinal anaesthesia ([Figure 2] and [Figure 3]), both having femoral thrombus extending distally. They did well after surgery, had a longer hospital stay of 28 and 36 days. Thrombectomy should only be considered in special situations such as in descending thrombosis with simultaneous surgical elimination of the external venous drainage or with impending gangrene.  Meta-analysis has also concluded its safety and feasibility, though the level of evidence available was poor. 
|Figure 3 : Percutaneous thrombectomy of the right femoral vein using Fogarty balloon catheter|
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Compression and Active Ambulatory Exercise Therapy
With anticoagulation, compression therapy of the affected limb and the maintenance of mobility are also important which helps to prevent progression of the thrombosis.  A class II elastic stocking up to knee irrespective of DVT site was advised for 2 years, No post thrombotic syndrome was noted, the findings are consistent with Scarvelis, et al.  Compliance to our regimen was good.
Long Term Anticoagulation
All our patients were advised oral anticoagulation for a minimum of three months. As in other series any continuation of anticoagulation beyond this time was done on an individual basis.  The patients with idiopathic DVT and those who underwent thrombectomy were put on warfarin for 6-8 months. We noted no significant hemorrhagic complication or recurrent thrombosis or embolism during follow-up.
| Conclusions|| |
In our two years study, DVT in < 45 year age group is high with unknown risk factors- probably genetic being the most common followed by orthopaedic trauma and immobility due to other medical illness. Sex was equally distributed, with distal DVT being the commonest irrespective of aetiology. Painful swollen limb was the most common presentation.
The clinical symptoms and signs lack sensitivity and specificity. When suspected, Colour Doppler is a reliable non-invasive investigation. Irrespective of the etiology, LMWH are efficient and safe. The length of warfarin therapy should be individualised, weighing haemorrhage and recurrent thrombosis especially in idiopathic DVTs. Further, idiopathic DVTs require long term follow up to watch for recurrent thrombosis. Compression and physical therapy are necessary adjuncts to treatment. Thrombectomy is safe and feasible, should be considered appropriately when the response to medication is poor or the limb is under threat.
Considering the low morbidity and safety, home treatment with LMWH is advocated in consensus with other studies under surveillance. Extrapolation of our incidence to the general population will not be appropriate owing to small sample size. Further studies are warranted to stratify risks and incidence in our population.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]