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| REVIEW ARTICLE |
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| Year : 2015 | Volume
: 2
| Issue : 1 | Page : 25-27 |
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Distal Lower Extremity Deep Vein Thrombosis
Indrani Sen, Sunil Agarwal
Department of Vascular Surgery, Christian Medical College, Vellore, Tamil Nadu, India
| Date of Web Publication | 5-Mar-2015 |
Correspondence Address:
Dr. Indrani Sen
Department of Vascular Surgery, Christian Medical College, Vellore, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0972-0820.152830
Distal DVT comprises of thrombosis of the infra-popliteal veins. This subgroup lacks standard clinical practice guidelines due to differing viewpoints on the etiopathogenesis, natural history, treatment and outcome. Most originate in the calf and resolve spontaneously. Detection also depends on the diagnostic modality used with invasive methods like venography yielding a higher incidence. It is seen more often in patients with transient risk factors (recent surgery, recent plaster immobilization, recent travel). Thrombus propagation/ extension can occur in 25%- 36% with symptomatic PE in 6-36%. Recurrence occurs in 4-29 % , chronic venous insufficiency( post thrombotic syndrome) can occur in 4- 23 %. The overall event rate (death, PE, extension, bleeding) is about 5% which can be further lowered with treatment Keywords: Distal, deep vein thrombosis, management
How to cite this article:
Sen I, Agarwal S. Distal Lower Extremity Deep Vein Thrombosis. Indian J Vasc Endovasc Surg 2015;2:25-7 |
| Introduction | |  |
Deep vein thrombosis (DVT) was first described in India by Susruta in his Susruta Samhita. Venous thromboembolism comprising of DVT and pulmonary embolism (PE) has remained a major health burden affecting about 3,00,000 adults/year in the West with a similar incidence emerging in India. Though the disease has existed for years, public awareness about prevention is recent with war correspondents and long distance travelers succumbing to "killer legs" or the "economy class syndrome." Research on DVT, PE and the postthrombotic syndrome has been the focus of research in the last few decades with significant support from industry.
Distal deep vein thrombosis (DDVT) comprises of thrombosis of the infra-popliteal veins: Axial (peroneal, posterior tibial, and/or anterior tibial) veins and/or muscular calf (soleal or gastrocnemius) veins, not involving the popliteal or higher veins. This subgroup lacks standard clinical practice guidelines due to differing viewpoints on the etiopathogenesis, natural history, treatment, and outcome. In this article, we discuss the current evidence towards the necessity of treatment for DDVT.
| Natural History | | |
Most DDVT originates in the calf and resolve spontaneously. It occurs due to an imbalance in the components of Virchow's triad (stasis, vessel wall injury, and hypercoaguability). The activation of the inflammatory and coagulation cascades occurs to a lesser extent than that caused by proximal DVT. This depends to a certain extent on the severity of the prothrombotic stimulus.
Most DDVT is asymptomatic, symptoms usually occur with proximal involvement. Although less common, isolated DDVT has an incidence of about 45% in out-patients and 27% in inpatients tested for symptomatic leg swelling. Common manifestations sch as leg pain, swelling or redness may be present, but the degree of suspicion for DVT should be high; especially in the presence of risk factors. About 99% of patients with documented proximal DVT have involvement of their calf veins. Asymptomatic leg thrombi may be seen in upto 70% of patients with clinically symptomatic PE. Detection also depends on the diagnostic modality used with invasive methods like venography yielding a higher incidence.
Distal deep vein thrombosis is seen more often in patients with transient risk factors (recent surgery, recent plaster immobilization, recent travel). Population estimates of DDVT are not available. Other traditional risk factors for DVT [Table 1] are reported with varying frequencies.
In DDVT, thrombus propagation/extension can occur in 25-36% with symptomatic PE in 6-36%. Recurrence occurs in 4-29%, chronic venous insufficiency (postthrombotic syndrome) can occur in 4-23% [Figure 1]. The overall event rate (death, PE, extension, bleeding) is about 5%, which can be further lowered with treatment.
| Management | | |
Historically, venography has been the "gold standard" for the diagnosis of DVT. However, this is invasive and not clinically feasible - it has been largely replaced by venous duplex and compression ultrasound as the first line investigation in the management of DVT. This is usually combined with assessment of the Wells score and D-dimer. The detection rate of isolated DDVT with ultrasound depends on the examination protocol, with a meticulous examination strategy; the sensitivity is above 90% in dedicated centers. Routine venous ultrasound has a low sensitivity (range, 59.8-67.0%; pooled sensitivity, 63.5%): False negative and positive results need follow-up scans or other diagnostic modalities depending on the clinical scenario.
| Treatment and Prevention | | |
The natural history of thrombus evolution is not well studied with reports of varied rates of incidence and complications. The ideal approach to diagnosis and management of DDVTs is unclear. Although the overall incidence of both isolated calf vein DVT and the complications is lower when compared to proximal DVT; a recent meta-analysis shows that there is a tendency to adverse events in the absence of treatment. The fairly high incidence of these complications is mirrored in clinical practice-the authors feel that the reported rates of complications justify treatment for all symptomatic DDVT. The American College of Chest Physicians (ACCP) recommendations for diagnosis and treatment of DVT of the leg aim to reduce the overall false-negatives to 2% or less (as defined by symptomatic DVT or PE within 3-6 months after a negative test), reduce the risk of fatal PE after testing to <0.1% (1 in 1,000) and reducing the risk of fatal hemorrhage due to anticoagulation to <0.1% (1 in 1,000).
The ACCP recommendations for diagnosis and treatment of isolated DDVT are:
- In nonhospitalized patients with acute isolated distal leg DVT (IDDVT) who do not have severe symptoms or risk factors for proximal extension*, repeat the leg ultrasound at 1 and 2 weeks or sooner (Grade 2C)
- If there are severe symptoms or risk factors for extension [Table 2] in a patient with isolated acute DDVT, treat with initial anticoagulation (Grade 2C).
Treatment must be individualized: Patients who are averse to the hassle and anxiety of repeated ultrasound testing may prefer anticoagulation over serial ultrasounds; other patients at high risk of bleeding may prefer serial ultrasound.
Anticoagulation is prescribed along the same approach as for patients with acute proximal DVT (Grade 1B). In patients managed with serial imaging anticoagulation is recommended if the thrombus extends proximally-even if it remains confined to the distal veins. In patients with an isolated DDVT of the leg provoked by surgery or by a nonsurgical transient risk factor, the ACCP suggests treatment with anticoagulation for 3 months over treatment of a shorter or longer period regardless of bleeding risk. Patients with unprovoked IDDVT may require longer and more intense anticoagulation than those with secondary IDDVT. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14]
Isolated calf muscle vein thrombosis (ICMVT), including soleal and gastrocnemial veins, comprises of 20-40% of calf vein DVT-have a risk of extension to proximal veins. ICMVT anticoagulation has an effect only on unprovoked episodes if risk factors persist while compression therapy/stockings seemed sufficient in low-risk patients.
At present, optimal treatment of IDDVT is still a controversial issue. Different approaches need to be adopted for unprovoked or secondary events as well as for deep or muscle veins, and more studies are needed to investigate the therapeutic and preventive roles of mechanical and pharmacological therapy.
| References | | |
| 1. | Schulman S, Rhedin AS, Lindmarker P, Carlsson A, Lärfars G, Nicol P, et al. A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism. Duration of Anticoagulation Trial Study Group. N Engl J Med 1995;332:1661-5.  |
| 2. | De Martino RR, Wallaert JB, Rossi AP, Zbehlik AJ, Suckow B, Walsh DB. A meta-analysis of anticoagulation for calf deep venous thrombosis. J Vasc Surg 2012;56:228-37.e1. |
| 3. | Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ, et al. Antithrombotic therapy for venous thromboembolic disease: American college of chest physicians evidence-based clinical practice guidelines (8 th Edition). Chest 2008;133 6 Suppl: 454S-545. |
| 4. | Righini M, Bounameaux H. Clinical relevance of distal deep vein thrombosis. Curr Opin Pulm Med 2008;14:408-13. |
| 5. | Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D, et al. Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: Results from the OPTIMEV study. Thromb Haemost 2009;102:493-500. |
| 6. | Kearon C, Ginsberg JS, Anderson DR, Kovacs MJ, Wells P, Julian JA, et al. Comparison of 1 month with 3 months of anticoagulation for a first episode of venous thromboembolism associated with a transient risk factor. J Thromb Haemost 2004;2:743-9. |
| 7. | Palareti G, Schellong S. Isolated distal deep vein thrombosis: What we know and what we are doing. J Thromb Haemost 2012;10:11-9. |
| 8. | Lautz TB, Abbas F, Walsh SJ, Chow C, Amaranto DJ, Wang E, et al. Isolated gastrocnemius and soleal vein thrombosis: Should these patients receive therapeutic anticoagulation? Ann Surg 2010;251:735-42. |
| 9. | Sales CM, Haq F, Bustami R, Sun F. Management of isolated soleal and gastrocnemius vein thrombosis. J Vasc Surg 2010;52:1251-4. |
| 10. | Lagerstedt CI, Olsson CG, Fagher BO, Oqvist BW, Albrechtsson U. Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis. Lancet 1985;2:515-8. [ PUBMED] |
| 11. | Anderson FA, Spencer FA. Risk factors for venous thromboembolism. Available from: http://www.circ.ahajournals.org. [Last cited on 2014 Jan 18]. |
| 12. | Macdonald PS, Kahn SR, Miller N, Obrand D. Short-term natural history of isolated gastrocnemius and soleal vein thrombosis. J Vasc Surg 2003;37:523-7. |
| 13. | Gillet JL, Perrin MR, Allaert FA. Short-term and mid-term outcome of isolated symptomatic muscular calf vein thrombosis. J Vasc Surg 2007;46:513-9. |
| 14. | Schwarz T, Schmidt B, Beyer J, Schellong SM. Therapy of isolated calf muscle vein thrombosis with low-molecular-weight heparin. Blood Coagul Fibrinolysis 2001;12:597-9. |
[Figure 1]
[Table 1], [Table 2]
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