Thromboembolic Disorders PDF

Approach to the Thromboembolic Disorders Prof. Koray Ak, M.D. MU School of Medicine Dept of Cardiovascular Surgery Istanbul Turkey @dr.korayak  ???? Which of the followings is not true about "6 P" sign? A. Pulsenessness B. Parasthesia C. Peeling D. Pallor E...

Approach to the Thromboembolic Disorders Prof. Koray Ak, M.D. MU School of Medicine Dept of Cardiovascular Surgery Istanbul Turkey @dr.korayak  ???? Which of the followings is not true about "6 P" sign? A. Pulsenessness B. Parasthesia C. Peeling D. Pallor E. Pain  ???? Choose the correct choice about thromboembolic disorders (TE)? A. Infective endocarditis is the most common cause for the TE material originated from the heart B. Factor V leiden disease is a well known cause for arterial TE disorders C. Pulmonary embolism is regarded as an arterial TE disorder D. Blue toe syndrome results from macroembolic TE disorders. E. Anticoagulation with Heparin is essential in the medical management of TE disorders.  ???? Which of the followings is true about the treatment of acute limb ischemia? A: After a 2 hour period of ischemia in lower limbs, patients may end up with irreversible alterations like necrosis of a leg B: Anticaogulation is preferred in the treatment of chronic, not acute, limb ischemia C: Patients with acute limb ischemia often have the symptoms of pulmonary embolisms concurrently D: Embolectomy is a method of treatment in the majority E: Paresthesis and Paralysis are both early symptoms of acute limb ischemia  ???? Which of the followings is not true about deep venous thrombosis? A: Physical examination usually shows “Six P sings” B: Immobility is accepted to be a major risk factor C: Anticoagulation should be prescribed in the treatment D: Pulmonary embolism is a life threatening complication of deep venous thrombosis E: Measurement of blood level of D -dimer is not a great deal in the diagnosis  Thromboembolic Disorders What is thrombosis ? – Blockage of vein or artery by a clot Why ? – Damaged vessel wall – Reduced blood flow – ↑ Coagulation – Combination Thromboembolic disorders THROMBOSIS EMBOLISM  Thromboembolic Disorders ARTERIAL VENOUS Arterial TE disorders Arterial Thromboembolic Disorders Acute Arterial Emboli Cardiac Noncardiac – Atrial Fibrillation AAA – Mitral Stenosis Atherosclerosis – Intracardiac Thrombi – Endocarditis what are the menifestation of arterial evebtn ? Arterial Thromboembolic Disorders Extremities Brain “ stroke” Heart “ myocardial infarction ” GIS “ mesenteric ischemia” Lungs “ pulmonary emboli ” Other organs Arterial Thromboembolic Disorders 6P signs are sings of arterial thromboembolic disorder not venous Major Signs in extremities (6P) – Pain – Numbness and Tingling “Paresthesias” – Pale color – Pulselessness (Absence or decreased Pulse) – ↓ temparature “palor” – Weakness and eventually Paralysis Arterial Thromboembolic Disorders Diagnosis – Physical Exam Pulseness Pain Palor Pale color Paralysis Paresthesis Diagnosis can be done with PE in the majority of these patients presence of one or more than one of those findings. – Doppler ultrasonography – DS or CT-MRI angiography Arterial Thromboembolic Disorders Triphasic-Biphasic-Monophasic flow Arterial Thromboembolic Disorders Arterial Thromboembolic Disorders Treatment Surgery in first 6 to 8 hours – Embolectomy – Bypass Medical treartment as an adjunct Anticoagulation Heparin Antiplatelet agents EMBOLECTOMY Surgical Embolectomy Procedure Differantial Diagnosis BUERGERS DISEASE ATHEROSCLEROSİS OBLITERANS  Venous Thromboembolism Two major clinical manifestations Deep vein thrombosis ( DVT ) Pulmonary embolism is not caused of arterial thrombosis it is caused bu deep vain thrombosis Pulmonary Embolism  Deep vein thrombosis (DVT)  Thrombus in one or more deep veins - legs >>> arms - portal, mesenteric, splenic, cerebral, renal  Proximal DVT - Popliteal  iliac veins - Lead to >90% of PE  Distal or calf DVT - Distal to popliteal - Posterior tibial, peroneal veins - Most calf DVT asymptomatic - Rarely lead to PE  Superficial thrombosis - Not DVT; don’t lead to PE Deep Vein Thrombosis  What Causes the Blood to Clot when it Should (and Shouldn’t)? Activation of Venous coagulation stasis THROMBOSIS Injury to the blood vessel wall Virchow’s Triad  Risk Factors for VTE  Major surgery  Previous VTE  Trauma – major, local leg  Family history of VTE  Cancer (some)  Thrombophilia: - Factor V Leiden  Cancer treatments - Prothrombin 20210A  Immobilization – bedrest, - Deficiency of AT, Pr C, Pr S stroke, paralysis - Antiphospholipid antibody  Acute medical illness  Increased age  Acute infection  Obesity  Acute or chronic inflammatory diseases  Etc  Estrogen, pregnancy, postpartum Whenever a patient develops DVT or PE, ask the question: “Why did this happen?” 70 yo woman with breast cancer 3 years ago, on tamoxifen, family history of VTE who develops acute DVT after a hernia repair DVT Why did this happen?  VTE is often multifactorial age Predisposing factors hernia repair DVT tamoxifen Triggering + FH, ?coag factor abnormality ? Genetic factor  Deep Vein Thrombosis Diagnosis – History – Physical Exam Suspect !!!!!!!! – Doppler USG ??? – MRI – Venography – Fibrin Degradation product d-dimer  Deep Vein Thrombosis History – Sudden onset pain – Risk factors!! In aortic thrombosis we Physical examination see 6p and in vain thrombosis we – Swelling see homans signs – Prominent superficial veins – Homans’ sing: pain on dorsiflexion of the foot Deep Vein Thrombosis  Deep Vein Thrombosis Signs – Pain – Red swollen extremities – İncreased skin temparature Venous thrombophilia – Reccurent venous thrombosis – F V Leiden: subs of glutamine for arginine and is activated protein C resistance – More prevelant in caucasians  Deep Vein Thrombosis Differantial Diagnosis – Cellulitis – Heart Failure with edema – Ruptured Bakers Cyst – Chronic Venous insufficiency  Deep Vein Thrombosis SUSPECT DVT? Start Heparin and order Doppler Doppler negative Low suspicion Doppler poor Doppler positive Withhold tx Venogram MRI Still ? Continue Heparin Repeat doppler 2-3 days And start warfarin  Deep Vein Thrombosis Treatment – Heparin – Antiaggregan : ASA, Clopidogrel – Warfarin – IVC Filters  Deep Vein Thrombosis Post-phlebetic syndrome Occurs in 10-30 % of DVT pts Loss of deep venous valvular function Signs – Pain – Edema – Skin Discoloration – Ulceration Loss of Valvular Function after DVT Post-phlebetic Syndrome  Pulmonary Emboli Untreated DVT causes PE in 30-50%