Venous thrombosis

Venous thrombosis
A deep vein thrombosis in the right leg. Note the swelling and redness.
Classification and external resources
Specialty
ICD-10	I80-I82
ICD-9-CM	453
Patient UK	Venous thrombosis
MeSH	D020246

A venous thrombus is a blood clot (thrombus) that forms within a vein. Thrombosis is a term for a blood clot occurring inside a blood vessel. A common type of venous thrombosis is a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. If the thrombus breaks off (embolizes) and flows towards the lungs, it can become a life-threatening pulmonary embolism (PE), a blood clot in the lungs.

When a blood clot breaks loose and travels in the blood, this is called a venous thromboembolism (VTE). The abbreviation DVT/PE refers to a VTE where a deep vein thrombosis (DVT) has moved to the lungs (PE or pulmonary embolism).

An inflammatory reaction is usually present, mainly in the superficial veins and, for this reason this pathology is called most of the time thrombophlebitis. In fact, the inflammatory reaction and the white blood cells play a role in the resolution of venous clots.

Classification

Superficial venous thromboses cause discomfort but generally not serious consequences, as do the deep venous thromboses (DVTs) that form in the deep veins of the legs or in the pelvic veins. Nevertheless, they can progress to the deep veins through the perforator veins or, they can be responsible for a lung embolism mainly if the head of the clot is poorly attached to the vein wall and is situated near the sapheno-femoral junction. Clinical trials suggest that fondaparinux, a direct factor Xa inhibitor, reduces extension and recurrence of superficial venous thrombosis, and progression to symptomatic embolism.

Since the veins return blood to the heart, if a piece of a blood clot formed in a vein breaks off it can be transported to the right side of the heart, and from there into the lungs. A piece of thrombus that is transported in this way is an embolus: the process of forming a thrombus that becomes embolic is called a thromboembolism. An embolism that lodges in the lungs is a pulmonary embolism (PE). A pulmonary embolism is a very serious condition that can be fatal depending on the dimensions of the embolus. Venous thromboembolism (VTE) refers to both DVTs and PEs.

Systemic embolisms of venous origin can occur in patients with an atrial or ventricular septal defect, through which an embolus may pass into the arterial system. Such an event is termed a paradoxical embolism.

Causes

Venous thrombi are caused mainly by a combination of venous stasis and hypercoagulability—but to a lesser extent endothelial damage and activation. The three factors of stasis, hypercoaguability, and alterations in the blood vessel wall represent Virchow's triad, and changes to the vessel wall are the least understood. Various risk factors increase the likelihood of any one individual developing a thrombosis.

Risk factors

• Acquired
  • Older age
  • Major surgery and orthopedic surgery
  • Cancers, most particularly pancreatic, but not cancers of the lip, oral cavity, and pharynx
  • Immobilization, as in orthopedic casts the sitting position, and travel, particularly by air
  • Pregnancy and the postpartum period
  • Antiphospholipid syndrome (such as lupus anticoagulant)
  • Trauma and minor leg injury
  • Previous VTE
  • Oral contraceptives
  • Hormonal replacement therapy, esp. oral
  • Central venous catheters
  • Inflammatory diseases/some autoimmune diseases
  • Nephrotic syndrome
  • Obesity
  • Infection
  • HIV
  • myeloprolirative neoplasms including essential thrombocytosis and
  • Polycythemia vera
  • Chemotherapy
  • Heart failure

• Inherited
  • Antithrombin deficiency
  • Protein C deficiency
  • Protein S deficiency (type I)
  • Factor V Leiden
  • Prothrombin G20210A
  • Dysfibrinogenemia
  • Non O-blood type

• Mixed
  • Low free protein S
  • Activated protein C resistance
  • High factor VIII levels
  • Hyperhomocysteinemia
  • High fibrinogen levels
  • High factor IX levels
  • High factor XI levels

The factor V protein is mutated in carriers of factor V Leiden, which is the most common inherited DVT risk factor.

The overall absolute risk of venous thrombosis per 100.000 woman years in current use of combined oral contraceptives is approximately 60, compared to 30 in non-users. The risk of thromboembolism varies with different types of birth control pills; Compared with combined oral contraceptives containing levonorgestrel (LNG), and with the same dose of estrogen and duration of use, the rate ratio of deep venous thrombosis for combined oral contraceptives with norethisterone is 0.98, with norgestimate 1.19, with desogestrel (DSG) 1.82, with gestodene 1.86, with drospirenone (DRSP) 1.64, and with cyproterone acetate 1.88. Venous thromboembolism occurs in 100–200 per 100.000 pregnant women every year.

Regarding family history, age has substantial effect modification. For individuals with two or more affected siblings, the highest incidence rates is found among those ≥70 years of age (390 per 100 000 in male and 370 per 100 000 in female individuals), whereas the highest incidence ratios compared to those without affected siblings occurred at much younger ages (ratio of 4.3 among male individuals 20 to 29 years of age and 5.5 among female individuals 10 to 19 years of age).

Pathophysiology

In contrast to the understanding for how arterial thromboses occur, as with heart attacks, venous thrombosis formation is not well understood. With arterial thrombosis, blood vessel wall damage is required for thrombosis formation, as it initiates coagulation, but the majority of venous thrombi form without any injured epithelium.

Red blood cells and fibrin are the main components of venous thrombi, and the thrombi appear to attach to the blood vessel wall endothelium, normally a non-thrombogenic surface, with fibrin. Platelets in venous thrombi attach to downstream fibrin, while in arterial thrombi, they compose the core. As a whole, platelets constitute less of venous thrombi when compared to arterial ones. The process is thought to be initiated by tissue factor-affected thrombin production, which leads to fibrin deposition.

The valves of veins are a recognized site of VT initiation. Due to the blood flow pattern, the base of the valve sinus is particularly deprived of oxygen (hypoxic). Stasis excacerbates hypoxia, and this state is linked to the activation of white blood cells (leukocytes) and the endothelium. Specifically, the two pathways of hypoxia-inducible factor-1 (HIF-1) and early growth response 1 (EGR-1) are activated by hypoxia, and they contribute to monocyte and endothelial activation. Hypoxia also causes reactive oxygen species (ROS) production that can activate HIF-1, EGR-1, and nuclear factor-κB (NF-κB), which regulates HIF-1 transcription.

HIF-1 and EGR-1 pathways lead to monocyte association with endothelial proteins, such as P-selectin, prompting monocytes to release tissue factor filled microvesicles, which presumably initiate fibrin deposition (via thrombin) after binding the endothelial surface.

Prevention

Evidence supports the use of heparin in people following surgery who have a high risk of thrombosis to reduce the risk of DVTs; however, the effect on PEs or overall mortality is not known. In hospitalized non-surgical patients, mortality decreased but not statistically significant. Heparin may also decrease the risk of PE and DVT, but it increases major bleeding events yielding little or no overall clinical benefit. It does not appear however to decrease the rate of symptomatic DVTs. Using both heparin and compression stockings appears better than either one alone in reducing the rate of DVT.

In hospitalized people who have had a stroke and not had surgery, mechanical measures (compression stockings) resulted in skin damage and no clinical improvement. Data on the effectiveness of compression stockings among hospitalized non-surgical patients without stroke is scarce.

The American College of Physicians (ACP) gave three strong recommendations with moderate quality evidence on VTE prevention in non-surgical patients: that hospitalized patients be assessed for their risk of thromboembolism and bleeding before prophylaxis (prevention); that heparin or a related drug is used if potential benefits are thought to outweigh potential harms; and that graduated compression stockings not be used. As an ACP policy implication, the guideline stated a lack of support for any performance measures that incentivize physicians to apply universal prophylaxis without regard to the risks. Goldhaber recommends that people should be assessed at their hospital discharge for persistent high-risk of venous thrombosis, and that people who adopt a heart-healthy lifestyle might lower their risk of venous thrombosis.

In those with cancer who are still walking about yet receiving chemotherapy LMWH decreases the risk of VTE. Due to concerns of bleeding its routine use is not recommended. In adults who have had their low leg casted or placed in a brace for more than a week, LMWH decreased VTE risk. Following the completion of warfarin in those with prior VTE, long term aspirin is beneficial.

Treatment

Evidence-based clinical guidelines from the American College of Chest Physicians were published in February 2012 for the treatment of VTE. Medications used to treat this condition include anticoagulants such as heparin, fondaparinux and more recently dabigatran has shown promise. Vitamin K antagonists such as warfarin are also commonly used.

See also

• Portal vein thrombosis

External links

• Postgraduate Medicine Journal: A Clinical Review of Venous Thromboembolism