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Deep vein thrombosis

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Deep vein thrombosis



Introduction 

Deep vein thrombosis (DVT) is a blood clot in one of the deep veins in the body.

Blood clots that develop in a vein are also known as venous thrombosis.

DVT usually occurs in a deep leg vein, a larger vein that runs through the muscles of the calf and the thigh.

It can cause pain and swelling in the leg and may lead to complications such as pulmonary embolism. This is when a piece of blood clot breaks off into the bloodstream and blocks one of the blood vessels in the lungs.

DVT and pulmonary embolism together are known as venous thromboembolism (VTE).

 

Who is at risk?

Each year, 1 in every 1,000 people in the UK is affected by DVT.

Anyone can develop DVT, but it becomes more common with age. As well as age, risk factors include:



previous venous thromboembolism



a family history of blood clots



medical conditions such as cancer and heart failure



inactivity – for example, after an operation



being overweight or obese



 

Warning signs

In some cases of DVT, there may be no symptoms, but it is important to be aware of the signs and risk factors of thrombosis.

See your GP as soon as possible if you think you may have a blood clot. DVT can cause pain, swelling and a heavy ache in your leg.

 

Treating DVT

Treatment for DVT usually involves taking anticoagulant medicines, which help reduce the ability of the blood to clot.

You will also be prescribed compression stockings to wear every day, as these help prevent complications and improve symptoms.

Avoiding DVT

There are several things you can do to help prevent DVT occurring, such as stopping smoking, losing weight if you are overweight, and walking regularly to improve the circulation in your legs.

There is no evidence that supports taking aspirin to reduce your risk of developing DVT.

 

 

Assessing risk

Surgery and some medical treatments can increase your risk of developing DVT. It is estimated that 25,000 people who are admitted to hospital die from preventable blood clots each year.

The Department of Health has made the prevention of DVT a priority across. All patients admitted to hospital should be assessed for their risk of developing a blood clot and, if necessary, given preventative treatment.

This recommendation was made by the National Institute for Health and Care Excellence (NICE) in January 2010. For more information, read the 2010 NICE guidelines on Venous thromboembolism – reducing the risk.

 

Symptoms of deep vein thrombosis (DVT) 

In some cases of deep vein thrombosis (DVT) there may be no symptoms, but possible symptoms can include:



pain, swelling and tenderness in one of your legs (usually your calf)



a heavy ache in the affected area



warm skin in the area of the clot



redness of your skin, particularly at the back of your leg below the knee



DVT usually affects one leg, but this is not always the case. The pain may be made worse by bending your foot upward towards your knee.

If DVT is not treated, a pulmonary embolism (a blood clot that has come away from its original site and become lodged in one of your lungs) may occur. 

If you have a pulmonary embolism, you may experience more serious symptoms, such as:



breathlessness, which may come on gradually or suddenly



chest pain, which may become worse when you breathe in



collapsing suddenly 



Both DVT and pulmonary embolism are serious conditions that require urgent investigation and treatment.

 

Causes of deep vein thrombosis (DVT) 

Deep vein thrombosis (DVT) sometimes occurs for no apparent reason. However, the risk of developing DVT is increased in certain circumstances.

 

Inactivity 

When you are inactive your blood tends to collect in the lower parts of your body, often in your lower legs. This is usually nothing to worry about because when you start to move, your blood flow increases and moves evenly around your body.

However, if you are immobile (unable to move) for a long period of time – such as after an operation, because of an illness or injury, or during a long journey – your blood flow can slow down considerably. A slow blood flow increases the chances of a blood clot forming.

 

In hospital

People in hospital have a higher risk of getting a blood clot because DVT is more likely to happen when you are unwell or inactive, or less active than you usually are.

As a patient, your risk of developing DVT depends on the type of treatment you are having. You may be at higher risk of DVT if any of the following apply:



you are having an operation that takes longer than 90 minutes, or 60 minutes if the operation is on your leg, hip or abdomen



you are having an operation for an inflammatory or abdominal condition, such as appendicitis



you are confined to a bed, unable to walk, or spending a large part of the day in a bed or chair for at least three days



You may also be at a higher risk of DVT if you are much less active than usual because of an operation or serious injury and have other DVT risk factors, such as a family history.

When you are admitted to hospital you will be assessed for your risk of developing a blood clot and, if necessary, given preventative treatment.

 

Blood vessel damage

If the wall of a blood vessel is damaged, it may become narrowed or blocked, which can result in the formation of a blood clot.

Blood vessels can be damaged by injuries such as broken bones or severe muscle damage. Sometimes blood vessel damage that occurs during surgery can cause a blood clot, particularly in operations on the lower half of your body.

Conditions such as vasculitis (inflammation of the vein wall), varicose veins and some forms of medication, such as chemotherapy, can also damage blood vessels.

 

Medical and genetic conditions

Your risk of DVT is increased if you have a condition that causes your blood to clot more easily than normal. These conditions include:



cancer – treatments such as chemotherapy and radiotherapy can increase this risk further



heart and lung disease



infectious diseases, such as hepatitis



inflammatory conditions, such as rheumatoid arthritis



thrombophilia – a genetic condition that makes your blood more likely to clot



Hughes syndrome – when your blood becomes abnormally "sticky" 



 

Pregnancy

Pregnancy makes your blood clot more easily. This is your body's way of preventing too much blood loss during childbirth. 

Around 1 in 1,000 pregnant women develop DVT at some point during their pregnancy. See DVT – Helen's story for an example of this.

 

Contraceptive pill and hormone replacement therapy (HRT)

The combined contraceptive pill and hormone replacement therapy (HRT) both contain the female hormone oestrogen. Oestrogen causes the blood to clot slightly more easily, so your risk of getting DVT is slightly increased. There is no increased risk from the progestogen-only contraceptive pill.

Other causes

Your risk of developing DVT is also increased if you or a close relative have previously had DVT and you are:



overweight or obese



a smoker



dehydrated



over 60 – particularly if you have a condition that restricts your mobility




 

How the blood clots

Your blood contains cells called platelets and proteins known as clotting factors. When a blood vessel is cut, the platelets and clotting factors form a solid clot that acts as a plug to stop the wound bleeding.

Normally, blood clotting occurs when a blood vessel is damaged and bleeds. If the blood clots when a vessel is not damaged, a clot can form within a vein or artery (thrombosis) and restrict the blood flow.

 

Diagnosing deep vein thrombosis 

If you think that you may have deep vein thrombosis (DVT), see your GP as soon as possible. 

Your GP will ask you about your medical history and your symptoms. However, it can be difficult to diagnose DVT from symptoms alone, so your GP may recommend one of the following tests:

 

D-dimer test

A specialised blood test known as the D-dimer test is used to detect pieces of blood clot that have been broken down and are loose in your bloodstream. The larger the number of fragments found, the more likely it is that you have a blood clot in your vein.

However, the D-dimer test is not always reliable. Blood clot fragments can increase after an operation or injury, or if there is inflammation in your body (when your immune system reacts to an infection or disease). This means that additional tests, such as an ultrasound scan, need to be performed to confirm DVT.

If the D-dimer test is negative, it rules out the possibility of a DVT in up to 97% of cases.

 

Ultrasound scan

An ultrasound scan can be used to detect clots in your veins. A special type of ultrasound known as a Doppler ultrasound can also be used to find out how fast the blood is flowing through a blood vessel. This helps doctors identify when blood flow is slowed or blocked, which could be caused by a blood clot.

 

Venogram

If the results of a D-dimer test and ultrasound scan cannot confirm a diagnosis of DVT, a venogram might be used. 

A special dye is injected into a vein in your foot, which travels up the blood vessels of your leg. An X-ray is taken to see the dye. If there is a blood clot in your leg, the dye will not be able to flow round it and will show up as a gap in your blood vessel.

 

Treating deep vein thrombosis (DVT) 

If you have deep vein thrombosis (DVT), you will need to take a medicine called an anticoagulant.

 

Anticoagulation

Anticoagulant medicines prevent blood clots getting bigger. They can also help stop part of the blood clot breaking off and becoming lodged in another part of your bloodstream (an embolism).

Although they are often referred to as "blood-thinning" medicines, anticoagulants do not actually thin the blood. They alter chemicals within it, which prevents clots forming so easily.

Two different types of anticoagulants are used to treat DVT:



heparin



warfarin



Heparin is usually prescribed first because it works immediately to prevent further clotting. After this initial treatment, you may also need to take warfarin to prevent another blood clot forming.

 

Heparin

Heparin is available in two different forms:



standard (unfractioned) heparin



low molecular weight heparin (LMWH)



Standard (unfractioned) heparin can be given as:



an intravenous injection – an injection straight into one of your veins



an intravenous infusion – when a continuous drip of heparin is fed through a narrow tube into a vein in your arm (this must be done in hospital)



a subcutaneous injection – an injection under your skin



 

LMWH is usually given as a subcutaneous injection.

A dose of standard heparin can work differently from person to person, so the dosage must be carefully monitored and adjusted where necessary. You may need to stay in hospital for 5 to 10 days and have frequent blood tests to ensure you receive the right dose.

LMWH works differently from standard heparin. It contains small molecules, which means its effects are more reliable and you will not have to stay in hospital and be monitored.

Both standard and LMWH can cause side effects, including:



a skin rash and other allergic reactions



bleeding 



weakening of the bones (if taken for a long time)



In rare cases, heparin can also cause an extreme reaction that makes existing blood clots worse and causes new clots to develop. This reaction, and weakening of your bones, is less likely to occur when taking LMWH.

In most cases, you will be given LMWH because it is easier to use and causes fewer side effects.

 

Warfarin

Warfarin is taken as a tablet. You may need to take it after an initial heparin treatment to prevent further blood clots occurring. Your doctor may recommend that you take warfarin for three to six months. In some cases, warfarin may need to be taken for longer, even for life.

As with standard heparin, the effects of warfarin vary from person to person. You will need to be closely monitored with frequent blood teststo ensure you are taking the right dosage.

When you first start taking warfarin, you may need to have two to three blood tests a week until your regular dose is decided. After this, you should only need to have a blood test every four weeks at an anticoagulant outpatient clinic.

Warfarin can be affected by your diet, any other medicines that you are taking, and by how well your liver is working.

If you are taking warfarin, you should:



keep your diet consistent



limit the amount of alcohol you drink (no more than three to four units a day for men and two to three units a day for women)



take your dose of warfarin at the same time every day



not start to take any other medicine without checking with your GP, pharmacist or anticoagulant specialist



not take herbal medicines



Warfarin is not recommended for pregnant women, who are given heparin injections for the full length of treatment.

 

Rivarixoban

The National Institute for Health and Care Excellence (NICE) recommends rivarixoban as a possible treatment for adults with DVT, or to help prevent DVT.

Rivarixoban prevents blood clots forming in blood vessels by stopping a substance called Factor Xa from working.

Treatment usually lasts for three months and involves taking rivarixoban twice daily for the first 21 days, followed by once daily until the course ends.

Compression stockings

Compression stockings help prevent calf pain and swelling, and lower the risk of ulcers developing after having a DVT. They can also help prevent post-thrombotic syndrome. This is damage to calf tissue caused by the increase in venous pressure that occurs when a vein is blocked (by a clot) and blood is diverted to the outer veins. See complications of DVT for more information.

After having a DVT, stockings should be worn every day for at least two years because symptoms of post-thrombotic syndrome may develop several months or even years after having DVT.

Compression stockings should be fitted professionally and the prescription is reviewed every three to six months. They need to be worn all day, but can be taken off before going to bed or in the evening while you rest with your leg raised. A spare pair of compression stockings should also be provided.

 

Exercise

Your healthcare team will usually advise you to engage in regular walking exercise once compression socks have been prescribed.

This can help prevent symptoms of DVT returning and may help to improve or prevent complications of DVT, such as post-thrombotic syndrome.

 

Raising your leg

As well as wearing compression stockings, you might be advised to raise your leg whenever you are resting. This helps to relieve the pressure in the veins of the calf and stops blood and fluid pooling in the calf itself.

When raising your leg, make sure that your foot is higher than your hip. This will help the returning blood flow from your calf. Putting a cushion underneath your leg while you are lying down should help raise your leg above the level of your hip.

You can also slightly raise the end of your bed to ensure that your foot and calf are slightly higher than your hip.

 

Inferior vena cava filters

Although anticoagulant medicines and compression stockings are usually the only treatments needed, inferior vena cava (IVC) filters may be used as an alternative. Usually, this is because anticoagulant treatment needs to be stopped or is not suitable.

IVC filters are small mesh devices that doctors can place in a vein. They trap large fragments of a blood clot and stop it travelling to the heart and lungs.

They may be used to help prevent blood clots developing in the legs of people diagnosed with:



deep vein thrombosis (DVT)



pulmonary embolism



multiple severe injuries



They can be placed in the vein permanently, or newer types of filters can be removed once the risk of a blood clot has decreased.

The procedure to insert an IVC filter is performed using local anaesthetic (where you are awake but the area is numb). A small cut is made in the skin and a catheter (a thin, flexible tube) is inserted into a vein in the neck or groin area. The catheter is guided using anultrasound scan. The IVC filter is then placed through the catheter into the vein.

 

 

Complications of deep vein thrombosis 

The two main complications of deep vein thrombosis (DVT) are pulmonary embolism and post-thrombotic syndrome.

 

Pulmonary embolism

A pulmonary embolism is the most serious complication of DVT. It happens when a piece of blood clot (DVT) breaks off and travels through your bloodstream to your lungs, where it blocks one of the blood vessels. In severe cases this can be fatal.

If the clot is small, it might not cause any symptoms. If it is medium-sized, it can cause breathing difficulties and chest pain. A large clot can cause the lungs to collapse and result in heart failure, which can be fatal.

About 1 in 10 people with an untreated DVT develops a severe pulmonary embolism.

 

Post-thrombotic syndrome

If you have had a DVT, you may develop long-term symptoms in your calf known as post-thrombotic syndrome. This affects around 20-40% of people with a history of DVT.

If you have DVT, the blood clot in the vein of your calf can divert the flow of blood to other veins, causing an increase in pressure. This can affect the tissues of your calf and lead to symptoms that include:



calf pain



swelling



a rash 



ulcers on the calf (in severe cases) 



When a DVT develops in your thigh vein, there is an increased risk of post-thrombotic syndrome occurring. It is also more likely to occur if you are overweight or if you have had more than one DVT in the same leg.

 

Preventing deep vein thrombosis

If you are admitted to hospital or are planning to go into hospital for surgery, your healthcare team will assess your risk of developing a blood clot while you are there.

Surgery and some medical treatments can increase your risk of developing DVT – see causes of DVT for more information.

If you are considered at risk of DVT, there are various recommendations your healthcare team can make to prevent a blood clot occurring.

 

Before you go into hospital

If you are planning to have an operation and are taking the combined contraceptive pill or hormone replacement therapy (HRT), you will be advised to stop the drugs temporarily four weeks before you have your operation.

Similarly, if you are taking a drug to prevent blood clots, such asaspirin, you may be advised to stop taking this one week before your operation.

There is less risk of DVT when you have a local rather than general anaesthetic. If it is possible for you to have a local anaesthetic, your healthcare team will discuss this with you.

 

While you are in hospital

There are a number of things your healthcare team can do to help reduce your risk of DVT while in hospital.

They should make sure you have enough to drink and do not becomedehydrated. They should also make sure you start to move around as soon as you are able to.

Depending on your risk factors, you may also be offered:



anticoagulant medicine, which helps prevent blood clots



compression stockings or a compression device to help keep the blood in your legs circulating



Compression stockings are worn around your feet, lower legs and thighs, and fit tightly to encourage your blood to flow more quickly around your body.

Compression devices are inflatable and work in the same way as compression stockings, inflating at regular intervals to squeeze your legs and encourage blood flow.

 

When you leave hospital

You may need to continue treatment with compression stockings or an anticoagulant medicine when you leave hospital.

Before you leave, your healthcare team should advise you how to use your treatment, how long it should continue for, and who to contact if you are having any problems.

 

Exercise

Your healthcare team will usually advise you to engage in regular walking exercise once compression socks have been prescribed.

This can help prevent symptoms of DVT returning and may help improve or prevent complications of DVT, such as post-thrombotic syndrome.

Smoking and diet

You can reduce your risk of DVT by making changes to your lifestyle, such as:



not smoking



eating a healthy, balanced diet



getting regular exercise



maintaining a healthy weight or losing weight if you are obese



 

 

Travelling

If you are at risk of getting a DVT or have had a DVT previously, consult your GP before embarking on long-distance travel.

If you are planning a long-distance plane, train or car journey (journeys of six hours or more), ensure that you:



drink plenty of water



avoid excessive alcohol, as it can lead to dehydration



avoid taking sleeping pills, as it can cause immobility



perform simple leg exercises, such as regularly flexing your ankles



take occasional short walks when possible



take advantage of refuelling stopovers, where it may be possible to get out and walk about



wear elastic compression stockings



 

Travel insurance

When travelling abroad, it is very important to make sure that you are prepared should you or a member of your family fall ill.

Make sure you have full travel insurance to cover the costs of any healthcare you may need to receive. This is particularly important if you have a pre-existing medical condition, such as cancer or heart disease, that may increase your risk of developing DVT.

DVT can be a very serious condition, and it is important that you receive medical assistance as soon as possible. Prompt treatment of DVT will help minimise the risk of complications.

 

How to tell if you might have a DVT or pulmonary embolism


Signs to look out for after your hospital treatment include:



pain or swelling in your leg



the skin of your leg feeling hot or being discoloured



the veins near the surface of your leg appearing larger than normal



becoming short of breath



pain in your chest or upper back



coughing up blood

 



If you experience any of the above symptoms, get medical help immediately.
 
Deep vein thrombosis