VTE-DVT-PE explanation etiology patophysiology.pptx

Venous thromboembolism

1. VTE DVT DEWI TRISNAWATI Pembimbing Dr. dr. An Aldia Asrial , Sp. JP, FIHA

2. Physiology of Vein Pathophysiology of Heart Disease, sixth edition, Leonard S. Lily Veins collect blood from all tissues and organs and return it to the heart The walls of veins can be thinner than those of corresponding arteries  lower in pressure Blood pressure in a peripheral venule is only about 10 percent of that in the ascending aorta, and pressures continue to fall along the venous system. The blood pressure in venules and medium-sized veins is so low that it cannot overcome the force of gravity  Valves

3. Artery and Vein

4. VTE, DVT, PE Continuum? DVT is a condition in which a thrombus typically forms in one or more of the deep veins of the calf or thigh PE occurs when all or part of a thrombus originating in the deep veins detaches from the vessel wall and travels in the venous system as an embolus , ultimately obstructing pulmonary arteries Venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis, is a condition characterized by abnormal blood clot formation in the pulmonary arteries and the deep venous vasculature. Pathophysiology of Heart Disease, sixth edition, Leonard S. Lily

5. Predisposing Factors VTE Strosng Risk (OR >10) Fracture of lower limb Hospitalization for heart failure or atrial fibrillation /flutter (within previous 3 months) Hip or knee replacement Major trauma Myocardial infarction (within previous 3 months) Previous VTE Spinal cord injury Moderat Risk Factors (OR 2-9) Arthroscopic knee surgery Autoimune disease Blood transfusion Central venous lines Intravenous catheters and leads Chemoterapy CHF or respiratory failure Erythropoiesis-stimulating agents Hormone replacement therapies (depend on formulations) Moderat Risk Factors (OR 2-9) (2) In vitro fertilization Oral contraceptive therapy Post partum period Infections Inflamatory bowel disease Cancer Paralytic stroke Superficial vein thrombosis thrombophilia Weak risk factor (OR<2) Bed rest > 3 days DM Arterial hypertension Immobility due to sitting (prolonged air travel) Increasing age Laparoscopic surgery Obesity Pregnancy Varicose veins Pastori D, et.al. A Comprehensive Review of Risk Factors for Venous Thromboembolism: From Epidemiology to Pathophysiology. Int J Mol Sci. 2023 Feb 5;24(4):3169. doi : 10.3390/ijms24043169. PMID: 36834580; PMCID: PMC9964264.

6. Pathophysiology of VTE

7. Pathophysiology Stasis of laminar flow  platelets contact with endothelium  coagulation factors accumulate and retards the influx of clotting inhibitors Hypercoagulable state e.g inherited deficiencies of antithrombin, protein C, and protein S, cancer/neoplastic disease Vascular damage can denude the endothelium  expose subendothelial collagen, as a substrate for the binding of von Willebrand factor and platelets  initiates the clotting cascade, leading to clot formation DAMP( Damage-Associated Molecular Patterns ) PAMP ( Pathogen Associated Molecular Patterns ) Pastori D, et.al. A Comprehensive Review of Risk Factors for Venous Thromboembolism: From Epidemiology to Pathophysiology. Int J Mol Sci. 2023 Feb 5;24(4):3169. doi : 10.3390/ijms24043169. PMID: 36834580; PMCID: PMC9964264.

8. Dislodgement of blood clot Lower extremity (65-90%) Pelvic venous system Renal venous system Upper extremity Right heart

9. Deep Vein Thrombosis Deep venous thrombosis (DVT) is a manifestation of venous thromboembolism (VTE). Deep venous thrombosis (DVT) is a manifestation of venous thromboembolism (VTE). Edema - Most specific symptom Leg pain - Occurs in 50% of patients but is nonspecific Tenderness - Occurs in 75% of patients Warmth or erythema of the skin over the area of thrombosis Clinical symptoms of pulmonary embolism (PE) as the primary manifestation Pathophysiology of Heart Disease, sixth edition, Leonard S. Lily

10. Diagnosis of deep vein thrombosis and imaging strategies Clinical assessment and pre-test probability score Asymptomatic Calf or thigh discomfort particularly when standing or walking Unilateral leg swelling Signs : edema, localized warmth and erythema, tenderness, calf pain produced by dorsiflexion of the foot ( Homans sign )

11. Calf pain at dorsoflexion of the foot : Associated with the presence of thrombosis Very poor predictive value for the presence or absence of DVT

12. Diagnosis The most thoroughly studied and validated clinical decision score is the Wells DVT score Determine the patients likelihood and confirm the diagnosis of VTE Asses the sign and symtoms of VTE, Determine probability of patient having a VTE event based on history, physical examination and risk scoring ( e.g Well) Perform applicable diagnostic testing European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

13. D-dimers are fibrin degradation products and are increased in any condition with increased fibrin formation, such as venous thrombosis.D – dimer can be measured in whole blood plasma to provide an indirect index of ongoing activation of the coagulation system D – dimer examination can be done with ELISA or latex agglutination assay. D-dimer <0,5 mg/mL can exclude DVT diagnosis D – dimer is sensitive but not specific, so negative results are useful for DVT exclusion, whereas positive values are not specific to DVT, so they can not used as a single test for DVT diagnosis A low Well’s score criteria plus normal D-dimer implies a low clinical risk of VTE D-Dimer European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

14. Ultrasound first line DVT imaging modality sensitivity 94.2% for proximal DVT , and 63.5% for isolated distal DVT specificity 93.8% European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

15. Two distinct ultrasound assessment approaches are practised to investigate for DVT in symptomatic patients: two or three point compression ultrasound scanning (CUS) and whole leg ultrasound scanning (WLUS). In CUS , deep vein patency is only assessed in two or three venous territories (usually the common femoral vein, the popliteal vein the femoral vein) . Although the most proximal segments of the tibial veins can be interrogated during popliteal assessment, isolated calf DVT is not excluded by this technique. However, WLUS provides a more extensive examination , where the entire deep vein network of the leg is scanned from the common femoral vein to the distal veins European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

16. Computed tomography venography CTV offers definite advantages over ultrasound when evaluating the pelvic veins or the inferior vena cava (IVC) and can detect concurrent medical conditions that cause pain and swelling. European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis Magnetic resonance direct thrombus imaging may help distinguish between acute recurrent thrombus and a persisting thrombus in the same location, with further implications for treatment regimens Magnetic resonance venography (MRV)

17. Venography Invasive Historically, contrast venography was the first line imaging for the diagnosis of DVT and considered the gold standard. Although effective, this procedure is invasive, requires IV contrast, and involves exposure to radiation. European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

18. Classification of deep vein thrombosis Anatomical level Depending on the venous territory involved, DVT may be classified as proximal and distal. Thrombosis of the iliac, femoral, and/or popliteal veins is classified as proximal DVT , regardless of the presence of concomitant calf (distal) DVT. Similarly, thrombosis that is confined to calf (distal) deep veins may be termed as calf or distal DVT. European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

19. DVT may be categorised as either provoked or unprovoked , depending on the presence or absence of associated risk factors . Unprovoked DVT refers to venous thrombosis in the absence of clearly identifiable environmental or acquired risk factors. Similarly, provoked DVT occurs in the presence of such risk factors , which can be further classified as transient or persistent (depending on whether they persist after the event) and into major or minor Aetiological classification European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

20. RECOMMENDATION FOR THE DIAGNOSIS AND INVESTIGATION OF DVT European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

21. Treatment Phases of anticoagulation for deep vein thrombosis Anticoagulation treatment for DVT may be divided into three distinct phases: (1) an initial treatment phase (up to 10 days) with the aim of rapidly instigating anticoagulation therapy to prevent propagation of DVT and PE; (2) a principal treatment phase (first three months) to maintain therapeutic levels of anticoagulation to prevent propagation of DVT and PE, and reduce the risk of early recurrent VTE; and (3) an extended treatment phase (beyond three months, with no scheduled stop date) with the specific aim of reducing the long term risk of recurrent VTE. European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

22. Treatment Anticoagulation European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

23. UFH An APTT ratio of 1.5 e 2.5 should be reached within 24 hours of starting treatment. A lower APTT in the first 24 hours is associated with a higher incidence of recurrent DVT European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

24. European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

25. Mazzolai , L. et.al. ESC 2018. Diagnosis and management of acute deep vein thrombosis: a joint consensus document from the European Society of Cardiology working groups of aorta and peripheral vascular diseases and pulmonary circulation and right ventricular function

26. Bleeding and other adverse events

27. Thrombus removal strategies Surgical thrombectomy Thrombectomy may be performed for acute iliofemoral DVT under general anaesthesia with common femoral venotomy and thrombus extraction using a Fogarty embolectomy catheter from the level of IVC. Distally, the thrombus can be extruded through the venotomy by manual massage of the entire leg, starting at the foot, or with gentle catheterisation and thrombectomy Catheter directed thrombolysis Catheter directed thrombolysis (CDT) involves the delivery of a thrombolytic drug through a multiple side hole catheter positioned directly into the thrombosed vein.

28. Pharmacomechanical catheter directed thrombolysis. The term refers to procedures combining the use of lytic infusion for thrombolysis with adjunctive catheter based devices to promote mechanical removal of thrombus

29. PULMONARY EMBOLISM

30. Predisposing factors

31. Pathophysiology and determinants of outcome

32. Hemodinamic Instability Accordingly, clinical symptoms, and signs of overt RV failure and haemodynamic instability, indicate a high risk of early (in-hospital or 30 day) mortality. High-risk PE is defined by haemodynamic instability and encompasses the forms of clinical presentation shown in Table 4

33. DIAGNOSIS Clinical presentation The clinical signs and symptoms of acute PE are non-specific. In most cases, PE is suspected in a patient with dyspnoea , chest pain, presyncope or syncope, or haemoptysis . Clinical presentation and Assessment of clinical (pre-test) probability

34. AVOIDING OVERUSE DIAGNOSTIC TEST 8 TANDA YANG BERKAITAN DENGAN TIDAK ADANYA PE : Usia < 50 th Pulse < 100 bpm SaO2 >94% No unilateral leg swelling No hemoptisis No recent trauma or surgery No history of PE No oral hormon use

35. PEMERIKSAAN PENUNJANG D-dimer testing D-dimer levels are elevated in plasma in the presence of acute thrombosis because of simultaneous activation of coagulation and fibrinolysis EKG

36. IMAGING

37. ECHOCARDIOGRAPHY

38. Combined parameters and scores for assessment of pulmonary embolism severitY y

39. Strategies for patient follow-up after pulmonary embolism

40. Treatment in the acute phase Oxygen therapy and ventilation Pharmacological treatment of acute right ventricular failure

41. Initial anticoagulation Reperfusion treatment