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      Drugs & Diseases > Emergency Medicine

      Deep Venous Thrombosis (DVT) Clinical Presentation

      Updated: Jun 05, 2019
      • Author: Kaushal (Kevin) Patel, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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      Presentation

      History

      Deep venous thrombosis (DVT) classically produces pain and limb edema; however, in a given patient, symptoms may be present or absent, unilateral or bilateral, or mild or severe. Thrombus that does not cause a net venous outflow obstruction is often asymptomatic. Edema is the most specific symptom of DVT. Thrombus that involves the iliac bifurcation, the pelvic veins, or the vena cava produces leg edema that is usually bilateral rather than unilateral. High partial obstruction often produces mild bilateral edema that is mistaken for the dependent edema of right-sided heart failure, fluid overload, or hepatic or renal insufficiency. Massive edema with cyanosis and ischemia (phlegmasia cerulea dolens) is rare.

      Leg pain occurs in 50% of patients, but this is entirely nonspecific. Pain can occur on dorsiflexion of the foot (Homans sign). Tenderness occurs in 75% of patients but is also found in 50% of patients without objectively confirmed DVT. When tenderness is present, it is usually confined to the calf muscles or along the course of the deep veins in the medial thigh. Pain and/or tenderness away from these areas is not consistent with venous thrombosis and usually indicates another diagnosis. The pain and tenderness associated with DVT does not usually correlate with the size, location, or extent of the thrombus. Warmth or erythema of skin can be present over the area of thrombosis.

      Clinical signs and symptoms of pulmonary embolism as the primary manifestation occur in 10% of patients with confirmed DVT.

      Even with patients with classic symptoms, as many as 46% have negative venograms. [2] Furthermore, as many as 50% of those with image-documented venous thrombosis lack specific symptoms. [3, 93] DVT simply cannot be diagnosed or excluded based on clinical findings; thus, diagnostic tests must be performed whenever the diagnosis of DVT is being considered. (See Workup)

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      Physical Examination

      No single physical finding or combination of symptoms and signs is sufficiently accurate to establish the diagnosis of deep venous thrombosis (DVT).

      The classic finding of calf pain on dorsiflexion of the foot with the knee straight (Homans sign) has been a time-honored sign of DVT. [94] However, Homans sign is neither sensitive nor specific: it is present in less than one third of patients with confirmed DVT, and is found in more than 50% of patients without DVT.

      Superficial thrombophlebitis is characterized by the finding of a palpable, indurated, cordlike, tender, subcutaneous venous segment. Forty percent of patients with superficial thrombophlebitis without coexisting varicose veins and with no other obvious etiology (eg, intravenous catheters, intravenous drug abuse, soft tissue injury) have an associated DVT. Patients with superficial thrombophlebitis extending to the saphenofemoral junction are also at higher risk for associated DVT.

      If a patient is thought to have pulmonary embolism (PE) or has documented PE, the absence of tenderness, erythema, edema, or a palpable cord upon examination of the lower extremities does not rule out thrombophlebitis, nor does it imply a source other than a leg vein. More than two thirds of patients with proven PE lack any clinically evident phlebitis. Nearly one third of patients with proven PE have no identifiable source of DVT, despite a thorough investigation. Autopsy studies suggest that even when the source is clinically inapparent, it lies undetected within the deep venous system of the lower extremity and pelvis in 90% of cases.

      Patients with venous thrombosis may have variable discoloration of the lower extremity. The most common abnormal hue is reddish purple from venous engorgement and obstruction. In rare cases, the leg is cyanotic from massive ileofemoral venous obstruction. This ischemic form of venous occlusion was originally described as phlegmasia cerulea dolens (“painful blue inflammation”). The leg is usually markedly edematous, painful, and cyanotic. Petechiae are often present.

      In relatively rare instances, acute extensive (lower leg–to-iliac) occlusion of venous outflow may create a blanched appearance of the leg because of edema. The clinical triad of pain, edema, and blanched appearance is termed phlegmasia alba dolens (“painful white inflammation”), a term originally used to describe massive ileofemoral venous thrombosis and associated arterial spasm. This is also known as milk-leg syndrome when it is associated with compression of the iliac vein by the gravid uterus. The affected extremity is often pale with poor or even absent distal pulses. The physical findings may suggest acute arterial occlusion, but the presence of swelling, petechiae, and distended superficial veins point to this condition. As many as half the patients with phlegmasia alba dolens have capillary involvement, which poses a risk of irreversible venous gangrene with massive fluid sequestration. In severely affectedpatients, immediate therapyisnecessarytoprevent limb loss.

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      Pulmonary Embolism

      As many as 40% of patients have silent pulmonary embolism (PE) when symptomatic deep venous thrombosis (DVT) is diagnosed. [4] Approximately 4% of individuals treated for DVT develop symptomatic PE. Almost 1% of postoperative hospitalized patients develop PE. The 10-12% mortality rate for PE in hospitalized patients underscores the need for prevention of this complication. Treatment options include anticoagulation therapy and placement of an inferior vena cava filter. If evidence of right heart failure is present or if adequate oxygenation cannot be maintained, the thrombus may be removed with pharmacomechanical thrombolytic intervention.

      Electrocardiography may demonstrate ST-segment changes in patients with PE. The arterial oxygen saturation (PaO2) level may be lowered. All or none of these findings may be present, and the embolization may remain subclinical or silent. (See the images below.)

      Deep Venous Thrombosis (DVT). Lung scans are shown Deep Venous Thrombosis (DVT). Lung scans are shown. LPO = left posterior oblique.
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      Deep Venous Thrombosis (DVT). Spiral computed tomo Deep Venous Thrombosis (DVT). Spiral computed tomography scan showing a pulmonary thrombus.
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      Deep Venous Thrombosis (DVT). This is the appearan Deep Venous Thrombosis (DVT). This is the appearance of a normal pulmonary angiogram.
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      Deep Venous Thrombosis (DVT). This is a positive p Deep Venous Thrombosis (DVT). This is a positive pulmonary angiogram.
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      PE is most often diagnosed by means of ventilation/perfusion lung scanning, which is reported as having a low, moderate, or high probability of depicting PE. When the results of these studies are equivocal, the use of spiral CT scans may be able to demonstrate intravascular thrombosis. In many institutions, the criterion standard for diagnosing PE is pulmonary angiography.

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      Paradoxic Emboli

      Although rare, paradoxic emboli can occur in patients with cardiac defects (usually atrial septal defect), who are at risk for the passage of emboli to the arterial circulation and resultant stroke or embolization of a peripheral artery. Patients can present after cardiac failure occurs late in life, with resultant bedrest that increases the risk for deep venous thrombosis.

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      Recurrent Deep Venous Thrombosis

      Without treatment, one half of patients with deep venous thrombosis (DVT) have a recurrent, symptomatic venous thromboembolism (VTE) event within 3 months. After anticoagulation for an unprovoked VTE event is discontinued, the incidence is 5-15% per year. Presentations are similar, with pain and edema. However, the diagnosis may be difficult (ie, differentiating acute from chronic thrombus). Recurrence increases the risk of postthrombotic syndrome (PTS).

      A review by Martinelli et al indicates that hormonal therapy, including estrogen-containing agents, does not appear to be associated with recurrent VTE in women younger than 60 years receiving anticoagulation with rivaroxaban or enoxaparin/vitamin K antagonists for confirmed VTE. [95] However, it was noted that abnormal uterine bleeding occurred more frequently with rivaroxaban than with enoxaparin/vitamin K antagonists.

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      Postthrombotic Syndrome

      Postthrombotic syndrome (PTS) is a chronic complication of deep venous thrombosis (DVT) that manifests months to many years after the initial event. Symptoms range from mild erythema and localized induration to massive extremity swelling and ulceration, usually exacerbated by standing and relieved by elevation of the extremity. Evaluations of the incidence or of improvements with therapy have been problematic because reporting is not standardized. Furthermore, correlation between objectively measured hemodynamic changes and the severity of PTS is poor. [96]

      After symptomatic DVT is treated with anticoagulation, the incidence of PTS at 2 years is 25-50% despite long-term anticoagulation for iliofemoral DVT, and after 7-10 years, the incidence is 70-90%. [97, 98] The only current treatment is use of a compression hose and elevation. In many patients, this is only partly effective in relieving swelling, pain, and venous ulcers. In the United States, the annual direct cost of post–DVT, PTS-related venous ulcers is estimated to be $45 million per year, and 300,000 work days are lost. [99]

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