Deep vein thrombosis requires watchful diagnosis

Cate Swannell
Med J Aust
Published online: 9 June 2019

THE non-specific nature of the signs and symptoms of deep vein thrombosis means GPs and other physicians must maintain a high index of suspicion for the potentially deadly condition, according to the authors of a narrative review published today in the Medical Journal of Australia.

Deep vein thrombosis (DVT) is a common manifestation of venous thromboembolism, and usually occurs in the deep veins of the legs or arms. Mortality is high; death within 30 days occurs in about 6% of patients with DVT, primarily through pulmonary embolism. Among treated patients, about 20–50% develop post-thrombotic syndrome (PTS) after DVT.

The authors of the review, led by Professor Graeme Hankey, Professor of Neurology at the University of Western Australia, and Dr Paul Kruger, a haematologist at Fiona Stanley Hospital, PathWest Laboratory Medicine, and the Population Health Research Institute in Canada, wrote that the clinical presentation of DVT was “often non-specific”.

“Accurate diagnosis requires sequential integration of clinical features, assessment of pre-test clinical probability, and confirmatory investigations that include D-dimer testing and imaging.

“Symptoms and signs of leg or pelvis DVT include leg pain, swelling, erythema and dilated superficial veins. Arm DVT has similar symptoms localised to the arm. Some DVTs are asymptomatic.”

Alternative diagnoses for limb DVT include cellulitis, lymphoedema, chronic venous insufficiency, haematoma and, for leg DVT, ruptured Baker cyst, they wrote.

Anticoagulation remains the gold standard treatment for DVT, with direct oral anticoagulants (DOACs) such as apixaban or rivaroxaban; initial parenteral anticoagulation followed by a DOAC (dabigatran or edoxaban) or initial parenteral anticoagulation overlapped by warfarin and continued for at least 5 days.

“The choice of anticoagulant should consider medical issues such as efficacy, safety, renal and hepatic function, and concurrent medications,” Hankey and colleagues wrote. “In addition, practical issues such as availability, familiarity of use, patient preference, and cost should be considered.”

Compression stockings have been shown to have a beneficial effect after diagnosis. In rare cases, inferior vena cava filters, thrombolysis and surgical thrombus removal may be considered.

Situations which are likely to impact the choice of anticoagulant agent and duration of treatment include DVT which occurs in pregnant women, patients with cancer, distal DVT, recurrent DVT, antiphospholipid syndrome or those with superficial vein thrombosis, Hankey and colleagues wrote.

“The diagnosis of DVT requires a high index of suspicion because symptoms and signs are often non-specific,” they concluded. “Anticoagulation continues to be the cornerstone of therapy. The optimal anticoagulant and duration of therapy are determined by the clinical assessment.”

  • Cate Swannell



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