Venous thrombosis

Vein occlusion can develop for many reasons, and its most important and fatal complication is pulmonary embolism. Vein occlusion are divided into two as superficial and deep vein.

Superficial vein occlusion (thrombophlebitis)

Superficial vein occlusion may develop spontaneously, due to surgical or intravenous drug treatments. The cause of development and risk factors are similar to those with deep vein occlusion. In 10% of cases, embolism (clot removal) develops to the lung, 20% of them are serious.

Treatment

• Antibiotics may not be required since bacterial infection is not observed in the majority of cases.
• Anti-inflammatory therapy 5-7 days (ibuprofen)
• Blood thinners (anticoagulant therapy) are applied to patients who may develop deep vein thrombosis.
• Surgical treatment can be applied in coagulants developing in varicose veins.

Deep vein thrombosis (Occlusion) (DVT)

• 90% of DVT is in the lower extremity, most often it develops in the thigh and below knee.
• Clinically 60% are silent.
• It develops more frequently in the left leg.
• In 70% of cases where a clot is thrown into the lung, a clot is detected in the deep vein.
• Over 50% of patients with deep vein occlusion have a clot in the lung

The cause of vascular occlusion

1. Slow blood flow

1. Increased coagulation
2. Damage to the vessel wall

1. Causes of slowing of vein blood flow

• Inactivity
• Bed rest for more than four days
• Long-term travels
• Paralysis due to spinal cord injury or stroke
• Long-term motorcycle use
• Plaster cast due to broken leg
• Previous vascular occlusion

1. Increased tendency to clot

• Malignant tumors
• Inflammation disorders
• Kidney failure
• Sepsis
• Estrogen increase
• Pregnancy
• <3 months after birth
• Abortion, curettage
• Birth control drug, use of estrogen
• Genetic disorders

Genetic disorders that increase the tendency to clot

• Protein C and S deficiency
• Factor V Leiden presence
• AntithrombinIII deficiency
• High homocysteine
• Antiphospholipid antibodies
• Many genetic disorders, such as fibrinogen and plasminogen disorders, also increase the tendency to clot.
• For example, if Factor V, which is one of the natural coagulation factors in our body, is genetically impaired, passes through the mother and father and becomes a Factor V Leiden shape, the tendency to clot 80 times more than normal people.

If vascular occlusion develops in these people, they should use anti-clotting medication for life.

1. Damage to the vessel wall

• Intravenous drug addiction
• Trauma
• Central nutrition
• Bed rest

Other reasons

• Recent surgery
• Age over 60
• Heart disease
• Obesity
• Having severe artery disease in the leg

Clinical findings

Sudden pain and limitation of movement begins. Rarely due to advanced edema in the leg, a picture may develop, which may result in gangrene, shock and death. Side pain, respiratory distress and bloody cough may develop due to thrown clot into the lung.
In the late period, edema and ulcer develop due to the damage of the valves in the vein.

Figure 1. Deep vein occlusion

Questions to patients with suspected venous obstruction or those with venous obstruction;

• Have you or your family developed a clot in the leg or lung?
• Have you made a long-term trip recently?
• Have you had bed rest for more than three days?
• Have you had surgery or trauma in the past 2-3 months?
• Is there a pregnancy in the last 3 months? (Miscarriage, curettage)
• Are you using birth control pills?
• Do you smoke?
• Do you have any other health problems (cancer, rheumatic, heart failure)?
• Do you have chest pain and shortness of breath?

Diagnosis of deep vein thrombosis

In patients who are considered to have vein occlusion, the final diagnosis is made quite easily by performing Doppler ultrasound.

Treatment of deep vein thrombosis

• Raising the leg (It is kept above the heart level.)
• Blood thinning and anticoagulant therapy (Anticoagulation): Intravenous anticoagulation therapy (heparin) for the first week, followed by 3 months tablet (oral anticoagulant).
• Mobilization after 3-4 days
• • Clot-dissolving therapy: The first choice for early and rapid elimination of thrombosis (clot) in the deep vein is catheter-directed thrombolysis (clot dissolver). There are two main elements of this treatment. First; The second is the mechanical breakdown of the clot, and the second is the chemical melting of the clot. It facilitates the penetration of clot-dissolving drugs into the coagulation clot by mechanical methods. 45% success is achieved in the first three days.
• The patient is given varicose stockings.

Vascular Opening Methods in Deep Vein Occlusion

There are two veins (veins) in the leg, superficial and deep, carrying dirty blood that has lost oxygen. Our deep vein carries 90% of the dirty blood from the leg. Acute deep venous thrombosis (DVT) is the formation of a clot in one or more veins.

60% of deep vein occlusion is observed in calf shadow and 40% in groin and intra-abdominal region.

Diffuse deep vein thrombosis causes acute pain, swelling and discoloration of the legs. This picture is also in the acute period;

1. Serious edema, pain, redness develops from the groin on the leg
2. Feeding of the leg due to advanced payment is impaired and gangrene may develop
3. May cause lung embolism
4. During the first 15 days, the clot can disappear at various degrees, the current may begin, and the leg may relax.

In the chronic period;

1. Clot-related obstruction may continue chronically
2. Although the clot has been opened to varying degrees over a long period of time, the valves develop disruption and related deep venous insufficiency.

In patients with chronic or obstructed venous insufficiency in the chronic period, the so-called posttrombotic syndrome is revealed. The problems we see in this acute period continue increasingly and chronically. In this table, due to the effect of high venous pressure in the leg veins; advanced edema, color darkening, hardening and ulcers develop especially in the wrist area. This table becomes more problematic unless action is taken.

For this reason, it will be very useful to open the vein early in order to protect the patient from the problems arising in the acute and chronic periods especially in the groin and above deep vein thrombosis.

Systemic clot-dissolving drug use (Thrombolysis)

The clots normally formed in the vein also activate the clot dissolving system and the associated clot may partially or completely dissolve. Drugs known as plasminogen activators that stimulate the clot dissolving system are used to accelerate this process and provide near opening. These drugs activate the plasminogen trapped in the clot and turn it into an active form called plasmin. Plasmin acts by breaking down the organized clot, fibrin. The broken fibrin products are removed from the body through circulation.

The plasminogen activator, which is given to the systemic circulation from the vein, is distributed in equal amounts (systemic thrombolysis) to all parts of the body. However, the drug given according to this application cannot penetrate into the clot in a sufficient dose and may cause bleeding in other parts of the body. Therefore, these drugs can be administered directly into the clot with the help of a catheter, both to increase efficacy and to reduce the risk of bleeding. Although this method is less, it can cause bleeding anywhere in the body. Especially in patients with previous surgery, the risk of bleeding increases.

Direct clot dissolving agent application via catheter

According to the studies published recently, the success with traditional anticoagulation in the treatment of iliofemoral deep vein thrombosis is 18%, while this rate can increase to 80% with catheter-directed thrombolysis. Especially in patients with iliofemoral DVT, the procedures for successful vascularization in time have been shown to seriously improve the quality of life by preventing the future posttrombotic syndrome.

In percutaneous mechanical thrombectomy, more penetration of the plasmid into the clot can be achieved by mechanically breaking down the clot. A device removes the small clot from the body.

If the risk of thrombolysis is very high, direct venous thrombectomy is recommended surgically.

For patients who are bedridden and very unhealthy, treatment with anticoagulating agents (blood thinning agents) alone may be recommended.

In the thrombosis that develops in the left leg of the left main artery due to compression of the left main vein, it will be appropriate to place a stent in the compression area in order to prevent it from forming again after clearing the clot.

Following the procedure, anti-clotting drugs are given intravenously for a few days and are given orally for long-term use.

Direct clot dissolving agent application via catheter

If the patient comes with deep vein occlusion, if there is no harm in using clot melter, a catheter is placed with a local anesthetic under the knee from the leg to the knee region, and locally anesthetized catheter is applied for 24-48 hours or longer. With this application, the vessel can be opened close to the vessel in a significant amount.

ECOS: Ecosonic system

By using low energy, high frequency ultrasonic sound waves, the permeability of clot dissolving agents to the clot is increased. A guidewire is sent through the catheter placed in the below-knee region under local anesthesia. This guide wire is advanced to the beginning of the clot by advancing the ultrasonic catheter and the clot melter is applied together with the ultrasonic sound waves. It is applied for about 24-48 hours. With this method, the success rate is slightly higher than direct application. Also, since the clot is not mechanically disintegrated in this method, the risk of embolism is low and does not damage the valves.

Angiojet pharmacomechanical system

Device that breaks down the clot and vacuums it from the environment. While the saline of the device that runs at high speed is broken down by hitting the clot wall, it is aspirated at the same time.

A very low amount of clot melter is given together, allowing the clot to dissolve more easily. Under local anesthesia, a local anesthetic catheter is placed from behind the leg behind the knee, and the clot in the vein is cleaned with an angiojet sent from the nose in about 10-20 minutes.

Complications during acute vein thrombosis cleaning

The biggest complication when applying systemic thrombolysis is bleeding. Most often, the catheter may bleed from the access point to the vein or from the areas where the vein was injured during the procedure. The most feared form of bleeding is intracranial (inside the brain) bleeding that causes stroke. During the procedure, pulmonary embolism may rarely develop, as the clot breaks down into pieces. These risks should also be considered when using mechanical thrombectomy devices.

Surgical thrombectomy

Surgery is often used only in those who are very symptomatic or after other methods fail, so the expected results may not be impressive. Posttrombetic syndrome, 10 years after the attack, was found to develop in approximately 30% of patients who underwent surgery, and in 70% of the group using only blood thinners.

ANTALYA VARICOSE VEINS/Dr.İlhan Gölbaşı