DEEP VEIN THROMBOSIS (PHLEBOTHROMBOSIS)

• Deep vein thrombosis is the formation of a blood clot within the deep veins, most commonly those of the lower extremities
• Mostly an asymptomatic disease, only one fourth of the cases of DVT present with minor complaints
• Symptoms include oedema, warmth, and dull pain of the affected extremity. Patients also presents with features of pulmonary embolism, a severe complication of DVT
• Proximal DVT : DVT of the lower extremity affecting the femoral vein, and/or the popliteal vein
• Distal DVT : DVT of the lower extremity that is confined to the veins beyond the calf vein trifurcation (below knee joint)
• Venous thromboembolism : An umbrella term that encompasses DVT and pulmonary embolism

Virchow's triad- it describes three factors that are thought to contribute to thrombosis

Venous stasis

• Prolonged bed rest (4 days or more)
• A cast on the leg
• Limb paralysis from stroke
• Spinal cord injury
• Extended travel in a vehicle

Hypercoagulability

• Surgery and trauma - 40% of all thrombo embolic disease
• Malignancy
• Increased estrogen
• Inherited disorders of coagulation - Deficiencies of protein-s, protein-c, anti-thrombin iii
• Acquired disorders of coagulation- Nephrotic syndrome, Anti-phospholipid antibodies

Endothelial injury

• Trauma
• Surgery
• Invasive procedure
• Iatrogenic causes – central venous catheters

Other Risk factors :

• Obesity
• Smoking
• IV drug use

• May be asymptomatic
• Localized unilateral symptoms – Typically affects deep veins of the legs, thighs or pelvis
• More common in the left lower extremity
• Calf pain or tenderness, or both
• Swelling with pitting oedema
• Increased body temperature
• Superficial venous dilatation
• Cyanosis can occur with severe obstruction
• Possible signs of Pulmonary embolism – Dyspnoea, dizziness, haemoptysis, and pleuritic pain

Inspection

• Swelling is mainly found just around the ankle or little higher up
• Phlegmasia alba dolens /white leg - Swollen leg may become very much painful and white
• Phlegmasia cerulean dolens- When all the deep veins become blocked, the skin become congested and blue

• Clinical examination confirms 20-30% of cases of DVT

Imaging studies

• Invasive - venography, radiolabeled fibrinogen test
• Non-invasive – USG ( colour-flow Duplex scanning), MRI techniques

Homans sign: Pain in the posterior calf or knee with forced dorsi flexion of the foot

Moses sign: Gentle squeezing of the lower part of the calf from side to side is painful

D dimer

General therapeutic measures

• Bed rest
• Encourage the patient to perform gentle foot & leg exercises every hour
• Increase fluid intake up to 2 L /day unless contraindicated
• Avoid deep palpation

Specific treatment

• Anticoagulation – molecular weight heparin( 5 days), followed by warfarin (for at least 3 months)
• Thrombolytic therapy for DVT
• Surgery for DVT - clot removal and partial interruption of the inferior vena cava to prevent pulmonary embolism
• Filters for DVT - Inferior vena cava filters reduce the rate of pulmonary embolism
• Compression stockings- Graduated compression stockings, Intermittent pneumatic compression devices

Ayurvedic Treatment

Internal medicines

• Punarnavadi Kashaya
• Manjishtadi Kashaya
• Sahacharadi Kashaya
• Shunti choorna
• Sahacharadi sevya taila
• Partharishta
• Navaka guggulu
• Kaishora guggulu
• Shaddaranam gutika
• Dashamoola hareetaki lehya

Procedure

• Jaloukaavacharana