Deep vein thrombosis of lower extremities - Causes, symptoms and treatment. MF.

When talking about vascular health, it is necessary to mention such an insidious disease as thrombosis. Insidious - because of the timely treatment of a doctor and proper treatment depends not only the quality of life of the patient, but life itself.

Venous thrombosis is an acute disease caused by blood clotting in the lumen of the vein with the formation of thrombi, which leads to a violation of its patency. It is necessary to distinguish between the concepts of "thrombophlebitis" and "phlebothrombosis".Phlebitis is the inflammation of the vein wall due to a common or local infection. Phlebotrombosis develops due to changes in coagulation properties of blood, damage to the vascular wall, slowing of blood flow, etc. Since thrombosis is often accompanied by phlebitis, often many doctors equate the diagnosis of thrombosis and thrombophlebitis.

Thrombi prevent normal blood flow, besides they can completely clog the vein and block the blood flow.

Causes of deep vein thrombosis

The main cause is increased coagulability of the blood and this is an occasion to consult a doctor. Along with this, damage to the vascular wall and slowing of the blood flow are revealed. These three factors are known as the Triad of Virochov.

Risk factors:

- advanced age;
- pregnancy and childbirth( especially the risk after a caesarean section);
- complex fractures, extensive cavitary operations and joint operations;
- overweight;
- long flights and trips;
- smoking;
- operations;
- taking certain medications that affect the blood coagulation system

With prolonged forced bed rest, conducive conditions for the development of deep vein thrombosis are created, because the blood flow slows down, there is no adequate muscle contraction, as a result of which the reverse flow of blood to the heart is disrupted.

Deep vein thrombosis is also affected by healthy young people who are forced to stand or sit for a long time, for example when working with a computer, frequent long flights or trips by car.

Symptoms of deep vein thrombosis

Symptoms of thrombosis depend on which vein is affected( vein thrombosis of the retina, portal vein, mesenteric vein, etc.).The most common thrombosis of deep veins of the lower extremities. Clear signs of thrombosis may be severe swelling and discoloration of the skin at the site of the thrombus, indirect signs of thrombosis - small swelling on the legs, periodic pain in the calf muscles, redness, a feeling of heat or heaviness in the legs. Depending on the location of venous thrombosis, the ankle, the lower leg, or the entire thigh may swell. But very often thrombosis of the deep veins of the lower extremities develops without symptoms of venous insufficiency, leading immediately to complications in which a sudden lethal outcome is possible.
The higher the thrombosis rises, the more dangerous it is for the thrombus to come off.

Examination for suspected thrombosis

The leading method for diagnosing thrombosis is duplex scanning. Radiopaque phlebography is used for doubts in duplex studies and for the localization of thrombi above the inguinal fold. Its reliability there is higher than the uzi of research. A special contrast agent is injected into the vein of the patient and the veins are viewed using X-rays. This will determine the precise location of the thrombus position.

In doubtful cases, MR or CT angiography is prescribed.

The level of D-dimer blood confirms the very fact of the presence of thrombosis( it is increased).

Thrombosis in the veins can be such that it completely covers the blood flow and tightly presses, "grows" to the venous wall, and is then called occlusal. There is no risk of a thrombus from coming off. With free blood flow and the presence of mural overlays with duplex scanning, not overlapping the venous lumen, there is talk of parietal thrombosis. He is also not dangerous. In the case when there is a thrombus head, freely washed by blood from four sides, thrombosis is called flotation, this thrombus is very dangerous for the development of thromboembolism. The first species can go to the second if the thrombus grows upwards with insufficient treatment. The transition of the second species to the first can be either after detachment of the floating head, or after its growth to the wall of the vein.

If suspected complications, in particular pulmonary embolism, X-ray examination of the lungs, in particular, scintigraphy with a radioactive marker. Only during radionuclide lung scintigraphy and detection of deep vein thrombosis during UZDG( ultrasound dopplerography) can diagnosis of thromboembolism of the pulmonary artery be confirmed. Additionally, ECG and ECHR can be prescribed. With the development of a collapoid reaction( a marked decrease in blood pressure below the norm with loss of consciousness) with massive thromboembolism, all of the above studies and further treatment are carried out only in a hospital urgently.

Complications of deep vein thrombosis

A life-threatening situation arises with a flotation( torn off) thrombus due to the development of pulmonary thromboembolism. Separation of the venous thrombus can lead to massive thromboembolism, followed by immediate death, sub-massive thromboembolism of the pulmonary artery( severe hypertension in the small circulation with pulmonary artery pressure values ​​of 40 mm Hg and higher) or thromboembolism of small pulmonary artery branches with symptoms of respiratoryinsufficiency and so-called infarct-pneumonia.

Other consequences of thrombosis of the veins of the lower limbs, which in 3 to 35-70% lead to disability caused by chronic venous insufficiency in the background of postthrombophlebitic syndrome, are no less important.

Treatment of deep vein thrombosis

When a doctor makes a diagnosis of thrombosis treatment should begin immediately. Treatment is carried out on an outpatient basis or in a hospital depending on the stage and severity of the disease.

Treatment of thrombosis directly depends on their embologenity. Promptly treated embologogenic thromboses - in other words, those with a floating thrombus head. The type of operation depends on the localization of thrombosis. Can be used operations of thrombus removal, vein ligation, suturing( plication) of the vein, application of an arteriovenous shunt, installation of a cava filter. Part of the operations, in addition to preventing the spread of thrombosis up, aims to remove thrombotic mass. Before the operation, complete physical and psychological rest is necessary, so as not to provoke an opening of the thrombus.

Drug treatment for thrombosis:

Occlusal thrombosis treats conservatively. With drug treatment, the doctor appoints patients anticoagulants, which reduce blood clotting and reduce the likelihood of blood clots. The main drug is heparin and its derivatives.

The basis for the treatment of such thromboses is the prevention of its transition to a flotation thrombosis, and only then everything else. The first condition is achieved by heparin therapy, which is aimed at reducing blood coagulability. The use of heparin in its pure form is possible only in a stationary way, due to a large number of complications when used in the necessary doses and, therefore, the need for clear medical control over its purpose. The doctor who prescribes heparin, fears primarily the development of bleeding, so the dosage is selected with special attention. And, in theory, before every injection of heparin, as well as insulin, it is supposed to check blood coagulation, but this is often not done, but in vain. And if we take into account that the definition of the clotting time is no longer up-to-date, and the APTTV method should replace it, which is costly for everyone, since the blood is taken from the vein and not a simple clinical laboratory is needed but a coagulologic one, it becomes clear thatthis is almost a dead end for many doctors, medical institutions and patients.

In addition, heparin can interact not only with the points of application of the clotting system( antithrombin 3), but also with other blood proteins, thereby reducing its main effect. And the content of antithrombin 3 is not defined everywhere. And quite often, after setting quite normal serious doses of heparin, doctors do not get the desired effect due to these reasons.

Aspirin is an effective remedy for the prevention of recurrent thrombosis, however, prolonged use may lead to gastrointestinal problems, such as heartburn, gastritis, nausea, stomach pain, etc. To avoid such undesirable consequences, it is necessary to take the drugs in a special enteric coating. For example, you can use the drug Trombo ACC, each tablet is covered with a special film shell, resistant to the action of hydrochloric acid in the stomach and dissolving only in the intestine. Thus, the substances that make up the drug do not harm the stomach. For better effect this tool is recommended to take every day, not courses.

The low molecular weight heparins , representing a fraction of heparin molecules in a certain range of molecular weight, are more convenient in all respects in the treatment of thrombosis. Their appointment once or twice a day is very convenient. In addition, the patient can inject subcutaneously into the abdominal wall to himself, for which a disposable syringe is provided with the entire dose of the medicine. There is no need to check blood clotting, as there is no overdose with proper consideration of the patient's weight, and as a consequence, they give fewer complications. The effect of low molecular weight heparins is much less dependent on the state of the blood and the presence in it of the inflammatory proteins and the level of prothrombin 3. The most common in Russia are: clexane, fractiparin, fragin.

In recent years in the west, approbation preparations of an even narrower anticoagulant spectrum of action( fondaparinux and idraparinux sodium).Convenience of appointment and unnecessary laboratory control over them allow the use of low molecular weight heparins for treatment in outpatient settings.

Not all deep vein thromboses that require conservative treatment can be treated on an outpatient basis, even with such drugs. The second condition for outpatient treatment should be considered the possibility of uzi control of thrombosis at any appropriate time with worsening of the condition or the appearance of new complaints, increased edema, etc. Of course, it is important to have a competent doctor who can be contacted, if necessary, an understanding of the risk and the patient's consent to such treatment.

Non-embolic thromboses of the femoral vein and below can be treated in the clinic if all these rules are observed.

Out-patient medical treatment of deep vein thrombosis

After the initial reception of phlebologist and suspicion of deep venous thrombosis, duplex scanning is done on the same day. A cursory examination by a doctor of an ultrasound diagnosis is unacceptable, since the price of the error is too high and if the reliability of the conclusion is uncertain, it is not necessary to send the patient home. The need for a thorough examination of the pelvic veins also does not cause doubt, and again an inadequate examination of the iliac veins, fusion of the internal and external iliac veins in the presence of symptoms of ileofemoral thrombosis does not allow the phlebologist to be sure of the correctness of the outpatient treatment strategy.

In women with concomitant gynecological pathology, examination of the internal iliac vein is necessary to exclude such a dangerous and insidious "intern thrombosis", sometimes causing a thromboembolism of the pulmonary artery even in the absence of clinical signs of venous thrombosis on the leg.

Based on the study, a conclusion is made about the possibility of treating out-patient thrombosis. If the patient's consent is obtained, low-molecular heparins are prescribed in the therapeutic dosage based on weight, and the first injection should be started on the day of the doctor's visit and diagnosis.

The injection into the subcutaneous tissue of the abdomen is quite simple, but it is always better if the doctor explains the process clearly to you, or better to entrust injections to the doctor himself. After explaining the treatment schedule, elastic compression is assigned the next visit after 5-7 days. Despite the outpatient treatment, of course, the patient is given a sick leave sheet.

The administration of oral( in tablets) indirect anticoagulants( warfarin, coumadin) can occur both on day 3 after the start of injections of low molecular weight globulins, and somewhat later, depending on the physician's preferences. As a rule, the abolition of low molecular weight globulins occurs when an international normalized ratio( many) is from 2 to 3 units, or a prothrombin index( PTI) from 40 to 60. The last indicator is less correct, because below 30 units it can not be determined at all, and eachunit after 35 very much changes the level of coagulability of blood during table translation of RTI in INR.Measuring PTI is the last century of medicine.

Since the 80s, the countries of the west have switched to the MNO indicator. And although its measurement is more expensive and the analysis is taken from the vein - this forced and uncomfortable need to check the coagulation system is done for the benefit of the patient.

After starting to drink indirect anticoagulants, the patient donates blood 3 days after the beginning of their admission and then as prescribed by the treating doctor in the first week up to 3 times, in the second week up to 2 times, and then 1 time a week in the first month of admission. In the future, but to take indirect anticoagulants need at least 3 months the rate of blood donation - 1 time in 2 weeks, with the used dose of the drug.

Multiplicity of uzi of the study of veins is the following: in the absence of impairment, the following uzi is done 1 week after the first, then a week later, and further on the appointment of a phlebologist. As a rule, already on the second scan, the dynamics of thrombosis is visible, and more often it is positive for the patient. In the absence of dynamics or deterioration, it is worth considering the issue of hospitalization or pre-examination for the elimination of oncopathology, because it is known that half of the patients with cancer die from thrombosis.

The thrombus dissolution procedure is called thrombolysis. Thrombolysis is performed by a vascular surgeon. In a blood clotted vessel, a catheter is inserted through which thrombolytic( thrombolysis agent) enters directly into the thrombus. Unfortunately, this procedure can cause bleeding, so thrombolysis is prescribed in rare and severe cases. But at the same time, its significant advantage in comparison with other medicamental methods is the possibility of dissolving blood clots of large sizes. In particular, thrombolysis is effective in thrombosis of the veins of the upper vena cava( veins of the upper limbs and neck), which is associated with a higher risk of pulmonary embolism, compared with thrombosis of the inferior vena cava system.

Surgical treatment of deep vein thrombosis

Surgical removal of thrombus is recommended in severe forms of thrombosis when there is a possibility of tissue necrosis. The procedure is called venous thrombectectomy.

Cava filters are installed in the vein with flotation thrombus. Implantation of the cava filter is indicated by the patient for contraindications to the use of anticoagulants. The lower hollow vein is the main trunk vessel, through which blood moves from the lower extremities, the internal organs of the pelvic cavity and the abdominal cavity, to the heart and lungs. Therefore, in case of inefficiency of drug treatment of thrombosis, you may be recommended to implant a filter into the lower vena cava to prevent the development of thromboembolism( migration of the thrombus pieces through the inferior vena cava system).A filter in the lower vena cava is usually inserted through the femoral vein, but can also be inserted through the system of the superior vena cava( vein of the neck and upper limbs).

Deep vein thrombosis prophylaxis

The highest probability of deep vein thrombosis is observed after operations and prolonged immobilization( compliance with bed rest).In this case, the following preventive measures can be applied:

• taking medications that dilute blood( anticoagulants) before or immediately after surgery.
• use of elastic bandages that help prevent blood flow disorders in the lower limbs.
• use of compression devices( blowing regularly "socks" or "socks" to help regulate venous blood flow during the period of immobilization
• whenever possible early activation of patients after surgery and performing a set of exercises to help improve the muscle tone of the lower extremities and venous blood flow. Measures to prevent deep vein thrombosis in healthy people are the same as in the prevention of varicose veins. The use of elastic compression will help reduce pain and swelling,will improve blood flow

  A sharp change in activity can lead to thrombosis

  As the study showed, long hours behind the wheel to participate in a sports marathon, and then a similarly long journey back in the car can cause deep vein thrombosis due to a sharp change in the levelThe

  can be exemplified by the stories of Chris and Tammy Lifka from Chicago, beautiful runners who are in excellent physical condition, who suffered from deep vein thrombosis after the end of the regular competition.

  The increased risk of thrombosis is due to the fact that after the finish the tension drops sharply, and a number of body functions, including blood pressure, also decrease. Many athletes are familiar with the feeling of squeeze that they experience after the end of the competition. And it is immobility that disrupts normal blood flow, turning the blood almost into a "gel".Hours behind the wheel of a car soon after that lead to the fact that the blood stagnates in the veins of the lower limbs.

  To avoid deep vein thrombosis after sporting events, doctors and scientists recommend: 1. drinking enough fluids during and after the competition;2. continue to move after the end of the competition;3. postpone leaving at least one day after the competition;4. take breaks for a small workout, when you have to drive for a long time.

  Doctor therapist Naumenko ON