International Journal of Research in Medical Sciences

Khandait V et al. Int J Res Med Sci. 2019 Sep;7(9):3391-3395

[Link] pISSN 2320-6071 | eISSN 2320-6012

DOI: [Link]
Original Research Article

Deep vein thrombosis: experience from a tertiary care centre in

central India
Vinod Khandait1, Harshwardhan Khandait2, Shadman Ali1*

1
Department of Medicine, 2Medical Graduate, Government Medical College, Nagpur, Maharashtra, India

Received: 02 July 2019

Revised: 13 July 2019
Accepted: 13 August 2019

*Correspondence:
Dr. Shadman Ali,
E-mail: drshadmanali@[Link]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Deep vein thrombosis is a disease of potentially serious consequences and is still often unsuspected.
The present study was undertaken to look into etiological factors, management approaches and complications in
patients presenting primarily with DVT at a tertiary care centre.
Methods: This was a descriptive study profiling 75 confirmed DVT cases admitted at a tertiary care government
hospital over two years. Detailed assessment included thorough clinical examination, duplex venous ultrasound and
basic investigations, along with special investigations and CT angiography in selected few. Appropriate management
was provided, and details recorded. Patients were followed up clinically and by ultrasound after 1 week, 2 weeks and
3 months. The complications, if any were also recorded.
Results: The mean age of participants was 39.5±14.4 years, with 28% between 30-39 years. Majority (40%) did not
have any obvious predisposing factor and most of them presented with pain and swelling. Most (52%) of the cases
had involvement of both proximal and distal veins, 45.33% cases had involvement of only proximal veins whereas
only 2.67% had restricted involvement of distal veins. Around 60% of cases have complete clinical resolution and
approximately 50% cases have complete ultrasonographic resolution at the end of 3 months.
Conclusions: Young adults without any obvious risk factors may develop and present with DVT and hence factors
leading to thrombosis in them are recommended to be thoroughly evaluated. Duplex venous ultrasound is reliable
non-invasive diagnostic modality and is recommended for diagnosis of DVT in clinically suspected cases.

Keywords: Deep venous thrombosis, Duplexvenous ultrasound, Management

INTRODUCTION identified as having an acute venous thrombo-embolic

event in India annually.3 Recent studies have shown that
Often overlooked as an entity, venous thrombo-embolism DVT is quite common among younger age groups and
(VTE) (encapsulating both deep vein thrombosis and has been observed to be one significant cause of
pulmonary embolism) is the third most common morbidity and mortality, in contrast to previous evidence
cardiovascular illness after acute coronary syndrome and depicting higher incidence in elderly.4-7
stroke, with pulmonary embolism being the commonest
preventable cause of hospitalisation related deaths across Due to often silent nature of the condition it has been
world.1 Deep venous thrombosis (DVT) was presumed to difficult to estimate true incidence of VTE. Patients at
be a little less in occurrence in the Asian countries, a times present with non-specific signs and symptoms
myth broken only recently.2,3 Around 2.5 lac patients are making the diagnosis difficult; while, to initiate effective

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treatment, it is imperative to diagnose the condition as profile, quantitative D-dimer levels (assessed by Nyco
early as possible. Most of the literature available in India card reader), serum homocysteine levels (assessed by
is from the surgical disciplines and entails research on competitive chemi-luminescent assay) and serum anti-
post-operative patients. Only a handful studies have phospholipid antibodies. Those with clinical suspicion of
focussed on profiling idiopathic DVT. With this research pulmonary embolism were further subjected to CT
lacuna in mind, the present study was undertaken to look pulmonary angiography.
into etiological factors, management approaches and
complications in patients presenting primarily with DVT All patients received anti-coagulation with heparin (either
at a tertiary care centre. low molecular weight or unfractionated) and warfarin with
regular INR monitoring as standard treatment of DVT.
METHODS Heparin was continued for at-least five days with warfarin
overlap and until two successive INR done at-least one day
The present study was prospective observational in apart were within therapeutic range. Catheter directed
design, conducted over duration of two years at a tertiary thrombolysis and inferior vena cava filter placement was
care government hospital in Central India. Ethical done in selected patients, if recommended based on standard
clearance was obtained from Institutional Ethics indications and with due consideration of affordability.8 All
Committee prior to the commencement of study. patients were followed up to look for development of
complications such as recurrence, post-thrombotic syndrome
Inclusion criteria and pulmonary embolism.

• Patients presenting primarily with deep venous Chi-square test and student 't' test were used to compare
thrombosis, categorical data and continuous data respectively. SPSS
• Diagnosis confirmed by venous Doppler and patient (version17) was used for statistical analysis.
admitted to medicine wards of the institute,
• Patients giving consent. RESULTS

Exclusion criteria In this descriptive study profiling primary DVT cases

admitted at a tertiary care hospital, 120 patients presented
• Patients admitted for any other cause with symptoms and signs suggestive of deep vein
• Patients developing DVT during hospital stay thrombosis such as pain, swelling and tenderness of
• Patients with secondary DVT affected extremity. All of them were subjected to duplex
• Patients developing DVT due to trauma. venous ultrasound of affected limb to confirm the
diagnosis of DVT. Seventy five (62.5%) cases out of total
A total of 75 patients fulfilling the mentioned selection 120 had evidence of thrombosis in deep veins and
criteria were finally recruited following written informed fulfilled the mentioned selection criteria. These 75 cases
consent. After detailed history taking and physical were considered for final analysis. The mean age of
examination, those patients presenting with clinical participants was 39.5±14.4 years, with a major chunk (21,
features suggestive of deep vein thrombosis were 28%) belonging to the age group of 30-39 years. There
subjected to duplex venous ultrasound. The ultrasound was insignificant male preponderance with M:F ratio of
was conducted by senior faculty from the department of 40:35 (1.14:1).
radiology, who was not part of the study. Presence of
thrombus, its characteristics and extent were recorded. History and clinical examination led to observation of some
Side and site of involvement were recorded and classified important trends. All patients presented with pain and
as ‘Proximal’ (above knee deep vein thrombosis, swelling of affected extremity. Similarly, edema and
involvement of popliteal vein and above) and ‘Distal’ tenderness were observed in all cases. Homan’s sign was
(below knee deep vein thrombosis, involvement of positive in 37 (49.33%) cases, while skin changes in the
anterior and posterior tibial veins and soleal veins). form of erythema, discoloration, blebs etc. were present in
Patients having simultaneous involvement of above and 21 (28%) cases. Majority of the cases (30, 40%) did not
below knee veins were recorded as having both. Patients have any obvious predisposing factor.
were followed up clinically and by duplex ultrasound
after 1 week, 2 weeks and 3 months. Follow-up scans This was followed by smoking (17, 22.67%),
were categorized by the radiologist as ‘no change’, hyperhomocysteinemia (11, 14.67%), hypertension and
‘improved’, ‘worse’, ‘resolution’ or ‘chronic’ on the basis pregnancy or post-partum status (8, 10.67% each), and
of predefined radiological criteria. prolonged immobility, prior venous thromboembolism,
malignancy and chronic kidney disease (CKD) in 5 (6.67%),
Routine laboratory investigations such as complete blood 4 (5.33%), 3 (4%) and 1 (1.33%) cases respectively. Eleven
count, peripheral smear, renal function test, liver function (14.67%) participated reported to have multiple risk factors.
test, random blood sugar and baseline INR were done in None of the cases tested positive for anti-phospholipid
all patients, along with ECG and chest x-ray. In addition, antibodies. Similarly, none of the subjects had history of oral
participants also underwent following fasting lipid contraceptive use (Table 1).

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Table 1: Findings on history and clinical embolisation of clots. Rest of the 66 (88%) cases did not
examination (n= 75). receive any intervention.

Finding Number Percent Table 2: Management details of the

Predisposing factor participants (n= 75).
No known predisposing factor 30 40
Smoking 17 22.67 Management details Number Percent
Multiple risk factors 11 14.67 Type of heparin received
Hyperhomocysteinemia 11 14.67 Low molecular weight heparin 56 74.67
Hypertension 8 10.67 Unfractionated heparin 19 25.33
Pregnancy/post-partum 8 10.67 IVC filter placement and catheter directed
Prolonged immobility 5 6.67 thrombolysis (CDT)
Prior thromboembolism 4 5.33 Only IVC filter placement 5 6.67
Malignancy 3 4 Catheter directed thrombolysis
4 5.33
Others 2 2.67 with IVC filter placement
Dyslipidemia 1 1.33 No intervention 66 88
CKD 1 1.33
All the cases were followed up clinically as well as by
Clinical presentation duplex ultrasonography, at the end of first week, second
Pain 75 100 week and then at 3 months post discharge. Clinically, at
Swelling 75 100 the end of first week, 11 (14.67%) cases had no resolution
Edema 75 100 of signs and symptoms, partial resolution was observed in
Tenderness 75 100 63 (84%) cases and 1 (1.33%) had complete resolution.
Homan's sign 37 49.33 But after three months of follow up, 48 (64%) cases had
Skin changes 21 28 complete clinical resolution.

Mean value of hemoglobin, D-Dimer and serum On duplex ultrasonography, improvement was noticed in
homocysteine were 10.59±2.52 g/dL, 2.73±0.98 mg/L 47 (62.67%) cases whereas there was no change in 26
and 19.00±13.89 μmol/L respectively. Out of total 75 (34.67%) cases and resolution in 2 (2.67%) cases by the
cases, chest x ray was found to be normal in majority (69, end of first week. After 2 weeks, there was improvement
92%) of the cases, while cardiomegaly was seen in 3 in 67 (89.33%) cases, no change in 3 (4%) and resolution
(4%), dilated pulmonary artery in 2 (2.67%) and in 5 (6.67%). At the end of 3 months, resolution was seen
consolidation in 1 (1.33%) cases. in 36 (48%) and improvement in 14 (18.67%) cases.
However, 15 (20%) cases developed chronic changes.
ECG, Likewise, was also normal in majority (65, Total 10 (13.33%) cases were lost to follow up (Table 3).
86.67%) of the cases, with 4 (5.33%) cases each having
findings suggestive of left ventricular hypertrophy and Table 3: Follow-up outcome details of the
sinus tachycardia. Left ventricular strain pattern and right participants (n= 75).
bundle branch block were observed in 1 (1.33%) case
each. Follow-up timeline
Follow-up
After 1 After 2 After 3
outcome
Duplex venous ultrasound was undertaken revealed that Week weeks months
39 (52%) had involvement of both proximal and distal Clinical outcome
veins, 34 (45.33%) cases had involvement of only No
11 (14.67%) 0 (0.00%) 0 (0.00%)
proximal veins whereas only 2 (2.67%) had restricted resolution
involvement of distal veins. 57 (76%) cases had Partial
63 (84%) 64 (85.33%) 17 (22.67%)
involvement of left lower limb. DVT on the right side resolution
was observed in 16 (21.33%) cases and 2 (2.67%) had Complete
1 (1.33%) 11 (14.67%) 48 (64%)
bilateral involvement. resolution
Duplex venous ultrasonography outcome
Details of management of all the cases are as detailed in No change 26 (34.67%) 3 (4.00%) 0 (0.00%)
Table 2. All cases received anticoagulation, 56 (74.67%) Improved 47 (62.67%) 67 (89.33%) 14 (18.66%)
received low molecular weight heparin and 19 (25.33%) Resolution 2 (2.67%) 5 (6.67%) 36 (48.00%)
patients were given unfractionated heparin. Four patients
Chronic 0 (0.00%) 0 (0.00%) 15 (20.00%)
(5.33%) underwent catheter directed thrombolysis along
with IVC filter placement, whereas only IVC filter
placement was done in 5 (6.67%) cases. All of the cases At 3 months follow-up, when duplex ultrasonography
who underwent catheter directed thrombolysis had IVC findings were compared between those with both
filter placement done prior to thrombolysis to prevent proximal as well as distal DVT versus those with only

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proximal involvement; in cases with both proximal and 14.67% cases is similar to that of Kreidy et al, in which
distal involvement, 11 (28.2%) cases had findings more than 3 risk factors were reported to be present in
suggestive of improvement, whereas in proximal group 19.3% of cases.14
only 3 (8.82%) cases showed improvement, the
difference being significant. But when the clinical Cases with both proximal and distal involvement had
outcomes were compared at 3 months, the difference in significantly higher D-Dimer values as compared to those
resolution was not statistically significant. with only proximal DVT, which is to be expected
because of more fibrinolysis. Eleven (14.67%) cases had
As for complications, post-thrombotic syndrome was raised serum homocysteine levels. These findings
observed to develop in 6 (8%) cases and pulmonary correlate well with previous similar studies.16,17 DVT was
embolism in 3 (4%) cases. Recurrence of DVT was observed to occur more commonly during post-partum
observed in 2 (2.67%) cases and 2 (2.67%) cases period, especially after caesarean section, and with left-
developed coagulopathy as an adverse effect of treatment. sided predominance, which is in accordance with
available evidence.18-20
DISCUSSION
As for treatment implications, patients managed with
The present study was carried out on 75 cases of deep catheter directed thrombolysis (CDT) had faster
vein thrombosis admitted in medicine wards over a resolution, both clinically and on DVU, much in line with
period of 2 years. The objectives were to establish observations from previous similar studies.21,22
diagnosis of DVT by Doppler venous ultrasound in cases
presenting with signs and symptoms of DVT, to study After 3 months of follow-up, both proximal and distal
clinical profile including predisposing factors in cases DVT cases were compared with those with only proximal
presenting primarily with DVT and to look for clinical DVT, both clinically and on DVU. On DVU, cases with
and ultrasonographic outcome of DVT after three only proximal DVT had significantly higher proportion
months. of improvement in comparison to those with both
proximal and distal DVT. Schweizer et al, had also
Out of 120 cases presenting with clinical features of observed similar findings on follow-up DVU after 3
DVT, 75 (62.5%) had duplex venous ultrasound proven months in his study evaluating short and long term
thrombosis, which is largely in line with available outcomes after thrombolytic treatment of deep vein
evidence, except in the study by Lensing et al, in which thrombosis.22 This was the only point of significant
the low proportion (35%) could have been due to only difference between the two groups at 3 months follow-up.
femoral and popliteal veins being examined.9-11 The age
and gender distribution of in the present study is also Study of complications showed development of
similar to majority of previous similar studies. pulmonary embolism in 3 (4%) patients. Kasabe et al,
observed it to occur in 4% cases, which is similar to our
DVT is known to present with pain, swelling and tender study.15 The rate of recurrence of DVT (2.67%) is also
edema, which held true in the present study as well. Other similar to previous observations.8,23
commonly observed clinical features were Homan’s sign
(49.33%) and various skin changes (erythema, In conclusion, it can be said that, young adults without
discoloration, blebs etc.) (28%), which were similar to any obvious risk factors may develop and present with
previous observations.6,7,12 No predisposing factor was DVT and hence factors leading to thrombosis in them are
identified in majority (40%) of the participants. recommended to be thoroughly evaluated. Duplex venous
Chinglensena et al, also had not identified any risk factors ultrasound is reliable non-invasive diagnostic modality
in 45% cases and Kamerkar et al, did not find any known and is recommended for diagnosis of DVT in clinically
predisposing cause in 47.49% of their cases, similar to suspected cases.
our finding.6,7 In the Prospective Registry On Venous
thromboembolic Events (PROVE) also, it was concluded Funding: No funding sources
that the overall incidence of idiopathic DVT was similar Conflict of interest: None declared
to the incidence of DVT occurring after a precipitating Ethical approval: The study was approved by the
event.13 Hereditary thrombophilia could have been the Institutional Ethics Committee
predisposing factor in cases without any obvious risk
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