Venous Thromboembolic Disease

Question 1

What is a thrombus(i)?

Answer 1

Clot that forms in the vein and remains stationary

Question 2

What is an embolus(i)?

Answer 2

Cloth that breaks off and travels and lodges in another part of the venous system

Question 3

What does VTE include?

Answer 3

Deep vein thrombosis (DVT)
Pulmonary embolism (PE)
Thrombus or embolism involving any other vein…

Question 4

What are the key points in VTE epidemiology?

Answer 4

Incidence increases with age
- Women > men in childbearing years, then switches

Blacks slightly higher

Sudden death is the presenting symptom in 25% of cases

Question 5

What is Virchow’s Triad?

Answer 5

Venous stasis
Endothelial injury
Hypercoagulability

Question 6

What are some provoking factors for a provoked VTE?

Answer 6

Surgery - especially orthopedic and general
Trauma
Prolonged immobility
Pregnancy or OCP
Medications
Infection (COVID)

Question 7

What maybe included in the presentation of VTE?

Answer 7

Can be asymptomatic
Ipsilateral LE edema
LE erythema, pain, and warmth

Question 8

What should be included in a physical exam for VTE?

Answer 8

+/- calf tenderness
+/- palpable cord (more sensitive than Homan’s test)
+/- superficial venous dilation
+/- Homan’s sign

Question 9

What is Homan’s sign?

Answer 9

Passive dorsiflexion of the ankle with knee at 30 degrees - calf pain (often not reliable but often on test questions)

Question 10

What is the work-up for VTE?

Answer 10

D-dimer
Duplex venous ultrasound (test of choice)
Contrast venography (gold standard but not routine)

Question 11

When is a d-dimer useful?

Answer 11

When a patient has low risk probability of DVT, it is only helpful when negative to rule out DVT. If positive, then proceed to US because it is not specific.

Question 12

What is a pulmonary embolism?

Answer 12

Blood clot in the pulmonary artery system most likely caused by an embolism from a DVT

Question 13

What is the worst location for a PE?

Answer 13

Saddle, at the bifurcation of the PA. Occlusion of both Rand L pulmonary arteries.

Question 14

What location of PE is more likely to cause lung infarct or pleuritis?

Answer 14

Sub-segmental

Question 15

What sided heart failure can be associated with a saddle PE?

Answer 15

Right heart sided

Question 16

The presentation of PE’s are largely variable based on size and location, but what are some possible symptoms?

Answer 16

Major Most Common
Tachycardia
Tachypnea

Other Symptoms
Dyspnea
Pain with inspiration
Cough
Leg or chest pain
Hemoptysis
Wheezing
Cyanosis
Hypoxia

Question 17

What should be the initial work-up for PE?

Answer 17

Labs (CBC, CMP, Pregnancy, Coag. studies, Troponin, BNP, D-dimer [only if low risk])

EKG
Duplex US
POCUS Echo
CXR

Question 18

What is Fleischner’s sign?

Answer 18

Enlarged PA

Question 19

What is Westermark sign?

Answer 19

Lack of distal pulmonary vasculature

Question 20

What is Hampton’s hump?

Answer 20

Wedge shaped pulmonary infarct

Question 21

What sign’s can be seen on CXR, although all are rare?

Answer 21

Fleischner’s sign
Westermark sign
Hampton’s Hump

Question 22

What are some common findings in EKG in working-up PE?

Answer 22

Pattern of Right Heart Strain –> RBBB, right axis deviation, right atrial deviation, inverted T-waves leads II and V1 (closest to right side)

Question 23

What are you specifically looking for in echocardiograph when working-up PE?

Answer 23

Assessing for right ventricular dilation

Question 24

What is the preferred diagnostic test for PE?

Answer 24

CT-pulmonary angiography (CTPA)

Question 25

Is a CT-pulmonary angiography (CTPA) still the preferred test in working up PE in a pregnant patient?

Answer 25

Yes, still preferred if high suspicion or elevated D-dimer

Question 26

What is a critical requirement prior to ordering a ventilation-perfusion scan (VQ scan) to work-up a PE?

Answer 26

Normal CXR

Question 27

What is the treatment for VTE?

Answer 27

For most, anticoagulation If massive PE or unsuccessful treatment with anticoags then embolectomy

Question 28

For parenteral treatment, what is the preferred treatment?

Answer 28

LMWH (Lovenox) preferred over UFH because there is no monitoring, more predictable and once/twice daily

Question 29

Who can't receive Lovenox?

Answer 29

Patients with renal disease or failure, should be treated with UFH (Heparin)

Question 30

What is the treatment for VTE in pregnant patients?

Answer 30

LMWH is most preferred Coumadin (Warfarin) is HIGHLY CONTRAINDICATED (teratogenic)

Question 31

What DOAC's are available for the treatment of VTE?

Answer 31

Rivaroxaban (Xarelto) Apixaban (Eliquis) Dabigatran (Pradaxa) Edoxaban (Lixiana)

Question 32

What are the contraindications to DOAC's?

Answer 32

Thrombophilia Certain chemo drugs or other drug interactions Failure (recurrent thrombosis despite tx)

Question 33

What is the duration of treatment for a major transient provoked attack?

Answer 33

3 months + prophylaxis for subsequent exposures

Question 34

What is the duration of treatment for a cancer related VTE?

Answer 34

3-6 months or as long as the cancer is active

Question 35

What is the duration of treatment for an unprovoked VTE?

Answer 35

Minimum of 3-months, possible indefinite if no bleeding risk

Question 36

What is the duration of treatment for a recurrent unprovoked VTE?

Answer 36

Indefinite

Question 37

What is the duration of treatment for an underlying hypercoaguable state?

Answer 37

Indefinite

Question 38

What is thrombophlebitis?

Answer 38

Clot leading to inflammation of a deep vein, DVT or if superficial then superficial thrombophlebitis

Question 39

What are thrombophlebitis most commonly secondary too?

Answer 39

PICC lines, IVs

Question 40

If a patient presents with symptoms of thrombophlebitis with fever and chills what are you suspicious for?

Answer 40

Septic phlebitis (staph aureus most common pathogen)