Deep venous thrombosis

Causes

DVTs are most common in adults over age 60. However, they can occur at any age. When a clot breaks off and moves through the bloodstream, this is called an embolism. An embolism can get stuck in the brain, lungs, heart, or other area, leading to severe damage.

Blood clots may form when something slows or changes the flow of blood in the veins. Risk factors include:

• A pacemaker catheter that has been passed through the vein in the groin
• Bedrest
• Family history of blood clots
• Fractures in the pelvis or legs
• Giving birth within the last 6 months
• Obesity
• Recent surgery (most commonly hip, knee, or female pelvic surgery)
• Too many blood cells being made by the bone marrow, causing the blood to be thicker and slower than normal

Blood is more likely to clot in someone who has certain problems or disorders, such as:

• Cancer
• Certain autoimmune disorders, such as lupus
• Cigarette smoking
• Conditions in which you are more likely to develop blood clots
• Taking estrogens or birth control pills (this risk is even higher if you smoke)

Sitting for long periods when traveling can increase the risk of DVTs. This is most likely when you also have one or more of the risk factors listed above.

Symptoms

DVT mainly affects the large veins in the lower leg and thigh, almost always on one side of the body. The clot can block blood flow and cause:

• Changes in skin color (redness)
• Leg pain
• Skin that feels warm to the touch
• Swelling (edema)

Exams and Tests

Your health care provider will perform a physical exam. The exam may show a red, swollen, or tender leg.

The two tests that are often done first to diagnose a DVT are:

• D-dimer blood test
• Doppler ultrasound exam of the legs  

Blood tests may be done to check if you have an increased chance of blood clotting, including:

• Activated protein C resistance (checks for the Factor V Leiden mutation)
• Antithrombin III levels
• Antiphospholipid antibodies
• Complete blood count (CBC)
• Genetic testing to look for mutations that make you more likely to develop blood clots, such as the prothrombin G20210A mutation
• Lupus anticoagulant
• Protein C and protein S levels

Treatment

Your doctor will give you medicine to thin your blood (called an anticoagulant). This will keep more clots from forming or old ones from getting bigger. These drugs cannot dissolve clots you already have.

Heparin is usually the first drug you will receive.

• If heparin is given through a vein (IV), you must stay in the hospital.
• Newer forms of heparin can be given by injection once or twice a day. You may not need to stay in the hospital as long, or at all, if you are prescribed this newer form of heparin.

A drug called warfarin (Coumadin) is usually started along with heparin.

• Warfarin is taken by mouth. It takes several days to fully work.
• Heparin is not stopped until the warfarin has been at the right dose for at least 2 days.
• You will most likely take warfarin for at least 3 months. Some people must take it longer, or even for the rest of their lives, depending on their risk for another clot.

When you are taking warfarin, you are more likely to bleed, even from activities you have always done. If you are taking warfarin at home:

• Take the medicine just the way your doctor prescribed it
• Ask the doctor what to do if you miss a dose
• Get blood tests often to make sure you are taking the right dose
• Learn how to take other medicines and when to eat
• Find out how to watch for problems caused by warfarin

Newer blood thinning medicines that are taken by mouth are being developed. Your doctor may recommend one of these for you.

You will be given a pressure stocking to wear on your leg or legs, along with other discharge instructions. A pressure stocking improves blood flow in your legs, and reduces your risk for complications from blood clots. It is important to wear it every day.

In rare cases, you may need surgery if medicines do not work. Surgery may involve:

• Placeing a filter in the body's largest vein to prevent blood clots from traveling to the lungs
• Removing a large blood clot from the vein or injecting clot-busting medicines

Outlook (Prognosis)

Many DVTs disappear without a problem, but they can return. Some people may have long-term pain and swelling in the leg called post-phlebitic syndrome.

You may also have pain and changes in skin color. These symptoms can appear right away, or you may not develop them for 1 or more years afterward. Wearing tight (compression) stockings during and after the DVT may help prevent this problem.

Blood clots in the thigh are more likely to break off and travel to the lungs (pulmonary embolus, or PE) than blood clots in the lower leg or other parts of the body.

When to Contact a Medical Professional

Call your health care provider if you have symptoms of DVT.

Go to the emergency room or call the local emergency number (such as 911) if you have DVT and you develop:

• Chest pain
• Coughing up blood
• Difficulty breathing
• Fainting
• Loss of consciousness
• Other severe symptoms

Prevention

Wear the pressure stockings your doctor prescribed. They will improve blood flow in your legs and reduce your risk for complications of blood clots.

Moving your legs often during long plane trips, car trips, and other situations in which you are sitting or lying down for long periods of time can also help prevent DVT. People who are at very high risk for blood clots may benefit from heparin shots when they are on a flight that lasts longer than 4 hours.

Do not smoke. If you smoke, quit. Women who are taking birth control pills or estrogen must stop smoking. See: Smoking - tips on how to quit

Alternative Names

DVT; Blood clot in the legs; Thromboembolism; Post-phlebitic syndrome; Post-thrombotic syndrome

References

Ginsberg J. Peripheral venous disease. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 81.

Guyatt GH, Akl EA, Crowther M, et al. Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis. 9th ed. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):7s-47s. 

Snow V, Qaseem A, Barry P, et al. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2007;146(3):204-210.

Update Date: 2/19/2012

Updated by: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.