What is Deep Vein Thrombosis or well known as DVT. Did you ever heard about blood clot? A condition which a blood clot thrombus forms in a vein is known as venous thrombosis. Blood flow through the vein can be limited by the blood clot, resulting in swelling and pain. Most commonly occurs in the deep vein in the legs, thigh or pelvis but it can still happen elsewhere in the body (Pai and Douketis, 2012). The larger veins that go through the muscles of the calf and thigh are deep leg veins. They are not the veins that we can see just below our skins, neither are the same as varicose vein. Deep Vein Thrombosis is most common in adults over age 60 but it can happen at any age as well. DVT usually can cause embolism when a part or all of the blood clot in the vein breaks off from the site where it is formed and travel along the venous system. DVT can lead to long lasting problem. It can damage the vein and cause the leg to ace, swell, change color and leg sores after years.

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What cause deep vein clots to form? Blood clot can form in veins when you are inactive. For instant, clots can form if you are paralyzed or sit while on a long journey. Surgery, injury and cancer also can damage your blood vessel and lead to blood clot. If DVT remain in the legs it can cause a few complications including phlebitis and leg ulcer also can lead to pulmonary embolism. Phlebitis is a condition which blood clots with inflammation in superficial vein was rarely cause serious problem but if blood clot in deep veins happen require instant attention because it can lead to embolism.
Deep Vein Thrombosis can cause the blood flow in the vein is partially or completely blocked by the blood clot. The common site for DVT is in calf vein and a thigh vein is less commonly affected while DVT is rarely happen in other deep veins. There are few alternative names for DVT such as thromboembolism, post-phlebitic syndrome or post-thrombotic syndrome. A pulmonary embolism is a life-threatening complication and long-distance flights may contribute to the risk of DVT or also known as economy-class syndrome. Coronary heart disease, being overweight or obese, cigarette smoking, pregnancy, family history of DVT or recent surgery or injury also can lead for DVT to happen. A DVT is often just a one-of event after a major operation has been done. However, some people who develop a DVT have an ongoing risk of a further DVT. If have a blood clotting problem or continued immobility, then everybody are advised to seek for a medical care or take anticoagulation such as heparin injection (after which they are prescribed warfarin) to avoid further complication.
LITERATURE REVIEW
2.1 Histopathology
Histopathology refers to the microscopic examination of tissue in order to study the manifestations of disease. Examination of a biopsy or surgical specimen by pathologist, after the specimen has been processed and histological sections have been places onto glass slides also can well describe about the histopathology.
Regarding with DVT, its histopathology is quite complex to understand. Differential diagnostic considerations prior to thrombolytic treatment and surgery should include tumours. Definitive diagnosis can be achieved by a biopsy but CT and MRI also bring quite a role in diagnosing DVT.
However, CT and MRI just such a waste when the disease is at an advanced stage because any of these examinations should be done in the early stage of disease. Based on Phlebol (2006), soleal vein was the most frequent site of DVT. At first, primary thrombi would be formed at soleal veins, then its will propagate to proximal veins. The proximal veins would be occluded by fresh thrombi, thereafter secondary thrombi were made at non-drainage calf veins. Paterson and McLachlin found that most venous thrombi consisted of two regions. One of it is composed predominantly of fibrin and trapped erythrocyte while the other one are composed mostly by aggregated platelets. The fibrin-rich regions that attached the thrombi to the vessel wall, while the platelet-rich regions localized further from the site of attachment. These show that activation of coagulation system come before platelet activation and collection during the formation of venous thrombi (Lopez et al, n.d). Based on that information, we know that the use of anti-platelets drug in venous thrombosis is very limited. Histopathology evidence in DVT shows that coagulation occurs on or nearer to the endothelial surface. When coagulation starts on the endothelial surface, platelets may be regrouped to the fibrin clot rich in thrombin through adhesive interactions and it will result to further thrombus growth.
Based on everything that stated above, we can say that the platelet collection localize to regions of the clot that are far away from its site of attachment and anti-platelet drugs such as aspirin has prove that it can reduce the risk of DVT in our precious life.
2.2 Causes and Risk Factors
Deep Vein Thrombosis occurs when a blood clots forms in a deep vein in our body. DVT always happen in the legs but it can still happen in your arms, chest, or other areas of your body. The blood clot can block our circulation or lodge in a blood vessel in our lungs, heart, or other part of our body and can cause severe organ damage and can lead to death. This topic will reveal about every causes and risk factors that can lead to DVT.
There are many causes and risk of DVT. Some of that are:
A person will have DVT when a vein’s inner lining is damaged. There are many factors that can lead to this injury. For instant it can be cause by physical, chemical, or biological factors. Besides, surgery, serious injuries, inflammation and immune responses also can be the causes to it.
DVT can also happen when the blood flow is sluggish or slow. Immobility or lack of motion can cause sluggish or slow blood flow. This condition always occurs after the surgery, bed rest for a long period and having a long journey that take a long time.
A condition which blood is thicker or more likely tend to clot than normal (thrombophilia) also can result in DVT. This is due to inherited condition such as V Leiden factor that increase the risk of blood clotting. Apart from that, hormone therapy or birth control pills also can increase the risk of blood clot.
The contraceptive pill and hormone replacement therapy (HRT) has small increased risk of DVT since the oestrogen in it can cause the blood to clot slightly more easily.
People with cancer or heart failure can also increase the risk for DVT. Usually, investigation looking for the cause of DVT may show cancer to be the underlying cause.
Older people over the age 60 years also likely to have DVT particularly if they have poor mobility or having a serious illness that can stop them to do a lot of action.
Pregnancy also increased the risk for DVT to happen. Normally, within six month after they give birth or while they are pregnant.
Dehydration will increase the chances for DVT because the blood becomes more sticky an liable to clot.
As a male, precaution should be taken because men tend to develop a DVT more often than women.
Being an obese person also can lead to DVT.
There are many causes and risk of DVT that we are unaware of it for the certain time.DVT can happen anywhere in our body part and also can attack everybody in different ages but older people are more vulnerable to it. The most risky patient to have DVT is after having a surgery because the blood can easily clot if it not cared in a good ways. Lack active persons also are in a high risk of DVT since it will cause the blood to flow slowly and easily to clot. DVT also can be inherited and wrong pill intake also can result in DVT. In easy word, there are many causes and risks that can lead to DVT and every citizen around this world should take every safety precaution to avoid DVT.
2.3 Incidence and Comparison
There are many people around this world that have experience DVT. About 2 million Americans have experienced DVT each year without they are realizing it. Based on Convenient option for DVT (2012), the exact incidence of DVT is still unknown in Malaysia but there is growing evidence that DVT is not uncommon in Asians. Based on autopsy studies, hospital audits of admission to major hospitals and also subclinical DVT in high risk situations such as after major joint surgeries show that there is increment of the incidence. According to Prof Hatem Salem, Head of Department, Australian Centre for Blood Diseases, there is grave misconception that DVT is rare in Asians because he finds out that Asians too are at risk of DVT (Convenient option for DVT, 2012). Commonly, DVT happen after post-surgeries and a few reports have appeared with high incidence of DVT in orthopedic patients comparable to Western study. Dhillon, Askander and Doraisamy (1996) suggest that the present practice of withholding routine prophylaxis against thromboembolism in Asian patients undergoing high-risk orthopaedic procedure should be reconsidered.
In Western countries, DVT occurs in 45% to 84% of patients after hip and knee surgery in the absence of prophylaxis (Stulberg et al, 1984) but there is a firm belief that the complications is quite rare in Asian patients. Lack of awareness in Asia of a condition that become one of the main killer factors in West is due to the faith that thromboembolic disease is rare in Asia. Since DVT always have been linked with post-operative so every patient that have undergoes surgery should take a good care of their health to avoid DVT. However, there are few opinions that stated DVT is rare in Asians and the first report was made by Tinckler in 1964 stated that there is rarity of post-operative DVT and pulmonary embolism in Asians (Tun et al, 2004). A study that has been made in a few Asians country like Malaysia, Hong Kong and Japan also show that there is low incidence post-operative DVT has happened around this country.
A few incidences in Asians can be taken to make a comparison with the Western to show differences in frequency of DVT in this world. In developed countries of the Western area show that DVT and consequent pulmonary embolism is still becomes the number one threat to post-surgery while in Asian specifically in Malaysia show that there is still low incidence of DVT after the operation done.
A study has been made in United Kingdom to represent Western hemisphere and Malaysia as Asian’s representator. In UK, Sandler and Martin found that 9% of patients admitted to a general hospital died and 10% of these deaths were due to pulmonary embolism that originated from DVT of lower limb. Based on a study made in Hospital Universiti Sains Malaysia, Malaysia on 45 patients, only one positive DVT confirm among 45 patients that have been observed. There is only 2.2% and this good result show incidence of DVT among patient in Asia is still low (Tun et al, 2004).
In a nut shell, the incidence of postoperative DVT in Asian patients is not low as is commonly believed and also it is not high like we know. Larger studies are needed to settle this controversy and find out all the true fact regarding this matter. Based on study that has been made above, routine practice of withholding prophylaxis in Asian patients undergoing high-risk orthopaedic procedure should be reconsidered. We can conclude that DVT is still low in Asians but we should be aware of DVT in the future because it is too risky to take this matter as small things.
2.4 Mortality and Morbidity
If DVT is left untreated, there are many bad effects can happen and some of that can result in mortality and morbidity. There is short-terms morbidity in DVT such as cardiopulmonary consequences that may delay weaning from mechanical ventilation and there is also long-term morbidity like patient-centered consequences such as chronic venous insufficiency. Based on Vascular Medicine (1998), short-term mortality for DVT patient is reported to range between 7% and 15% only while long-term mortality has record a great number of deaths for patient with DVT. In a Dutch study of 355 patients, 90 died during follow up. Patients with a DVT are at risk for morbidity and mortality since a fragment of the thrombus can embolize to the lungs. Anthony and Bon (2004), suggested that about one half of patients with an untreated proximal DVT will develop a pulmonary embolism within 3 months. In the past, contrast venography has been used to rule out DVT. Nevertheless, due to some problem such as expenditure of manpower and time, space and equipment and most importantly is it also associated with morbidity, it was been terminated and been replaced with other machine that can overcome this problem. There are many indications of short-term mortality of patients with DVT such as cancer, pulmonary embolism and major bleeding. There are also many caused that can lead to long-term mortality such as malignancy, pulmonary embolism, acute myocardial infarction, ischemic stroke and anticoagulant related to hemorrhage.
2.5 Pathophysiology
2.6 Signs and Symptoms
There are few symptoms to recognize DVT but often DVT occurs without any symptoms. The symptoms of DVT are related to obstruction of blood returning to the heart and causing a pooling of blood in the leg. Patient with DVT will undergo swelling of the affected leg and the leg may feel warm and look reddish. Apart from that, patient calf or thigh may ache or feel tender if it is been touch or squeeze or when stand or move. There are no symptoms appear if the blood clot is small and for some cases, Pulmonary Embolism is the first sign that confirm for DVT. Basically, it can be hard to detect DVT since some of the symptoms are same with other health problems. Sign and symptoms alone are not enough to determine the DVT but when risk factor is take under considerable, then it can help to determine likelihood of DVT.
Some of the common sign and symptoms of DVT:
Pain
Swelling(edema)
Tenderness
Redness or skin color changes
Skin warmth
Discoloration
Distention of veins surface
Discomfort when the foot is pulled upward
Leg fatigue
Signs and symptoms occur vary depending on the severity of the condition and not all of these symptoms have to occur with deep vein thrombosis.
2.6.1 Conditions That May Cause Similar Symptoms
Patient is advised not to make any early assumption in having Deep Vein Thrombosis if they are undergo the symptom that stated above since there are a number of different conditions that can cause the same sign and symptoms like DVT.
Some of the conditions are:
Muscles aches and tears
Superficial thrombophlebitis (blood clot that forms in an inflamed part of a vein near the surface of the body)
Varicose veins (blood vessels that are abnormally swollen and twisted
Blood clots in arteries
Arthritis (inflammation of the join)
Cellulitis (infection in tissue under the skin)
Bone fracture
Lymphedema (swelling in the hands and feet caused by excess fluid retention)
Since DVT symptoms are quite same like other health problem, patient need to undergo specific procedure and special test to confirm the diagnosis or rule out the other problem.
IMAGING MODALITIES
3.1 First Line Evaluation
3.2 Second Line Evaluation
IMAGES FEATURE OF PATHOLOGY
TREATMENT AND PREVENTION
PROGNOSIS
CONCLUSION