Deep vein thrombosis natural history, complications and prognosis
Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. ; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D.  Kashish Goel, M.D.; Assistant Editor(s)-In-Chief: Justine Cadet
Deep Vein Thrombosis Microchapters
Deep vein thrombosis natural history, complications and prognosis On the Web
Thrombus formation typically begins in the calf veins and naturally progresses to the proximal veins and ultimately, breaks free from the site formation and travels to the pulmonary artery where it is called a pulmonary embolism. In many cases, patients with a thrombus can be asymptomatic until it progresses into the proximal veins.
- Many patients with a deep vein thrombosis (DVT) originating in the calf veins are asymptomatic until proximal vein involvement. However, even assymptomatic DVTs are associated with increased risk of death.
- About half of all calf DVTs resolve spontaneously, without intervention.
- One-sixth of all calf DVTs progress to involvement with the proximal veins.
- Typical onset of thrombus formation may occur during the intraoperative period though there is a potential latent onset up to many months after the initial surgery.
- Surgeries characteristically responsible for thrombus formation include:
- Knee replacement surgery is associated with twice the frequency of asymptomatic onset.
- Without treatment, one-fourth to one-third of symptomatic, isolated distal thrombi in the deep veins involve proximal veins.
- Patients with isolated calf DVT treated with five days of heparin therapy without a tandem oral anticoagulant therapy were at highest risk for recurrent or extension of DVT within three months of follow-up.
- Patients with untreated DVT have the potential to develop:
- Mortality rates associated with venous thrombosis can be very high.
Rule of 30's
- 30% will die in 30 days.
- 30% will have recurrence in 10 years. The actual number at 10 years has been reported to be 36%
- 30% will develop post phlebitic syndrome.
Venous thrombosis may lead to any of the following major complications:
- Recurrence may occur unevenly across the sexes; with men being almost four times more likely than women for a venous thrombosis recurrence.
- Major bleeding due to anticoagulation
- Death - Proximal vein thrombosis is responsible for more than ninety percent of acute pulmonary emboli. Acute PE is ultimately associated with a high mortality if not treated promptly. 
Other complications include:
- Post-thrombotic syndrome
- Phlegmasia alba dolens
- Phlegmasia cerulea dolens
- Lemierre syndrome
- Septic pelvic thrombophlebitis
The rate of complications in lower extremity DVT is higher from that in upper extremity DVT. Shown below is a table summarizing the differences in the rate of occurrence of complications.
|Complications||Upper extremity DVT||Lower extremity DVT|
|Recurrence of DVT||2-5%||10%|
|Post thrombotic syndrome||5%||56%|
Probability of recurrence can be estimated with the HERDOO2 rule:
- Redness in either leg
- D-dimer level ≥250 μg/L
- Obesity with body mass index ≥30
- Older age, ≥65 years
Per the authors, "Women with a first unprovoked VTE event and none or one of the HERDOO2 criteria have a low risk of recurrent VTE and can safely discontinue anticoagulants after completing short term treatment."
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