DVT/thrombophlebitis ➔ Venous insufficiency/PE

  • Superficial veins (surface, can usually see) drain into deep veins (deep in-between muscles)

    • Skeletal muscle forces blood upward and valves prevent blood from backward flow

  • Clots develop in deep veins ➔ thrombus ➔ ↓ blood flow or can embolize to pulmonary circulation

    • Plasmin breaks down Fibrin (in clot) ➔ D-dimer

Venous thromboembolism (VTE): DVT and PE


  • Virchow Triad

    1. Hyper-coagulability - cancer, pregnancy, factor V Leiden, AT deficiency

    2. Vascular injury - sub-endothelial exposure of collagen

    3. Venous stasis - immobilized (bed-bound, long trips sitting), locally applied heat (vasodilation ➔ slowed flow)


  • Unilateral & localized pain with swelling/feeling tight, warmth, erythema

    • MC in left calf

    • DVT ➔ distended superficial veins

  • ± discoloration, ± fever from inflammatory cytokines

  • Pulmonary embolism: dyspnea, CP, dizziness, low sat despite supplemental O2

  • Right iliac vein compresses left iliac vein ➔ ↑ risk of DVT in LLE

  • Homan sign may involve upward pressure on calf but how could you tell the difference between Homan or Meyer?

    • Homan sign isn't really helpful (and people love telling you this)

  • Meyer sign

    • compression of calf ➔ pain

  • Payr sign

    • medial plantar foot pressure ➔ pain

  • Homans sign

    • calf pain with dorsiflexion


  • D-Dimer if Wells' score < 3 (r/o DVT in low-moderate PTP)

  • US if Wells' score > 3

    • Compression US (CUS) with Doppler is diagnostic test of choice

      • Thrombosed veins are "non-compressible" on US

    • Venous duplex US has less accuracy than CUS but can be done

      • Contrast venography was gold standard

Pre-Test Probability (Wells' score) > 3 points = high PTP

1 Point each:

  • Paralysis, recent lower ext. ortho cast

  • Bedbound > 3d or major surgery in past 4wks

  • Localized tenderness in deep vein

  • Entire leg swollen

  • Calf swelling > 3 cm (compared to unaffected leg)

  • Pitting edema in affected leg

  • Collateral nonvaricose superficial veins

  • Active cancer/cancer tx

Minus 2 points: Alternative dx as likely

  • D-dimer is elevated in a lot of conditions (not specific) and is used to ↓ unnecessary imaging

    • From a test question perspective... I'd probably pick US

  • CUS: pressure applied with probe to a non-thrombosed vein lumen will be occluded on application (Non-thrombosed vein is compressible)

  • Migrating thrombophlebitis ➔ think cancer workup

  • Any VTE issue ➔ think hypercoag workup (preg, lupus)


  • Initial anticoagulation (10d) then long term anticoagulation (10d - 3mo)

    • Low molecular weight heparin (LMWH) alone (SQ injection): cancer, pregnancy, liver dz

    • LMWH + warfarin

    • LMWH 5-10d then DOACs (dabigatran or edoxaban)

    • DOACs (dabigatran or edoxaban) alone

  • Recurrent VTE or absolute CI to anticoagulation (recent surgery, hemorrhagic stroke, active bleeding) gets IVC filter

  • LMWH potentiates the natural anticoagulant in body (antithrombin)

    • No monitoring needed

    • Antidote: Protamine sulfate

  • Warfarin should not be given alone for initial anticoag because it takes too long to start working and ↑ risk of clotting when starting

    • Monitor PT, INR to therapeutic level: 2-3

    • Antidote: Vitamin K, fresh frozen plasma (FFP) for severe bleeding

  • Dabigatran reversal with idarucizumab, no antidote for edoxaban

  • IVC filter will not ↓ PE if thrombus origin is cardiac or renal/upper extremity veins

DVT/PE prophylaxis

Consider VTE ppx in hospitalized medical pts with ↑ risk of VTE

+ 3 points

  • Active cancer

  • Previous VTE

  • Reduced mobility

  • Thrombophilia

+ 2 points

  • Trauma/surgery in past mo

+ 1 points

  • > 70yo

  • HF/resp failure

  • Acute MI/CVA

  • Acute infection/Rheum

  • Obesity

  • Hormone tx

Venous insufficiency & varicose veins

  • Malfunctioning valves ➔ ↑ venous pressure ➔ fluid accumulation ➔ skin changes and ulcer formation

  • ↑ pressure ➔ reflux into superficial veins ➔ dilation ➔ varicose veins

  • RF: HX of thrombosis, ↑ BMI/ ↓ PA, pregnancy, smoking


  • Pain (worse with standing) relieved with elevation/walking

  • Stasis dermatitis: itchy, scaly, crusty, brown/purple, weeping

    • RBC breakdown ➔ hemosiderin deposits in skin ➔ hyper-pigmented skin

    • Atrophy ➔ fibrotic tissue without capillaries ➔ hypopigmented plaques (atrophie blanche)

  • Dependent pitting edema

  • Medial malleolus ulcers


  • Duplex US shows venous reflux


  • Compression stocking, exercise, leg elevation, wound care

    • Cosmetic ablation for varicose veins

  • Wound care


  • Superficial vein thrombus ➔ palpable cord, tenderness along vein course, warmth, erythema

    • IV catheter, factor 5 Laiden MCC, pregnancy, varicose veins

  • DX

    • R/o DVT with US

  • TX sx with NSAIDs, warm compress, elevation, encourage ambulation

    • Evaluate underlying cause and consider anticoagulation to prevent DVT