Venous thromboembolic complications (VTC) is a term that combines three acute vascular pathologies characterized by blood clots. These conditions include acute thrombophlebitis or varicothrombophlebitis (AF or VTC), deep vein thrombosis or acute venous thrombosis (DVT), and pulmonary embolism (PE). These diseases, which affect the venous system and are very dangerous, are characterized by a wide variety of manifestations and a severe malignant course. The social and economic significance of these diseases is due to fatal complications, the development of severe chronic post-thrombotic disease after thrombosis, frequent disability of patients, and high mortality, including hospital mortality.
The history of studying deep vein thrombosis goes back more than 400 years. The first mention of phlebothrombosis appeared in medical literature 300 years ago. A special interest in deep vein thrombosis arose after the creation of the theory of venous thromboembolism, when a triad of causes leading to the formation of blood clots in blood vessels was formulated: increased blood clotting, damage to the inner surface of the vessel and slowing of blood flow. These components remain relevant today. Further research was devoted to an in-depth study of the body's response to thrombosis and the factors that affect the spread of thrombotic masses, as well as the changes that occur in response to the thrombotic process in the body as a whole and in the coagulation system, in particular in the affected vessels. It should be noted that in recent years there have been global changes in diagnostics (modern ultrasound machines and spiral CT scans have appeared), new, more effective, safe and patient-friendly drugs for the treatment and prevention of thrombosis have been developed and put into practice, completely new, clear and specific standards for the treatment of such serious diseases have been developed, and approaches to tactics and methods of treatment have been radically changed.
The main risk factor for VTC is lower extremity varicose veins (LEV). In this disease, a significant amount of “excess” blood accumulates in the dilated veins of the legs. The blood flow rate slows down dramatically, which leads to blood clots in the superficial veins. It is known that with severe varicose vein changes, “abnormal” connections between the superficial and deep veins develop, so blood clots from the superficial veins easily enter the muscle connecting (perforating, communicating) veins, and then the deep veins. Deep vein thrombosis is already more dangerous and severe, and when blood clots spread through the bloodstream up to the heart, it leads to the most severe and fatal complication - pulmonary embolism.
Thrombophlebitis
Thrombophlebitis is a disease in which blood clots form in the superficial veins. As a rule, it occurs on the background of trauma, hypothermia and overheating, and is also a consequence of certain diseases, including blood (thrombophilia), past infections (mumps), hormonal disorders and severe blood clotting disorders (taking certain medications). However, most often blood clots are formed in altered superficial veins - varicose veins. In this case, the disease is called varicothrombophlebitis.
The main symptoms of thrombophlebitis are sudden appearance of a dense cord along the course of normal or varicose veins, painful when pressed and hot, the skin above it is sharply red. Thrombophlebitis is always accompanied by a pronounced inflammatory reaction of the tissues surrounding the veins. The most common symptom of the pathology is swelling of the leg, sometimes the body temperature may rise. Such seals are formed on the lower leg, but can gradually spread to other parts of the lower leg and thigh. In this case, one speaks of ascending thrombophlebitis, which is an indication of the malignancy of the process, the growth of a blood clot and a high risk of its migration due to the transition to deep veins and heart vessels. This condition is an indication for emergency surgery. Thrombophlebitis can also be localized, when blood clots have formed in one small area and are not particularly disturbing. In such cases, conservative treatment, the use of elastic compression and certain medications, as well as active local therapy is possible. However, it is necessary to realize that any thrombotic process in the body is always active, unpredictable and dangerous for the development of further complications - the formation of blood clots in other vessels, such as the heart or brain. Even with the onset of improvement and reduction of inflammation, the process can resume again after some time.
Based on this, any thrombophlebitis is an indication for surgical treatment - removal of the affected veins with blood clots. Such an operation is technically difficult, traumatic, and has a long rehabilitation period. Experts always insist that varicose veins should be removed on time, namely, at the initial stages without complications. After all, at this stage of the disease development, modern technologies of outpatient surgical treatment can be used, which can no longer be used in the complicated form of the disease.
Diagnosis of thrombophlebitis is carried out during the examination and does not cause difficulties. Additionally, an ultrasound of the veins is performed to clarify the localization of thrombotic masses and the absence of their spread to deep veins, as well as to select the method of surgery.
Phlebothrombosis
When blood clots occur in the deep veins, acute phlebothrombosis develops - a dangerous and severe disease of the veins of the lower extremities that requires immediate and extensive treatment. This particular disease is most dangerous due to the detachment of a blood clot and its entry from the deep veins into the heart vessels and possible death. Thus, venous thrombosis is a condition that is potentially life-threatening.
Phlebothrombosis can occur spontaneously (during a long flight and travel) in the elderly, as well as against the background of many diseases (heart, blood, oncological diseases, connective tissue diseases, congenital diseases of the coagulation system). Deep vein thrombosis is often caused by leg injuries and prolonged immobilization after them, sudden overheating, water imbalance due to an improper diet, taking certain medications, hormonal imbalance, and overweight. Thrombosis often complicates surgeries, as well as the course of pregnancy and childbirth.
The main manifestations of phlebothrombosis are sharp pain in the lower leg that occurs suddenly. A person feels as if a string is being pulled in the muscles, compression and swelling in the lower leg, which intensifies when walking and moving the foot. A clear symptom of thrombosis is severe swelling of the lower leg or thigh. Another common sign of thrombosis is a change in the color of the skin of the legs, its blueness. Therefore, if such symptoms occur, you should immediately consult a specialist for timely and adequate treatment.
Subsequently, with a favorable course of deep vein thrombosis, without its progression and development of the body, a condition called post-thrombotic disease is formed. This pathology develops gradually, in direct connection with the process of resorption of blood clots in the veins, because the thrombotic process affects the vein wall and venous valves, which no longer work normally. The disease is manifested by signs of chronic venous insufficiency, persistent pain and edema syndrome, the appearance of varicose veins, and subsequently - trophic changes in the skin of the lower legs and, as a result, trophic ulcers.
It should be noted that very often the clinical picture of phlebothrombosis is “blurred”, implicit, as if disguised as signs of another disease (in case of trauma), and sometimes it is asymptomatic (“silent” phlebothrombosis). As a result, severe complications suddenly arise, as if “out of the blue.” This most often happens during the period of immobilization after injuries.
Diagnostics of venous thrombosis is performed by ultrasound examination. Modern ultrasound devices allow to diagnose deep vein thrombosis quite clearly, visualize the localization of thrombotic masses, their nature (occlusive, parietal, floating), the boundaries of the thrombotic process, as well as assess the massiveness of the lesion, the degree of venous circulation disorder and the state of blood flow compensation pathways. In addition, laboratory tests of the blood and coagulation system are necessary to further monitor changes during treatment and determine its effectiveness. In some cases, contrast computed tomography - phlebography - may be performed. In addition to instrumental methods, laboratory diagnostics of the blood, coagulation system, and determination of the thrombosis marker D-dimer are necessary.
The treatment of phlebothrombosis directly depends on the timing of thrombosis. The sooner you start treating this dangerous condition, the more positive its effect will be. There is a concept of “golden” 6-12 hours - these are the first hours after the onset of the pathology, when an active effect on the “growing” thrombus is possible by administering special medications - thrombolytics that dissolve the thrombus. Such drugs can be administered both systemically, in the form of intravenous infusions, and locally, i.e. directly into the thrombosed vessel (the so-called catheter thrombolysis). If this time is missed, active and extensive conservative therapy is prescribed, aimed at various components of the thrombotic process.
The basis of treatment for any thrombosis is anticoagulants, a group of drugs that “thin” the blood and prevent it from clotting. These medications are administered in stages: first, more active direct anticoagulants are injected, and then the patient is switched to taking indirect anticoagulants in tablets for a long time. This treatment is aimed at stopping blood clots from forming and spreading, as well as helping the body to gradually “dissolve” blood clots. Gradual resorption of thrombotic masses in the veins takes a long time, several years. This process leads to the development of post-thrombotic disease, which affects both the vein wall and the valve apparatus. Note that these changes are often irreversible. If treatment is started in a timely manner, professionally and with modern drugs, the resorption of blood clots is, firstly, controlled and predictable, and secondly, much faster. When using the latest generation of anticoagulants, this process lasts 3-6 months and is more benign. In this case, the phenomena of CVI are less pronounced and compensated. The clear advantages of new anticoagulants include greater safety, no need for constant monitoring of blood coagulation parameters, and ease of administration. In addition, the mandatory components of the treatment of phlebothrombosis of any localization are the mandatory compliance with the regimen of elastic leg compression (elastic bandages or medical compression knitwear) and the use of phlebotropic drugs.
In certain situations, when the clinical picture of phlebothrombosis is pronounced, there is severe swelling of the limb and severe pain, and ultrasound revealed the localization of thrombotic masses in the upper thigh with spread to the pelvic veins, when there is a high probability of a piece of thrombus detachment and its migration into the heart vessels, as well as in situations where thrombosis affects several segments, when the effectiveness of conservative therapy is questionable and the achievement of a positive result seems doubtful, indications for surgical treatment are given.
In such an operation, blood clots are removed and venous blood flow is restored. Sometimes, if it is impossible to perform the operation and at high risk of developing fatal complications, a special “blood clot catcher” - a coffee filter - is implanted in the main vein of the abdominal cavity. Recently, preference has been given to temporary coffee filters, which are removed after reducing the risk of blood clots, since permanent filters, which were installed until recently, cause a large number of complications, aggravating the course of the disease and the process of blood clots resorption due to a pronounced violation of venous circulation. After the surgical intervention, a course of massive conservative therapy is mandatory in a hospital setting. Recently, a large number of studies have been conducted and low-traumatic methods of blood clot removal have been developed that can be performed on an outpatient basis.
It should be noted that in the context of timely and adequate treatment of phlebothrombosis, only 5% of cases develop DVT, which leads to death in 1% of patients.
Patients who have undergone phlebothrombosis should be under the supervision of a narrow specialist to monitor the course of the disease, the severity of clinical manifestations of post-thrombotic disease, and the effectiveness of the therapy. Such observation makes it possible to respond to any changes in a timely manner, adjust prescriptions, and guarantee the best possible positive treatment outcome.
Pulmonary embolism (PE)
In case of a malignant thrombotic process, its progression or lack of timely treatment, blood clots spread by blood flow from the veins of the legs to the veins of the heart. In this case, a condition called pulmonary embolism (PE) occurs. In this case, blood clots enter the vessels of the small circle of blood circulation and the lungs, causing a sharp overload of the respiratory and cardiac systems. Such disorders often result in death. This disease is one of the causes of death for a large number of people, along with heart attack and stroke, which are also thrombotic processes. The death rate is 30%. Massive DVT as a cause of sudden death ranks second after cardiac arrest due to heart disease and third among the causes of death in general.
TEMP is characterized by sudden onset, rapid development and severe cardiopulmonary disorders. In this state, loss of consciousness, coughing up blood, sudden blue face, severe shortness of breath, cough, interruptions in cardiac activity, and rhythm disturbances are possible. There is also severe chest pain that worsens with breathing, a sharp drop in blood pressure, and often a heart attack of the affected lung. However, classic manifestations are very rare, most often the disease is disguised as other diseases.
TELA is characterized by sudden onset, rapid development and severe cardiopulmonary disorders. In this state, loss of consciousness, coughing up blood, sudden blue face, severe shortness of breath, cough, interruptions in cardiac activity, and rhythm disturbances are possible. There is also severe chest pain that worsens with breathing, a sharp drop in blood pressure, and often a heart attack of the affected lung. However, classic manifestations are very rare, most often the disease is disguised as other diseases.
The risk factors for the occurrence of TELA include:
- old age,
- injuries, especially with prolonged immobilization
- obesity
- some surgical procedures,
- pregnancy
- early postpartum period,
- taking hormonal drugs,
- oncological diseases,
- chronic heart failure,
- systemic connective tissue diseases,
- rheumatism,
- atrial fibrillation,
- previous thrombosis,
- severe infections,
- bed rest,
- peripheral vein catheterization for infusion therapy,
- varicose veins,
- congenital diseases of the blood coagulation system.
VTC is a problem faced by both surgical and therapeutic specialists. The problem of diagnostics is the limited time for its implementation and the need to start treatment quickly. The diagnosis of this disease is based on the suspicion of the disease in the presence of characteristic symptoms and risk factors. The most informative diagnostic methods are angiopulmonography - contrast examination of lung and heart vessels under X-ray, as well as spiral computed tomography and contrast MRI. The disadvantage of the first method is its invasiveness. In terms of the quality of information obtained, all these methods are almost identical. Therefore, preference is still given to non-traumatic diagnostic methods - CT and MRI. Auxiliary methods include ECG, ultrasound of the heart, lung x-ray, lung scintigraphy, ultrasound of the veins of the lower extremities. In laboratory diagnostics, the level of D-dimer, specific cardiac troponins, and coagulation system parameters are examined.
Treatment of TELA is a serious clinical problem because of the time limitations for the effectiveness of measures and because of severe disorders of vital functions of the body and the need for their prompt correction.
If the patient is delivered to a medical facility in time, specific therapy will be initiated after assessing the degree of TEPA, performing the necessary diagnostic tests and conducting primary stabilization measures. In the first hours after the onset of DVT, the most effective and prognostically favorable treatment is thrombolysis, i.e. dissolution of the thrombus with certain substances. As a rule, systemic thrombolysis is performed (by intravenous infusion), but sometimes regional thrombolysis is also used, that is, the drug is injected directly into the vessel that is filled with thrombotic masses. This method will be most effective in the first 6-12 hours. After 48 hours from the onset of the disease, its effectiveness will decrease and even cause a high risk of complications - bleeding. Although sometimes a positive effect can be expected even after 2 weeks from the onset of the disease. In the future, massive anticoagulant therapy will be carried out in parallel, carried out in stages using different groups of anticoagulants. Therapy is often used as an alternative to thrombolysis. The main difference between these two methods of treatment is the speed of onset of the effect and the frequency of achieving the result - more aggressive thrombolytics are characterized by a rapid onset of action and complete restoration of vascular patency due to active thrombus breakdown. However, the risk of massive bleeding as a complication of thrombolytic treatment is several times higher. Therefore, thrombolytics are currently used in patients with a high TELA-associated risk of death in cases where the speed of pulmonary blood flow recovery is crucial for survival.
In specialized hospitals, surgical treatment is also possible, such as removal of blood clots (the operation is classified as cardiac surgery), mechanical and chemical thrombolysis or thrombectomy, and implantation of a coffee filter. However, surgical methods are rarely used because the possibilities are limited by the patient's condition, high risk of complications and mortality.
Intensive care measures, as well as symptomatic therapy, correction of respiratory failure, restoration of hemodynamics, adequate and rapid recovery of the body's vital functions are of great importance in the treatment of thromboembolism. It is also important to note the need for a high level of staff training to provide timely and up-to-date care.
The treatment of this formidable disease is based on a differentiated approach to the choice of treatment tactics and combined antithrombotic therapy. International standards and guidelines for the treatment of DVT based on the principles of evidence-based medicine have been developed and implemented in clinical practice.
These principles guide our practice as well. As a multidisciplinary clinic, Dobrobut Medical Center has all the modern facilities for the successful and timely treatment of any venous thromboembolic complications, including the possibility of providing emergency and urgent care.
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