VTE at Unusual Sites (2012)


Cerebral Venous Sinus Thrombosis


1% of all strokes. 75% of cases are female.

Sx: headache, stroke-like symptoms, intracranial hypertension, haemorrhagic infarcts

Associations: Head/neck infection, asparaginase, cancer, áHb, áplt, COCP, obesity

Ix: MR Venography


-       7 days LMWH (ICH is not a contraindication)

-       Followed by

o   Warfarin for 3 months if provoked – low risk of recurrence

o   Warfarin for >3 months if unprovoked, persisting risks, persisting abnormal MRI or AT/Prot C/Prot S deficiencies.


Retinal Vein Occlusion (RVO)


Sx: Acute painless visual loss

Associations: Hypertension, Diabetes, hypercholesterolaemia


-       Routine anticoagulation not beneficial

-       Possible role for LMWH in acute central RVO

-       Laser therapy, intraocular steroids and antiangiogenics


Upper Extremity DVT (UEDVT)


10% of all DVT

Primary – Idiopathic, Thoracic Outlet Syndrome (e.g. 1st rib)

Secondary – CVC line, Plaster cast, Lemierre Syndrome (Jugular vein thrombosis in infection)

Ix: USS or venography

Outcome: Unprovoked cases - 2% recurrence in 5 years, compared to 19% for lower limb DVT


-       Optimal duration of treatment not known

-       3-6 months associated with reduced risk of recurrence

-       Consider 6 weeks for line-associated if line removed


SVC Thrombosis



-       Angioplasty and stenting if severe symptoms in a non-malignant case

-       Long term anticoagulation if risk factors persist

-       Consider radiotherapy in malignant cases


IVC Thrombosis


Ix: Look for IVCT in cases of bilateral DVT

Outcome: Natural history is of permanent blockage with growth of collaterals


-       Anticoagulate as for DVT

-       Consider catheter-delivered thrombolysis or endovascular surgery



Intra-Abdominal Vein Thombosis (Portal, hepatic, mesenteric, splenic)


Portal – most commonly associated with cirrhosis (MPN in 25% of cases)

Hepatic – pain + ascites + hepatomegaly = Budd Chiari Syndrome.  50% are MPN, 30% JAK2+

Mesenteric – ischaemic gut

Splenic – rare in isolation



-       Long term AC if underlying MPN or PNH

-       Heritable thrombophilia testing not indicated as does not change management

-       PVT with cirrhosis – risk usually outweighs the benefit so avoid AC

-       MVT without peritonitis can be managed with 3-6 months AC


Renal Vein Thrombosis


No routine investigation for thrombophilia

Anticoagulation depends on the underlying cause and risk of haemorrhage


Ovarian Vein Thrombosis


Postpartum OVT – treat with 3-6 months AC

Incidental OVT found after TAH-BSO does not require treatment


Penile Vein Thrombosis


No treatment required


Superficial Lower Limb Vein Thrombosis (SVT)


Ix: Rule out DVT



-       AC if within 3cm of the superficial femoral junction (SFJ)

-       LMWH for 30 days if SVT + risk factors for extension

-       10 days NSAIDs for other SVTs