VTE at Unusual Sites (bsh 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

Management:

  • 7 days LMWH (ICH is not a contraindication)

  • Followed by

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

    • 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

Management:

  • 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

Management:

  • 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

 

Management:

  • 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

Management:

  • 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

Ix: JAK2, PNH

Management:

  • 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

Outcome:

Management:

  • 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