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This is a video exploring deep vein thrombosis presented by the University of Sheffield Radiology Society. Let's start off by looking at an example case to understand some of the key themes and presentations you may encounter. When presented with a potential DVT. Please post the video here and gather some thoughts and ideas. The following highlighted sections show many reasons. One would query a possible DVT. Key points include unilateral leg pain and swelling, recent surgical history. Let's now try to calculate her well score. Here is the case again and a table for the well score. Please pause the video and calculate the patient's score. After reviewing the case, there is no mention of cancer paralysis, paralysis of the lower extremities or mention of previous DVT. She has however been bedridden for five days last month. Scoring one point has calf swelling four centimeters larger compared to the asymptomatic side, scoring another point and has pitting edema that is confined to the right symptomatic leg. And she scores a final point for having superficial veins on the right side compared to the left. Overall, this patient scores four points as the score is over two, a diagnosis of DVT is quite likely a DVT may present with symptoms of a pulmonary embolism. So it is important to recognize this. There is another in depth video on pulmonary embolism in this teaching series that you may wish to watch. However, some of the key presentations include shortness of breath, chest pain, hemoptysis, and cough. Now, let's talk about some of the signs and symptoms of A DVT. A unilateral hot, swollen, painful or tender leg is characteristic of DVT presentation. There may be also additional signs such as peripheral edema or dilated superficial veins in the symptomatic leg. It is always important to have a look at the other leg as well. Risk factors for DVT include some of the criteria of the well score such as immobilization, recent surgery, hospitalization, active cancer or previous history of venous thrombosis. Advancing age is another risk factor. Pregnancy increases risk of VTE e not only because it makes the blood more likely to clot, but it can also cause periods of immobility, hereditary thrombophilias and estrogen containing drugs such as the combined pill are other risk factors. Now, let's talk about the pathophysiology. It all comes down to VT child's triad, which is three do means including hypercoagulability of the blood changes in vascular flow and endothelial dysfunction. Any of these components can make the blood more likely to form a thrombus in the venous system and present as a DVT. Some conditions that can make the blood hypercoagulable include dehydration active malignancy, thrombophilias and pregnancy, vascular stasis can contribute to alterations in vascular flow as vascular stasis can lead to blood pooling in the venous system and predisposed thrombosis, endothelial dysfunction acts as a stimulus for inappropriate activation of the coagulation cascade. If A DVT is suspected, the well score should be calculated from the criteria in the table shown on the left of the screen. If the wells score is less than two, perform a DDIMER test. If it is elevated, then request a venous ultrasound. A normal DDIMER test excludes a DVT. And you should consider an alternative diagnosis. If the well score is more than two, then a DVT is likely so immediately order a venous ultrasound. If the ultrasound is positive for a DVT, then start treatment according to local guidelines. However, if the ultrasound is negative, follow up with ad dimer test, remember, ad dimer is not specific and therefore a positive test cannot confirm DVT. If the patient is pregnant, then the well score and D dimer test cannot be used. So, consider the diagnosis of DVT with a high index of suspicion. If the DDIMER or ultrasound results are not available within four hours, start interim therapeutic anticoagulation until the results are available. If starting treatment, order a full blood count, U ND and LFT S and A clotting screen for baseline reading. But please do not delay treatment. Waiting for these results in the UK, proximal ultrasound or whole leg ultrasound may be used depending on the trust. While nice only recommends proximal ultrasound. The European Society of Vascular Surgeons recommends whole leg ultrasounds for calf DVTs in randomized controlled top trials, both have been found to be clinically equivalent and therefore equally safe and acceptable. The most definitive sign of A DVT is the inability to compress the vein fully due to the presence of the thrombus. As can be seen in the image on the left. Sometimes the thrombus can be directly visualized appearing hyperechoic or hypo echoic depending on the age of the clot. As can be seen on the image on the right absence of Doppler flow can be another indicator. The immediate first line management for DVT is anticoagulations with a DOAC if a doac is unsuitable warfarin or low molecular weight, heparin may be used. However, they require additional steps to consult guidelines before starting the most common direct for DVT is Apixaban or Rivaroxaban. Take into account the patient's comorbidities, contraindications and local guidelines before choosing the anticoagulant. Some contraindications to anticoagulation include active bleeding, recent intracranial hemorrhage, imminent surgery with high bleeding risk and platelet count below 50,000. Consult a hematologist. If the patient has contraindications for a confirmed proximal DVT, give anticoagulation for at least three months. If the DVT has a provoking factor which is no longer present, then consider stopping the treatment if the DVT was unprovoked. Consider continuing anticoagulation in patients with active cancer, anticoagulation should be given for at least six months. An IVC filter can be considered for patients who are getting recurrent DVTs or if anticoagulation is contraindicated for them. An IVC filter is a metal device which is inserted percutaneously through the groin and placed into the inferior vena cava to prevent large thromboses from traveling to the lungs and causing a pulmonary embolism. There are specific guidelines according to nice of when an IVC can be used if there is a contraindication to anticoagulation or if there is recurrent thrombosis despite anticoagulation, if a pe has occurred while on anticoagulation and all the recommended steps for treatment failure have been taken. There must be a strategy in place for the removal of the filter at the earliest possible opportunity. Here is a summary of management plans based on the nice guidelines and sign guidelines. It is worth mentioning. Nice does not recommend the use of compression stockings. So in summary, A DVT is caused by coagulation in the venous system due to any of the components in VT child triad such as hypercoagulability, vascular stais and endothelial dysfunction. A well score is used to guide diagnosis and investigations management includes anticoagulation, IVC filter or referral to hematology. Thank you for listening and we hope you found this video useful