Deep vein thrombosis classification scheme

Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] ;Kashish Goel, M.D.; Assistant Editor(s)-In-Chief: Justine Cadet

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Overview

Deep vein thrombosis (DVT) is classified based on the site of occlusion or clot formation. Symptom presentation and complication is largely influenced by location of the embolus.

Classification

Classification Based on Site of Thrombus Formation

• Upper extremity deep vein thrombosis (DVT): DVT of the upper limbs.
• Lower extremity DVT: DVT of the lower limbs, which is subdivided into two categories:
  • Proximal vein thrombosis: Occur in the legs, and involve the popliteal, femoral or iliac veins
  • Distal (calf) vein thrombosis: Confined to the deep calf veins

In studies including inpatients, 80% of DVTs are proximal and distal DVT accounts for only 20% of all DVTs, while studies with outpatients report a proportion of distal DVT as high as 60–70%.

Proximal Vein Thrombosis

Proximal vein thrombosis involves the proximal veins, including the popliteal, femoral, or iliac vein. Proximal vein thrombosis is responsible for more than 90% of acute pulmonary emboli and is associated with higher mortality. Clinically, proximal vein thrombosis is considered severe, as it is more commonly associated with serious, chronic diseases, such as:

• Active cancer.
• Congestive heart failure.
• Respiratory insufficiency.

More than 90% of cases of acute pulmonary embolism are due to emboli emanating from the proximal, rather than the distal vein, veins of the lower extremities.

Distal Vein Thrombosis

Distal or calf deep vein thrombosis involves infrapopliteal veins [ie, posterior tibial veins, peroneal veins, anterior tibial veins and muscular calf veins (soleal or gemellar veins)]. It is often associated with transient risk factors, such as:

• Recent surgery.
• Immobilization.
• Travel.

Calf Vein Thrombosis

• It causes 50% of DVTs.

• High risk of embolization.

• Recurrence rate is low compared to proximal DVTs.

ACCP Guidelines for Calf Vein Thrombosis -

• If symptoms are not severe with no risk factors, repeat ultrasound can be done weekly. (Grade 2C recommendation)

• If symptoms are severe, then treatment is required.(Grade 2C recommendation)

• If there is propagation of a thrombus, treatment is required. (Grade 1B recommendation)

• Duration treatment is low, 3 months.

Upper Extremity DVT

• It is uncommon and accounts for 4 % of all VTE.

• It is most likely due to:
  • Central venous catheters
  • Effort thrombosis (Paget schoroeder syndrome)
  • Cancer

• Risk of embolizing to PE is less. (10%)
• Risk of fatality is very low (1%).
• Catheter directed thrombolytic therapy.
• Anticoagulants for a period of 3 months.

Classification Based on Depth of Thrombus Formation

Superficial Versus Deep

• A palpable thrombus formation is classified as a superficial venous thrombus. Clots forming in the lower leg and thigh vasculature (lesser and greater saphenous veins, respectively) or the forearm and upper arm vasculature (radial, ulnar, cephalic and basilic vein, respectively) are also superficial.

• Thrombus formation in the brachiocephalic veins, the internal jugular and the superior vena cava are classified as deep.

Classification Based on Clinical Presentation

Subacute versus acute:

• Subacute thrombosis refers to thrombosis formation involving a narrowing of the vein involved and a hyperechogenic clot; flow may be partially obstructed by this narrowing.
• Acute thrombosis can refer to:

• A vein with a thrombus that is normal or, even, wider than usual with the contralateral side of the vein being unaffected.
• A clot that, during ultrasound echos, is not dense.
• A clot that may totally or partially obstruct blood flow.
• In the evaluation of the upper extremity, the subclavian and brachiocephalic veins inability to be compressed may pose challenges for determining subacute versus acute status.