ABSTRACT
It has been estimated that each year, nearly 200,000 people in the United States die from complications from venous thrombosis of the lower extremity.[1] The figures from Great Britain are no less impressive, with an estimated annual mortality rate of 21,000.[2] Lower extremity venous thrombosis frequently accompanies other disease processes, and several conditions predispose to its development (Table 9-1). Procedures such as transjugular and transsubclavian catheterization and infusion lines, transvenous pacemaker insertions, and intravenous hyperalimentation have led to a remarkable increase in the incidence of brachiocephalic and upper extremity venous thrombosis. This iatrogenic thrombosis is superimposed on a generally low, but potentially crippling incidence of upper extremity venous occlusion associated with thoracic outlet syndrome. While it was formerly believed that pulmonary embolism rarely occurred in patients with brachiocephalic or upper extremity venous thrombosis, an incidence of pulmonary embolism of 12% has now been documented.[3-5]
Despite a great deal of experience with lower extremity venous thrombosis, uncertainty continues regarding the optimum treatment during the acute stages and optimum methods of long-term management. However, there has been significant progress over the last several years in the development of noninvasive techniques for diagnosing both venous obstruction and venous insufficiency. As will be discussed in subsequent sections, these techniques have significant advantages over the invasive counterparts, such as contrast phlebography, and they have been shown to have comparable cost-effectiveness.[6]
The most common symptom reported by patients with lower extremity deep venous thrombosis (DVT) is pain. The pain may be mild and insidious in patients with thrombosis of the calf veins, or it may be acute and excruciating in patients with iliofemoral thrombosis and extensive venous occlusion such as phlegmasia cerulea dolens. Most commonly, it is described as a dull ache, throbbing sensation, feeling of tightness, or a feeling that the leg is about to burst. These symptoms are present at rest and may be aggravated by walking. Unfortunately, many patients, particularly those who are postoperative or critically ill from other diseases, have no symptoms related to the leg and their first manifestation of venous thrombosis is an episode of pulmonary embolism.
