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ORIGINAL ARTICLE
Year : 2016  |  Volume : 29  |  Issue : 3  |  Page : 554-558

Management of isolated calf vein thrombosis


1 General Surgery Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Shebein El-kom Teaching Hospital, Shebin Elkom, Egypt

Date of Submission10-Mar-2015
Date of Acceptance12-May-2015
Date of Web Publication23-Jan-2017

Correspondence Address:
Mohammed S Shalan
El Shohada, El Menoufia, 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.198699

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  Abstract 

Objective
The aim of the present study was to evaluate a protocol for managing isolated calf vein thrombosis.
Background
Deep vein thrombosis (DVT), which is common among the general population, can lead to fatal pulmonary embolism; therefore, its early diagnosis is essential. A recent study revealed that the reason for 10% of mortality in general hospitals in the UK was pulmonary embolism.
Patients and methods
Forty patients with isolated calf vein thrombosis were categorized into two groups: group A, which included 20 patients with provoked isolated calf vein thrombosis; and group B, which included 20 patients with unprovoked isolated calf vein thrombosis.
Results
In the provoked group, 16 patients had satisfactory resolution after 10 days of therapy (80%), four patients had no resolution (20%), and no patient had progression to the popliteal vein. On the other hand, in the unprovoked group, 14 patients had satisfactory resolution (70%), four patients had no resolution (20%), and two patients had progression to the popliteal vein (10%) (P = 0.34). Sixteen patients in the provoked group had no recurrence at the end of 3 months (80%), three patients had recurrence of the calf thrombosis (15%), and one patient had progression to the popliteal vein (5%), whereas in the unprovoked group, 14 patients had no recurrence (70%), four patients had recurrence of calf thrombosis (20%), and two patients had progression to the popliteal vein (10%) (P = 0.74).
Conclusion
Provoked calf vein thrombosis can be treated with low molecular weight heparin (LMWH) for 10 days and then the duplex should be repeated after 10 days. If there is no progression to thrombus, anticoagulation therapy is stopped and the patient is asked to use elastic stockings. Unprovoked calf vein thrombosis can be treated with LMWH for 10 days, and if there is no propagation to the thrombus, we can put the patients on low intensity warfarin dose regimen - for example, 1-2 mg to adjust INR in the range 1-1.9.

Keywords: deep vein thrombosis, isolated calf vein thrombosis, pulmonary embolism


How to cite this article:
Saleh HA, Zied NA, Shalan MS. Management of isolated calf vein thrombosis. Menoufia Med J 2016;29:554-8

How to cite this URL:
Saleh HA, Zied NA, Shalan MS. Management of isolated calf vein thrombosis. Menoufia Med J [serial online] 2016 [cited 2020 Aug 15];29:554-8. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/554/198699


  Introduction Top


Deep vein thrombosis (DVT) is a silent killer [1] .

It is a serious threat to recovery from surgery and is the third most common vascular disease, after ischemic heart disease and stroke [2] .

DVT is common among the general population, and, if left untreated, can lead to fatal pulmonary embolism (PE); therefore, its early diagnosis is essential. A recent study revealed the reason for 10% of mortality in general hospitals in the UK was PE [3] .

The estimated incidence of acute symptomatic DVT is approximately one in 1000 per annum in the general population [4] .

The three factors of Virchow's triad - venous stasis, hypercoagulability, and changes in the blood vessel wall endothelium such as physical damage or endothelial activation - contribute to DVT and are used to explain its formation [5] .

Despite treatment, 6% of patients with acute DVT develop potentially life-threatening PE, 12% recurrent DVT, and at least 20% debilitating post-thrombotic syndrome within 2 years after diagnosis [6] .

Calf vein thrombosis is defined as any clot involving the deep veins of the calf that did not extend into the popliteal vein. The calf veins are three paired veins (posterior tibial, peroneal, and anterior tibial) and two nonpaired muscular veins (soleal and gastrocnemial). Usually the most common veins involved are the peroneal [7] .

The deep venous distal thrombosis often starts from the calf muscular veins and can extend to proximal veins in 25% of the cases during the first week [8] .

The natural history of isolated calf muscle thrombi has not yet been fully elucidated. Isolated calf muscle vein thrombosis has been suggested as being the first step in the natural course of DVT and also in symptomatic PE, but there is a high likelihood of spontaneous regression [9] .

The goal in managing DVT remains the prevention of thrombus propagation, avoidance of embolization, and reduction of venous insufficiency due to intraluminal venous thrombosis. However, some studies have shown, in the absence of treatment, a trivial rate of propagation of calf vein thrombosis to the popliteal venous segment with no instances of pulmonary embolization [10] .


  Patients and methods Top


Our study was a randomized control follow-up clinical trial conducted on 40 patients having isolated calf vein thrombosis who attended the Menoufia University, ACMC (Arab Contractors Medical Center) and Wadi El Nile Hospitals during the period from May 2011 to May 2014. The study was conducted after taking an informed consent from each patient.

Exclusion criteria

The exclusion criteria included: thrombus in the popliteal vein or any vein above it; PE; multiple trauma; isolated calf vein thrombosis; psychic disturbances; ongoing anticoagulation therapy for any other causes; and isolated calf vein thrombosis with severe renal or hepatic failure.

On admission all patients subjected to the following:

  1. Full clinical assessment, where the modified Wells score for predicting the probability of DVT diagnosis was used as a cornerstone in clinical evaluation.
  2. The d-dimer assay using VIDAS testing, which was performed for all patients before starting heparin.
  3. Color-coded duplex ultrasonography of the venous system of symptomatic limb.


The patients were categorized into two groups:

Group A: It included 20 patients having provoked isolated calf vein thrombosis.

These patients were given LMWH or (fondaparinux) in the therapeutic dose for 10 days. Duplex was carried out at the end of the 10 days to assess for the resolution of thrombosis or extension to the popliteal vein.

If there was no extension of thrombosis to the popliteal vein, the anticoagulation therapy was stopped and the patient continued on elastic stocking for 2 years. The patients were followed up clinically for DVT and/or PE. Follow-up duplex was carried out after 3, 6, and 9 months to assess for the resolution or recurrence of thrombosis.

Group B: It included 20 patients with unprovoked calf vein thrombosis. These patients were given LMWH (fondaparinux) in the therapeutic dose for 10 days; at the end of the 10 days duplex was carried out. If thrombosis was resolved or there was no extension to the popliteal vein, LMWH or fondaparinux was stopped and the patient was given low intensity warfarin dose regimen - for example, 1-2 mg to adjust international normalized ratio (INR) in the range 1-1.9. If extension of thrombosis occurred, full therapeutic dosage was started for 3 months to make INR in the range 2-3.5.

On admission, all patients were subjected to the following:

(1) Full clinical assessment, where the modified Wells score for predicting the probability of DVT diagnosis was used as a cornerstone in clinical evaluation that included the following:

(a) Active cancer (patient had received treatment for cancer within the previous 6 months or currently receiving palliative treatment), paralysis or paresis or recent plaster immobilization of lower extremities, recently bedridden for 3 days or more, major surgery within the previous 12 weeks requiring general or regional anesthesia, localized tenderness along the distribution of the deep venous system, swelling in the entire leg, calf swelling at least 3 cm larger than that on the contralateral side (measured 10 cm below the tibial tuberosity), pitting edema confined to the symptomatic leg, collateral superficial veins (nonvaricose), previously documented DVT, and alternative diagnosis at least as likely as DVT.

A score of 2 or higher indicated that the probability of DVT was likely; a score of less than 2 indicated that the probability of DVT was unlikely.

(2) The D-dimer assay using VIDAS testing, which was performed for all patients before starting heparin.

VIDAS is a rapid test and takes only 35 min. The cutoff value of VIDAS is 500 ng/ml.

The D-dimer level of 500 ng/ml or more was considered positive for DVT; the D-dimer level below 500 ng/ml was considered negative for DVT.

(3) All patients underwent color-coded duplex ultrasonography of the venous system for the symptomatic limb.

(a) The sonographer was blinded to the results of the clinical assessment and the d-dimer testing. The pelvic veins and common iliac, external iliac, common femoral, and superficial femoral veins were scanned with the patients in supine position. The distal venous segment, including popliteal and calf veins, were scanned with the patients in the sitting position.

Statistical analysis

Data were presented as mean ± SD (X ± SD) or percentage (%). The means of two groups were compared using Student's t-test and the Mann-Whitney U-test.

The χ2 -test was used to find the association between qualitative variables. In addition, linear correlation and regression were used to test the correlation between the measured parameters and the studied groups.

Data were tabulated and statistically analyzed using the Statistical Package for Social Sciences (SPPS), version 10 software (Spss Inc, Chicago, U.S.A). P values less than 0.05 were considered statistically significant.


  Results Top


In the present study, 40 patients were included and divided into two groups.

Group A : It included 20 patients with provoked calf vein thrombosis.

Group B : It included 20 patients with unprovoked calf vein thrombosis.

Baseline demographic data of the studied groups (age, sex):

[Table 1] shows that there were 18 male patients (45%) and 22 female patients (55%). The mean age of studied group was 44.9 ± 10.3 years. The age range was 20-65 years. No statistically significant difference was found as regards the d-dimer assay results between the provoked isolated calf vein thrombosis and unprovoked isolated calf vein thrombosis groups ([Table 1]).
Table 1 Sociodemographic data


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All the studied patients were positive for the d-dimer: the mean value in the provoked group was 69.9 ± 14.4 and in unprovoked group it was 70.2 ± 11.2. No statistically significant difference was found between the studied groups as regards pain, swelling in the calf, and tenderness in the calf ([Table 2]).
Table 2 D-Dimer assay (VIDAS)


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Nineteen patients in the provoked group had pain in the calf (95%) and 18 patients in the unprovoked group had pain in the calf (90%). Eighteen patients in the provoked group had swelling in the calf (90%) and 17 patients in the unprovoked group had swelling in the calf (85%). Eighteen patients in the provoked group had tenderness in the calf (90%) and 19 patients in the unprovoked group had tenderness in the calf (95%). At the end of 10 days of therapy, 16 patients in the provoked group had satisfactory resolution (80%), four patients had no resolution (20%), and no patient had progression to the popliteal vein. On the other hand, in the unprovoked group, 14 patients had satisfactory resolution (70%), four patients had no resolution (20%), and two patients had progression to the popliteal vein (10%) ([Table 3] and [Table 4]).
Table 3 Comparison of clinical symptoms in the two groups


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Table 4 Comparison between provoked and unprovoked calf vein thrombosis regarding duplex ultrasound picture at the end of 10 days therapy


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At the end of 3 months, 16 patients in the provoked group had no recurrence (80%), three patients had recurrence of the calf thrombosis (15%), and one patient showed progression to the popliteal vein (5%), whereas, in the unprovoked group, 14 patients had no recurrence (70%), four patients had recurrence of calf thrombosis (20%), and two patients showed progression to the popliteal vein (10%) ([Table 5]).
Table 5 Comparison between provoked and unprovoked calf vein thrombosis regarding Doppler picture at the end of 3 months

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  Discussion Top


The aim of the present study was to evaluate a protocol for managing isolated calf vein thrombosis.

Optimal treatment of distal vein thrombosis is actually controversial: some investigators have recommended routine administration of oral anticoagulants; others have recommended serial ultrasound scan (at 1 and at 4-10 days, mean: 1 week) and administered oral anticoagulant only if thrombosis extends to the proximal veins. This debate exists because of the balance between the risk for anticoagulation and the risk for thrombosis complications. Bleeding is a possible complication in postoperative patients and in elderly patients, and thus it is unnecessary if the risk for PE is not very high. The rationale for distal vein thrombosis treatment is based on its possibility of proximal progression (10-20%) and risk for PE, reported recently as proximal thrombosis, up to 24.6% [11] .

In the present study there was no statistically significant differences between the two studied groups as regards age; sex; the d-dimer assay results; and pain, swelling, and tenderness in the calf muscles.

After the therapy for provoked isolated calf vein thrombosis with LMWH or fondaparinux in a full dose for 10 days, the patient was reassessed, and if there was no extension to the popliteal vein, the anticoagulation was stopped and the patient was asked to wear elastic stocking for 2 years with duplex follow-up in 3, 6, and 9 months to assess for resolution or recurrence of thrombus; this approach is effective and has shown good results.

In cases of unprovoked isolated calf vein thrombosis, we started the treatment with LMWH or fondaparinux in the therapeutic dose for 10 days; at the end of the 10 days we reassessed the patient for the propagation or resolution of thrombus. If there was no propagation of thrombus, we stopped the LMWH and put the patient on a low-intensity warfarin dose regimen - for example, 1-2 mg to adjust the INR in the range 1-1.9; if there was an extension of thrombosis, a full therapeutic dosage was started for 3 months to make INR in the range 2-3.5.

Only 2.9% of the patients with ID-DVT showed a progression of thrombosis to the proximal deep veins; the majority of thrombus progression, during the treatment period, was observed in patients with unprovoked isolated calf vein thrombosis. These results support the usefulness of a prolonged treatment in unprovoked isolated calf vein thrombosis cases [12] .



The management of isolated calf vein thrombosis is different than that of proximal DVT and treatment with oral anticoagulants in cases of isolated calf vein thrombosis should be chosen only in the indicated cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Autar R. Deep vein thrombosis: the silent killer. Wiltshire: Quay Books. Mark Allen Publishing; 1996a.  Back to cited text no. 1
    
2.
Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS. Does the patient have deep vein thrombosis? J Am Med Assoc 1998; 279 :1094-1099.  Back to cited text no. 2
    
3.
Sandler DA, Martin JF. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis? J R Soc Med 1989; 82 :203-205.  Back to cited text no. 3
    
4.
Cohen AT, Tapson VF, Bergmann JF, Goldhaber SZ, Kakkar AK, Deslandes B, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371 :387-394.  Back to cited text no. 4
    
5.
Bovill EG, van der Vliet A. Venous valvular stasis-associated hypoxia and thrombosis: what is the link?. Annu Rev Physiol 2011; 73 :527.  Back to cited text no. 5
    
6.
Prandoni P, Kahn SR. Post-thrombotic syndrome: prevalence, prognostication and need for progress. Br J Haematol 2009; 145 :286-295.  Back to cited text no. 6
    
7.
Masuda EM, Kistner RJ, Musikasinthorn C. The controversy of managing calf vein thrombosis. J Vasc Surg 2012; 55 :550-561.  Back to cited text no. 7
    
8.
Labropoulos N, Webb KM, Kang SS, Mansour MA, Filliung DR, Size GP, et al. Pattern and distribution of isolated calf deep vein thrombosis. J Vasc Surg 1999; 30 :787-793.  Back to cited text no. 8
    
9.
Ohgi S, Tachibana M, Ikebucjhi M, Kanaoka Y, Maeda T, Mori T. Pulmonary embolism in patients with isolated soleal vein thrombosis. Angiology 1998; 49 :759-764.  Back to cited text no. 9
    
10.
MacDonald PS, Kahn SR, Miller N, Obrand D. Short-term natural history of isolated gastrocnemius and soleal vein thrombosis. J Vasc Surg 2003; 37 :523-527.  Back to cited text no. 10
    
11.
Palareti G, Schellong S. Isolated distal deep vein thrombosis: what we know and what we are doing. J Thromb Haemost 2012; 10 :11-19.  Back to cited text no. 11
    
12.
Parisi R, Vison _a A, Camporese G, Verlato F, Lessiani G, Antignani PL, et al. Isolated distal deep vein thrombosis: efficacy and safety of a protocol of treatment. Treatment of Isolated Calf Thrombosis (TICT) Study. Int Angiol 2009; 28 :68-72.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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