Angiogram vs venogram?

Just some extra info:

Angiogram is the procedure where a special dye is injected and X-ray images are taken to see how the dye moves through your blood vessels. When it involves your veins, it's called venogram. On the other hand, if it's arteries, it's called arteriogram.

(Posted by: Vivian)

CAM+Psychosocial DVT

CAM Options for DVT


HERBAL TREATMENT Herbal treatment designed to improve blood flow, remove blood clot, improve symptoms and prevent relapses, and most importantly, to boost energy and strong body for better health and quality of life.
 
The purpose of herbal treatment is not to take the place of necessary orthodox medical treatment. Combination of the both is a better choice.


Herbs: Mistletoe, Nettle ,Rue, Oats, Fenugreek, White Willow, Black Cohosh and Garlic along with the Bach Flowers Wild Oats, Honeysuckle, Cerato, Vine and Beech




Physchosocial aspects:

DVT Teatment

The FDA approval of low molecular weight heparin has led to complete outpatient treatment of uncomplicated DVT and a decrease in length of hospital stay for patients diagnosed with uncomplicated PE. Although extremely cost-effective, this poses an enormous challenge for the physician and nurse to teach patients about the treatment, including self-injection of low-molecular weight heparin, and the initiation of Coumadin. Not to mention the definition of the disease, the implications such as the possibility of recurrence and preventative measures for the future.
Psychosocial and socioeconomic exclusionary criteria also limit outpatient treatment of DVT with LMWH. These criteria include a history of noncompliance with medical therapy; an unstable home environment; a history of substance abuse; an inability to pay for LMWH; an inability to care for themselves and no family member, friend, or nurse to care for them; a language barrier; and lack of access to a clinic or telephone. Although most of these barriers can be overcome using home health services, socioeconomic criteria can have a pivotal role in deciding whether patients are eligible for outpatient treatment in rural or inner-city hospital environments.

prepared by Chris


sources:

http://www.clotcare.com/clotcare/pulmonaryembolismsupportgroup.aspx
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1472975
http://www.herbchina2000.com/therapies/ATD.shtml
http://www.herbal-treatment.net/ blood_circulation_treatment.html

Thrombophilia Screen

Thrombophilia: A congenital or acquired predisposition to thrombosis.

Causes of thrombophilia

Inherited:
An inherited abnormality of one of the plasma proteins listed below:


* Factor V Leiden homozygous individuals have an 80 X risk of Venous
Thromboembolism (VTE).

Acquired Risk factors for thrombosis

Risk factors for arterial thrombosis include:
Hypertension
Smoking
Diabetes
Polycythaemia
Lupus anticoagulant

Risk factors for venous thrombosis include:
Conditions causing stasis e.g. advanced age, cardiac failure, oedema, nephritic syndrome, obesity, trauma, long distance travel, immobility, post-operative, pelvic obstruction, myocardial infarct, central venous catheter
Altered blood constituents that is acquired in oestrogen therapy, contraceptive pill, malignancy, pregnancy, antiphospholid syndrome, raised plasma homocysteine, or raised factors VIII, IX or XI.
Polycythaemia and thrombocythaemia.

Pathogenesis is multifactorial and relates to elevated levels of procoagulant, depressed levels of inhibitor proteins and physical factors (e.g. stasis, surgery).

What is thrombophilia screen used for?
It is used to investigate the cause of thrombophilia.

Who should be referred for a thrombophilia screen?
Patients with have the following:
- Spontaneous thrombosis, particularly at a young age, or associated with pregnancy
- Thrombosis at an unusual site e.g. sagittal sinus thrombosis
- Recurrent thrombosis
- Thrombosis in those with a VTE and a first degree relative with a history of VTE.

What is screened for in the patient’s blood sample?

Activated Protein C Resistance (APCR)
The APCR test is a sensitive screening test for Factor V mutations which may lead to an increased risk of thrombosis. APCR is the most common known hereditary predisposition to venous thrombosis. Activated protein C normally degrades activated factors V and VIII by proteolytic change to inhibit coagulation. Individuals with APCR have a mutated Factor V, which is resistant to degradation by activated Protein C.

Protein C
Heterozygous protein C deficiency increases the risk for venous thrombosis sevenfold. It is more likely to be of relevance in young (<>

Protein S
Protein S is a cofactor for activated Protein C mediated degradation of the coagulation factors Va and VIIIa.

Antithrombin
Antithrombin is a powerful physiological coagulation inhibitor, which inhibits the activity of thrombin and factor Xa and to a lesser degree on factors IXa, XIa and XIIa and Kallikrein.

Factor V Leiden and Prothombin Gene Mutation Testing
The Factor V Leiden mutation has been identified as a major cause of familial venous thrombosis and is inherited in an autosomal dominant fashion. Heterozygosity is associated with an 8-fold increased risk of venous thrombosis and homozygosity with an 80-100-fold increased risk.
The prothrombin mutation (G20210A) is linked to increased prothombin levels. It is inherited independently from the Leiden mutation in an autosomal dominant fashion and is associated with an approximate 3-fold increased risk of venous thrombosis.

Antiphospholipid Antibodies
Antiphospholipid antibodies are a family of autoantibodies that recognise various phospholipids and/or phospholipid-binding proteins. This antibody family includes lupus anticoagulants, anticardiolipin antibodies and anti-beta2-glycoprotein I antibodies. All confer an increased risk of thromboembolic .

The diagnosis of Antiphospholipid syndrome, which can occur in isolation, or in association with other systemic autoimmune disease, such as SLE, is made using clinical and laboratory criteria.

Clinical criteria
1. Thrombosis -arterial, venous or small vessel
2. Complications of pregnancy -recurrent miscarriage in the first trimester of pregnancy, foetal death in the 2nd or 3rd trimesters of pregnancy, and premature birth.

Laboratory criteria
1. Lupus anticoagulant detected on 2 or more occasions, at least 6 weeks apart.
2. Moderate or high levels of anticardiolipin antibodies detected on 2 or more occasions, at least 6 weeks apart.

To make a defintive diagnosis of antiphospholipid syndrome, patients must meet at least one of the clinical AND one of the laboratory criteria.

Important points to take note of before doing a thrombophilia screen:

- Patient needs to know nature and limitation of tests. Important to know what advice should be given if an abnormality is identified.
- Laboratory tests may be affected by other medical conditions and medication e.g. liver disease, pregnancy, anti-coagulants.
- Identification of a laboratory thrombophilic abnormality will not usually affect immediate treatment but may be of value in preventing further thrombosis and in counselling other family members so as to reduce their risk of a thrombosis.
- A person who develops spontaneous DVT may have a normal thrombophilia screen. This does not imply that the patient is normal and that the patient has no increased risk of thrombosis in the future or in the family member. There may be heritable defects that have yet to be discovered.
- As the clinical interpretation of a thrombophilia screen will depend upon each patient's circumstances it is sensible for patients to be referred to a specialist who has experience in counselling and testing such individuals and families (rather than just taking a blood sample and requesting thrombophilia investigations).


Sources:
Haematology at a Glance, 2nd Edition, Mehta & Hoffbrand
British Heart Foundation, Thrombophilia Factfile 02/2002, http://www.bhsoc.org/bhf_factfiles/bhf_factfile_feb_2002.pdf
Guidelines for Thrombophilia Screening in Patients Taking Oral Contraceptives,
http://www.gp-training.net/protocol/cardiovascular/thrombo.htm
ACT Pathology: Investigations for Thrombophilia
http://www.actpathology.act.gov.au/c/ap?a=da&amp;amp;did=1008510&pid=1059373329&sid=

Contributed by John Lee

Deep Vein Thrombosis
Signs & Symptoms
- leg pain
- leg tenderness
- swelling of leg
- increased warmth of leg
- changes in skin colour of leg (redness & bluish skin discoloration)
*Keep in mind many of the signs and symptoms are similar to many other conditions
eg. Muscle strains, skin infections, inflammation of superficial veins, cardiac related diseases (heart attack), lung related diseases (pneumonia)
*Nice to know: deep vein thrombosis related to pregnancy is also known as phlegmasia alba dolens.

Many patients do not show the symptoms until the clot dislodges and travels to the lung and causes pulmonary embolism.
- rapid heart rate
- shortness of breath
- sharp chest pain which worsens with deep breathing
- coughs up blood

Sources:
http://www.medicinenet.com/deep_vein_thrombosis/article.htm
http://www.nhlbi.nih.gov/health/dci/Diseases/Dvt/DVT_WhatIs.html

(Posted by: Vivian)

Anticoagulants and your favourite Clotting cascade

Investigations of DVT

Investigations of DVT

1. Doppler Ultrasound examination
2. Exclude pulmonary embolus (caused by DVT)
3. Thrombophilia screen
4. Venogram (gold standard)
5. MRV (magnetic resonance venogram) or MRI (may be better than other non-invasive techniques in diagnosing DVT in calf, but too expensive, so not used widely)

Ultrasonography
- best non-invasive diagnostic method
- average sensitivity & specificity of 97% for proximal DVT
- cannot be relied on to diagnose calf vein thrombosis (sensitivity too low 75%)
- three common techniques:

Compression ultrasound:
- looks at non-compressibility of the vascular lumen under gentle probe pressure
- if no residual lumen observed, vein is considered to be fully compressible, hence absence of DVT

Duplex ultrasonography:
- similar to above, but
- blood flow characteristics evaluated using pulsed Doppler signal
- blood flow in normal veins is spontaneous & phasic with respiration; can be augmented by manual compression distal to the ultrasound transducer
- if no phasic pattern, flow is defined as continuous, hence presence of venous outflow obstruction

Colour flow duplex imaging (colour coded Doppler ultrasonography aka colour Doppler):
- identical to above
- pulsed Doppler signals is used to produce images
- when a Doppler shift is recognized, it is assigned a colour (red or blue) according to its direction towards or away from the probe
- flowing blood displayed as a colour overlay to the grey scale ultrasound image, hence, easier to identify the veins
Therefore, Doppler ultrasonography
- shows direction and velocity of blood flow
- detects turbulent flow due to narrowing or blockage of blood vessels
- shows different rates of blood flow in different colours

Focus on Doppler Ultrasonography

Why the test is performed
- alternative to arteriography or venography
- help diagnose a blood clot, venous insufficiency, arterial occlusion (closing), abnormalities in the carotid artery blood flow caused by a narrowing and to evaluate trauma to the arteries
- also used to monitor arterial reconstruction and bypass grafts

How the test is performed
- done in the ultrasound or radiology department or in a peripheral vascular lab
- clear jelly (water-soluble gel) is squirted onto the inside of one of the patient’s thighs to help the ultrasound sensor (a handheld device called a transducer) slide around easily
- gel may be alternatively placed on the device
- a technician/doctor places the sensor against the patient’s skin
- once it's in place, an image appears on a video screen, and the technician/doctor moves the sensor up and down along the leg - from the groin to the calf - to view the veins from different angles
- the examiner presses the sensor into the patient’s skin firmly every few inches to see if the veins change shape under pressure
- the examiner then checks the other leg in the same way
- as the machine measures the blood flowing through a vein, it makes a swishing noise in time with the rhythm of your heartbeat
- the test usually takes 15-30 minutes
- most people don't feel any discomfort, but if the patient’s leg was swollen and sensitive to the touch before the test, the pressure of the sensor might cause some tenderness

Note, to examine the arteries: Blood pressure cuffs may be put around different parts of the body, including the thigh, calf, ankle, and different points along the arm. A paste is applied to the skin over the arteries being examined. Images are created as the transducer is moved over each area.

How to prepare for the test
The patient will need to remove clothing from the extremity being examined

How the test will feel
There is little or no discomfort associated with this test

Normal Values
- the vessels show no evidence of narrowing or closure
- the arteries have normal systolic and diastolic components
- blood pressure is normal

What abnormal results mean

• In the veins:
• Venous occlusion (closing of vein)
• Blood clots
• In the arteries:
• Arterial occlusive disease
• Spastic arterial disease (arterial contractions brought on by cold or emotion)
• Embolic arterial occlusion (obstruction in the artery by a blood clot, a fat globule, or an air bubble)

What the risks are
There are no risks specifically associated with this procedure

Special considerations
Cigarette smoking may alter the results of this test, because nicotine can cause the arteries in the extremities to constrict

Exclude Pulmonary Embolus (caused by DVT)
Investigations of pulmonary embolus:
- Arterial blood gases
- ECG
- CXR
- Ventilation / Perfusion scanning - May confirm or refute diagnosis
- Pulmonary angiography and echocardiography useful if haemodynamic instability
- Spiral CT might replace pulmonary angiography
- Lower limb investigations for DVT as above

Focus on Ventilation/Perfusion Scan (V/Q Scan)

Definition
- a pulmonary ventilation/perfusion scan is a pair of nuclear scan tests
- use inhaled and injected radioactive material (radioisotopes) to measure breathing (ventilation) and circulation (perfusion) in all areas of the lungs

Why the test is performed
- ventilation scan is used to see how well air reaches all parts of the lung
- perfusion scan measures the blood supply through the lungs
- most often performed to detect a pulmonary embolus
- evaluate lung function with advanced pulmonary disease (e.g. COPD), and to detect abnormal circulation (shunts) in the pulmonary blood vessels

How the test is performed
- the V/Q scan is actually two tests, so these tests may be performed separately or together
Perfusion scan:
- a health care provider injects radioactive albumin (mineral technetium) into the patient's vein
- the patient is immediately placed on a movable table that is under the arm of a scanner
- the machine scans the patient's lungs as blood flows through them to detect the location of the radioactive particles (identify areas of the lung that have reduced blood flow)
Ventilation scan:
- performed by scanning the lungs while the patient inhales radioactive gas

In a typical test:
- multiple pictures of the patient’s chest are taken from different angles, using a special camera that detects the radionuclide
- for half of these pictures, the patient is asked to breathe from a tube that has a mixture of air, oxygen, and a slightly radioactive version of a gas called xenon, which can be detected by the camera, and which measures airflow in different parts of the lung
- for the other half of the pictures, the camera tracks the injected radionuclide to determine blood flow in different parts of the lung
- a blood clot is suspected in areas of the lung that have good airflow but poor blood flow

How to prepare for the test
- fasting, special diet, medications not required
- a chest x-ray is usually performed prior to or following the scan

How the test will feel
- the table may feel hard or cold
- the patient may feel a sharp prick while the material is injected into the vein
- the mask used during the ventilation scan may give the patient a claustrophobic feeling
- the patient must lie still during scanning
- the radioisotope injection usually does not cause discomfort

Normal Values
The health care provider should take a ventilation and perfusion scan and then evaluate it with a chest x-ray. All parts of both lungs should take up the radioisotope uniformly.

What abnormal results mean
- results are usually available within a few hours, because the test is done only when the patient is suspected of having a potentially life-threatening condition (pulmonary embolus)
- the doctor interprets the pictures to determine whether the patient’s probability of having a blood clot in your lungs is high, low, or intermediate
- If the probability is high: blood-thinning medicine is ordered
- If it is low: immediate treatment may not be required, but the doctor will want to examine the patient again in a short time
- If it is intermediate, or if the V/Q scan cannot be clearly interpreted: pulmonary angiogram may be ordered to help determine whether the patient has a blood clot. This test is more definitive than a V/Q scan, but because it is more difficult and risky, the V-Q scan usually is done first

Perfusion scan results:
- decreased uptake of radioisotope during a perfusion scan: problem with blood flow, including occlusion of the pulmonary arteries
- a localized decrease in perfusion scan uptake (particularly when the ventilation scan is normal): pulmonary embolus
- larger areas of decreased perfusion scan uptake: condition such as pneumonitis
Ventilation scan results:
- decreased uptake of radioisotope during a ventilation scan: reduced breathing and ventilation ability or airway obstruction
- decreased ventilation uptake (plus x-ray evidence of consolidation): pneumonia
- larger areas of poor uptake: damage from chronic smoking or COPD

What the risks are
- risks are about the same as for x-rays (radiation) and needle pricks
Radiation risk:
- no radiation is emitted from the scanner (it detects radiation and converts it to a visible image)
- small exposure to radiation from the radioisotope. The radioisotopes used during scans are short-lived, with almost all radiation leaving the body in a few days. However, as with any radiation exposure, caution is advised for pregnant or breast-feeding women
Infection risk:
- slight risk for infection/bleeding at the site of the needle insertion (same for any other purpose of needle pricks)
- rare cases: a patient may develop an allergy to the radioisotope, which may include a serious anaphylactic reaction

Sources:
http://www.health.harvard.edu/diagnostic-tests/venous-ultrasound-of-the-legs.htm
http://www.nlm.nih.gov/medlineplus/ency/article/003775.htm
http://www.nlm.nih.gov/medlineplus/ency/article/003828.htm
http://www.health.harvard.edu/diagnostic-tests/ventilation-perfusion-scan.htm
http://www.bmj.com/cgi/content/full/326/7400/1180
http://www.surgical-tutor.org.uk/default-home.htm?system/vascular/venous_thromb.htm~right
http://www.merck.com/mmhe/sec03/ch021/ch021c.html#sec03-ch021-ch021c-122

Further reading on DVT (covers all PCL topics):
http://www.emedicine.com/med/topic2785.htm#section~workup

RISK FACTORS - DVT

Risk Factors

Most DVT victims are over 60 years of age; however, DVT can strike almost anyone at risk. Genetics plays a part, but so does environment. Factors and conditions that may increase the risk of DVT include:

1) Immobility
Immobility slows down the circulation of blood, and increases the risk if DVT. Those at risk includes patients with reduced mobility who are confined to bed due to illness or hospitalization.

2) Injuries
Blood vessels may be injured in a variety of ways including: a blow to the leg, athletic injuries, surgery, or radiation therapy for cancer. Traumatic injuries may set the stage for DVT because they initiate the blood clotting process and narrow the vein. This slows the passage of blood and encourages pooling.

3) Inherited Clotting Disorders
If blood clots run in your family, you may have an inherited clotting disorder. Among people of European descent, the most common genetic mutations that encourage clotting are the factor 5(V) Leiden and the prothrombin gene mutation. Individuals who inherit one of these mutations from either parent may experience recurrent episodes of DVT, but the risk is highest if both parents were affected.

4) Infections, Inflammatory Diseases
Infections and inflammatory diseases like systemic lupus erythematosus, Crohn's disease, rheumatoid arthritis, and glomerulonephritis may stimulate the blood clotting process and promote DVT.

5) Pregnancy
Pregnant women are 5 times more likely to develop DVT than non-pregnant women. Cases occur most often in the third trimester and immediately following delivery.

6) Oral Contraceptives
Hormonal preparations such as oral contraceptives or replacement estrogens may also increase the risk of clotting, particularly when combined with other risk factors like smoking, hypertension, or obesity (a Body Mass Index of 30 or higher).

7) Cancer
Some cancers release substances that increase the blood's tendency to clot (i.e. prothrombotic). Cancers of the ovaries, pancreas, lymphatic system, liver, stomach, and colon are particularly likely to provoke DVT.

8) Smoking
Tobacco smoke reduces the amount of oxygen carried in the blood and may damage vessel walls, potentially leading to clot formation. It is one of the most modifiable risk factors for cardiovascular disease.

9) Obesity
Once thought to be dangerous only in association with high cholesterol levels, obesity is now recognized on its own as a significant risk factor. Obesity is defined by the National Institutes of Health as having a Body Mass Index greater than 30 (approximately 30 pounds or more overweight). Central obesity, also known as the "apple shape," has been associated with cardiovascular disease - which may increase the risk of DVT.

10) Air Travel with Prolonged Sitting
Prolonged sitting during air travel slows down circulation and increases the blood's propensity to clot. In addition, tightly packed seating and long periods of immobility can contribute to an increased risk of DVT.
Even in young, healthy travelers, long stretches of time spent in cramped seats of an aircraft with very low humidity may set the stage for the formation of a blood clot in the lower leg.

prepared by:
Sri Murniati Rosli