DVT & PE in Athletes The Hidden Danger

DVT & PE in Athletes The Hidden DangerMarch 14th, 2017
Disclosures
Objectives
• Recognize the common signs and symptoms of DVT and PE
• Understand training room and on-field initial management
• Understand long term complications of diagnosis and treatment of
DVT/PE in athletes
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Overview
• Lower extremity DVT & PE
Spectrum of Venous Thromboembolic
3rd most common life threatening
cardiovascular disease
people
Half of patients develop
within 10 years
after period of immobilization
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Endurance sports
Smoking
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• Unilateral diffuse swelling
dorsiflexion • 60-88% sensitive, 30-72% specific
Lower Extremity DVT: Differential Diagnosis
Sports Injuries
diagnoses
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for testing
Pulmonary Embolism: History & Physical
inspiration
athletes)
• Hypoxia
• Tachypnea
• Syncope
• Hypotension
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• Referral to medical provider for advanced imaging
• CT angiography is initial test of choice if there is high clinical suspicion for
PE
Treatment
term complications
• Early ambulation
• No evidence to support use of compression stockings to prevent post-
thrombotic syndrome
• Should be determined through collaboration with trainer and physician • No well-established protocols exist
Lower Extremity DVT & PE: Complications
Deep Vein Thrombosis
risk of PE
have co-existing PE
• Post thrombotic syndrome
coexisting DVT
• Mortality rate
• 58% Hemodynamically
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Preparticipation exam?
• Personal and family history of VTE
• If significant risk factors or family history the athlete should be screened for
thrombophilias
Take Home Points
• VTE can happen in athletes despite being young, healthy and active
• There are many aspects of exercise and competitive sports that increase risk
for VTE
• DVT and PE often coexist
• If you suspect DVT or PE refer to medical provider for further work up
• If patient presents with unstable vital signs or syncope call 911 and provide
supportive care
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Thoracic outlet syndrome
(TOS) or occurs
spontaneously in the
reported cases per
in US
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Venous Thoracic Outlet Syndrome
• Compression of subclavian vein occurs with normal anatomy in extremes of
abduction and/or external rotation
venous compression
• Congenital or acquired bony abnormalities of the clavicle or first rib
Chronic compression of subclavian vein
Inflammation of soft
tissue around vein
with movement
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Common complaints
• Exercise fatigue
• Heaviness, pain
• “Dead arm”
• Primary malignancy of head, neck or arm or metastatic disease
• Infection
• Prominent superficial veins in
thrombosed vein
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Test Maneuver Positive Findings
towards affected shoulder.
Patient inhales and
Palpate ipsilateral radial
arm while palpating
ipsilateral radial pulse
at 90 degrees. Patient
actively opens and closes
hands for several minutes
Paget-Schroetter Syndrome: Imaging
Doppler US is the initial test of choice • Sensitivity is 78-100%
• Specificity is 82-100%
• Can have false negative if clot is under clavicle
• If clot is not present, the presence of collateral veins can indicate chronic compression
Plain x-ray • bony abnormalities of first rib or clavicle
• cervical rib
• Gold standard for diagnosis
• Indicated if US is inconclusive or if intervention is planned
Paget-Schroetter Syndrome: Complications
• occurs in 15% of patients
• More common in patients treated conservatively with anticoagulation alone
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• Treatment is aimed at preventing complications
• Various treatment options that can be used alone or in combination
• Optimal treatment and timing is controversial
• Choice of treatment depends on… • Age
• Duration of thrombus • Desire to return to previous level of activity
• Presence of PE
• Presence of thrombophilia
• older age
• Anticoagulation for minimum of 3 months
• May need lifelong anticoagulation because underlying anatomical problems
not corrected
Paget-Schroetter Syndrome:
Invasive Management
• Catheter directed thrombolysis • Success of recanalization of vein depends on largely on time from clot formation to surgery
• 50% of veins treated at 6 weeks were partially opened, none completely opened
• Surgery: resection of first rib or medial clavicle +/- scalenotomy to achieve
decompression of thoracic outlet
• Better for... • younger patients
• dominant limb
• desire to continue sport activity, unwilling to accept chance of restricted movement
• clot present <2 weeks
• Anticoagulation for 3-6 months after recanalization and decompression
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• No contact sports while on anticoagulation
• No well-established protocols
• Can do passive ROM while on anticoagulation
• Consensus opinion - can return to play 12 weeks after definitive treatment
and discontinuation of anticoagulation
Paget-Schroetter Syndrome: Take Home
• May present with vague symptoms that have been persistent
• Early recognition and diagnosis is key! The earlier treatment is initiated
the better prognosis for return to play and decreased incidence of
complications
Librarians at Middlesex Hospital - Nancy Goodwin & Janis Leird
Middlesex Hospital Family Medicine Residency
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References
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References
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References
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