Cardiovascular · Year 1 · from Cardiovascular

Case 1: Deep Vein Thrombosis - Virchow's Triad in Action

Patient Presentation

Demographics: 58-year-old female

Chief Complaint: Left leg swelling and pain for 3 days

History of Present Illness: A 58-year-old female presents with progressive swelling and pain in her left calf over the past 3 days. She reports that the discomfort started after returning from an 8-hour transatlantic flight 5 days ago. She describes a dull, aching pain that worsens with walking and when standing. She notes that her left calf appears larger than the right. She has a history of breast cancer treated with tamoxifen for the past 2 years.

Physical Examination:

  • Vital Signs: BP 128/78 mmHg, HR 88 bpm, RR 16/min, SpO2 98% on room air, Temp 37.2C
  • General: Mild distress due to leg discomfort
  • Left Lower Extremity:
  • Calf circumference 4 cm greater than right
  • Pitting edema to mid-calf
  • Warmth and erythema over posterior calf
  • Tenderness along deep venous distribution
  • Positive Homans sign (calf pain with dorsiflexion)
  • Right Lower Extremity: Normal

Workup

  • Wells Score for DVT: 3 points (active cancer +1, calf swelling >3cm +1, pitting edema +1) - Moderate probability
  • D-dimer: 1.8 mcg/mL (elevated, normal <0.5)
  • Compression Ultrasonography:
  • Non-compressible left popliteal vein
  • Echogenic material within vein lumen
  • Absent color Doppler flow
  • Left femoral vein also involved
  • Labs:
  • CBC: WBC 8.2, Hgb 12.4, Plt 245
  • PT/INR: 12.1 sec / 1.0
  • aPTT: 28 sec

Diagnosis

Acute proximal deep vein thrombosis of the left lower extremity (femoral and popliteal veins)

Hemostasis and Thrombosis Correlation:

Virchow's Triad Analysis:

  1. Stasis:
  • 8-hour flight with prolonged immobility
  • Venous pooling in dependent lower extremities
  • Stagnant blood allows coagulation factor accumulation
  • Prevents dilution and clearance of activated factors
  1. Endothelial Injury:
  • Prolonged venous distension damages endothelium
  • Loss of antithrombotic endothelial surface
  • Exposure of subendothelial tissue factor
  • Release of von Willebrand factor
  1. Hypercoagulability:
  • Active malignancy (breast cancer)
  • Tamoxifen therapy (estrogen-like effects)
  • Cancer produces procoagulant factors
  • Tissue factor expression by tumor cells

Why D-dimer is elevated:

  • D-dimer is a fibrin degradation product
  • Indicates active fibrinolysis of cross-linked fibrin
  • High sensitivity but low specificity for DVT
  • Negative D-dimer excludes DVT in low-probability patients

Coagulation Cascade Activation:

  1. Tissue factor exposure initiates extrinsic pathway
  2. Factor VII activation leads to factor X activation
  3. Thrombin generation converts fibrinogen to fibrin
  4. Factor XIII cross-links fibrin (stable clot)
  5. Plasmin gradually degrades fibrin (produces D-dimer)

Why proximal DVT is concerning:

  • Higher risk of embolization to pulmonary circulation
  • Large thrombus burden
  • Greater risk of post-thrombotic syndrome

Treatment

  1. Anticoagulation (immediate):
  • Rivaroxaban 15 mg BID for 21 days, then 20 mg daily
  • Alternative: Enoxaparin bridge to warfarin (INR goal 2-3)
  1. Duration: Extended anticoagulation (cancer-associated)
  • LMWH or DOAC preferred over warfarin in malignancy
  1. Compression stockings: 30-40 mmHg for post-thrombotic syndrome prevention
  2. Activity: Early ambulation with anticoagulation
  3. Monitor for PE symptoms: Dyspnea, chest pain, tachycardia
  4. Cancer follow-up: Continue surveillance

Clinical Image

Image Description: Clinical photograph showing unilateral left lower extremity swelling consistent with deep vein thrombosis. Note the visible edema and increased circumference of the affected leg compared to the contralateral limb.

Source: Wikimedia Commons - Deep vein thrombosis of the right leg License: CC BY-SA 4.0 URL: https://commons.wikimedia.org/wiki/File:Deep_vein_thrombosis_of_the_right_leg.jpg


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