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Tromboembolismo Venoso

Manifestações clínicas

As manifestações clínicas são variáveis e podem ser sintomáticas ou assintomáticas, bilaterais ou unilaterais e graves ou leves; quando presentes, podem ocorrer: dor, edema, eritema, cianose, dilatação do sistema venoso superficial, aumento de temperatura, empastamento muscular e dor à palpação.12

Wells e cols. descreveram uma forma simplificada de estratificação de risco quando há suspeita de TVP13 (Tabela 1) e de TEP14 (Tabela 2) baseados na apresentação clínica e fatores de risco.

Manifestações clínicas tabela 1

Manifestações clínicas tabela 2



Exames complementares

  • Dímero D –exame com certa limitação para TVP pela sua baixa especificidade quando positivo, sofrendo interferência de diversas situações. Todavia, por sua elevada sensibilidade e alto valor preditivo negativo, diante de um resultado negativo com probabilidade baixa pelo índice de Wells,13 o diagnóstico de TVP pode ser afastado.12
  • Ultrassom com Doppler – método de escolha para o diagnóstico de TVP. É seguro, não invasivo e de baixo custo.15
  • Venografia convencional – não é um exame recomendado por ser um método invasivo, com efeito nefrotóxico e risco de complicações intrínsecas ao método.1
  • Venografia por ressonância magnética – tem a mesma acurácia da venografia, sendo método alternativo aos pacientes que necessitam da venografia, mas que apresentam insuficiência renal ou alergia ao iodo.16
  • Venografia por tomografia computadorizada – seu principal uso é na suspeita de TEP, pois em um mesmo exame é possível estudar as artérias pulmonares e as veias dos membros inferiores.17

Referências

  1. Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD, et al. Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e351S-418S.

  2. Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med. 2010;38(4 Suppl):S495-501.

  3. Heit JA, Silverstein MD, Mohr DN, Petterson TM, O’Fallon WM, Melton LJ 3rd. Risk factors for deep vein thrombosis and pulmonary embolism: a populationbased case-control study. Arch Intern Med. 2000;160(6):809-15.

  4. Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):381S-453S.

  5. Anderson FA Jr, Spencer FA. Risk factors for venous thromboembolism. Circulation. 2003;107(23 Suppl 1):I9-16.

  6. Mcmanus RJ, Fitzmaurice DA, Murray E, Taylor C. Thromboembolism. BMJ Clin Evid. 2011;2011:0208.

  7. Lopes LC, Eikelboom J, Spencer FA, Akl EA, Kearon C, Neumann I, et al. Shorter or longer anticoagulation to prevent recurrent venous thromboembolism: systematic review and meta-analysis. BMJ Open. 2014;4(7):e005674.

  8. Streiff MB. Predicting the risk of recurrent venous thromboembolism (VTE). J Thromb Thrombolysis. 2015;39(3):353-66.

  9. Song K, Xu Z, Rong Z, Yang X, Yao Y, Shen Y, et al. The incidence of venous thromboembolism following total knee arthroplasty: a prospective study by using computed tomographic pulmonary angiography in combination with bilateral lower limb venography. Blood Coagul Fibrinolysis. 2016;27 (3):266-9.

  10. Caprini JA, Arcelus JI, Motykie G, Kudrna JC, Mokhtee D, Reyna JJ. The influence of oral anticoagulation therapy on deep vein thrombosis rates four weeks after total hip replacement. J Vasc Surg. 1999;30(5):813-20.

  11. Barros MVL, Pereira VSR, Pinto DM. Controversies in the diagnosis and treatment of deep vein thrombosis for vascular ultrasound. J Vas Bras. 2012;11(2):137-43.

  12. Osman AA, Ju W, Sun D, Qi B. Deep venous thrombosis: a literature review. Int J Clin Exp Med, 2018;11(3):1551-61.

  13. Wells PS, Anderson DR, Bormanis J, Guy F, Mitchell M, Gray L, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795-8.

  14. Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000;83(3):416-20.

  15. Hirsh J, Lee AY. How we diagnose and treat deep vein thrombosis. Blood. 2002;99(9):3102-10.

  16. Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuunemann HJ. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):7S-47S.

  17. English WJ, Williams DB, Soto FC. Thromboembolic disease in the bariatric patient: prevention, diagnosis, and management. In: Herron DM. Bariatric Surgery Complications and Emergencies. New York, NY: Springer International Publishing; 2016. p. 51-71.

  18. Rahme E, Dasgupta K, Burman M, Yin H, Bernatsky S, Berry G, et al. Postdischarge thromboprophylaxis and mortality risk after hip-or knee-replacement surgery. CMAJ. 2008;178(12):1545-54.

  19. Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med. 1988;318(18):1162-73.

  20. Raymundo SRO, Lobo SMA, Hussain KMK, Hussein KG, Secches IT. What has changed in venous thromboembolism prophylaxis for hospitalized patients over recent decades: review article. J Vasc Bras. 2019;18:e20180021.

  21. Samama CM, Vray M, Barré J, Fiessinger JN, Rosencher N, Lecompte T, et al. Extended venous thromboembolism prophylaxis after total hip replacement: a comparison of low-molecular-weight heparin with oral anticoagulant. Arch Intern Med. 2002;162(19):2191-6.

  22. Cohen AT, Davidson BL, Gallus AS, Lassen MR, Prins MH, Tomkowski W, et al. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomised placebo controlled trial. BMJ. 2006;332(7537):325-9.

  23. Agnelli G, Bergqvist D, Cohen AT, Gallus AS, Gent M. Randomized clinical trial of postoperative fondaparinux versus perioperative dalteparin for prevention of venous thromboembolism in high-risk abdominal surgery. Br J Surg. 2005;92(10):1212-20.

  24. Turpie AG, Bauer KA, Eriksson BI, Lassen MR. Fondaparinux vs enoxaparin for the prevention of venous thromboembolism in major orthopedic surgery: a metaanalysis of 4 randomized double-blind studies. Arch Intern Med. 2002;162(16):1833-40.

  25. Eriksson BI, Dahl OE, Rosencher N, Kurth AA, van Dijk CN, Frostick SP, et al. Oral dabigatran etexilate vs. subcutaneous enoxaparin for the prevention of venous thromboembolism after total knee replacement: the RE-MODEL randomized trial. J Thromb Haemost. 2007;5(11):2178-85.

  26. Eriksson BI, Dahl OE, Rosencher N, Kurth AA, van Dijk CN, Frostick SP, et al.; RE-NOVATE Study Group. Dabigatran etexilate versus enoxaparin for prevention of venous thromboembolism after total hip replacement: a randomised, double-blind, non-inferiority trial. Lancet. 2007;370(9591):949-56.

  27. Eriksson BI, Dahl OE, Huo MH, Kurth AA, Hantel S, Hermansson K, et al.; RE-NOVATE II Study Group. Oral dabigatran versus enoxaparin for thromboprophylaxis after primary total hip arthroplasty (RE-NOVATE II*). A randomised, double-blind, non-inferiority trial. Thromb Haemost. 2011;105(4):721-9.

  28. Eriksson BI, Dahl OE, Rosencher N, Clemens A, Hantel S, Feuring M, et al. Oral dabigatran etexilate versus enoxaparin for venous thromboembolism prevention after total hip arthroplasty: pooled analysis of two phase 3 randomized trials. Thromb J. 2015;13:36.

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