Deep Vein Thrombosis: Clinical Presentation, Diagnostic Evaluation, Anticoagulant Management, and Outcomes – A Case Report

Abstract

Deep vein thrombosis (DVT) is a common vascular disorder characterized by the formation of thrombi within the deep venous system, most frequently affecting the lower extremities. DVT represents a major component of venous thromboembolism (VTE) and is associated with significant morbidity and mortality due to complications such as pulmonary embolism and post-thrombotic syndrome.

Patients typically present with unilateral limb swelling, pain, warmth, erythema, and tenderness. Early diagnosis using clinical assessment and imaging studies is essential to prevent life-threatening complications.

We present the case of a 58-year-old male who presented with progressive swelling and pain of the left lower limb following prolonged immobilization after orthopedic surgery. Duplex ultrasonography confirmed extensive thrombosis involving the femoral and popliteal veins. The patient was successfully treated with anticoagulation therapy and supportive measures, resulting in symptom resolution and prevention of thromboembolic complications.

This case highlights the importance of early recognition, prompt diagnostic evaluation, and evidence-based anticoagulant therapy in achieving favorable outcomes in patients with deep vein thrombosis.

Introduction

Deep vein thrombosis refers to the formation of a blood clot within the deep venous circulation, most commonly involving the veins of the lower extremities. It is a major healthcare concern worldwide and contributes significantly to cardiovascular morbidity and mortality.

The pathogenesis of DVT is classically explained by Virchow’s triad, which includes:

• Venous stasis

• Endothelial injury

• Hypercoagulability

Several risk factors predispose individuals to DVT, including:

• Advanced age

• Major surgery

• Trauma

• Prolonged immobilization

• Malignancy

• Obesity

• Pregnancy

• Hormonal therapy

• Inherited thrombophilia

Untreated DVT may progress to pulmonary embolism, chronic venous insufficiency, or post-thrombotic syndrome. Therefore, timely diagnosis and management are crucial.

Case Report

Patient History

A 58-year-old male presented to the emergency department with complaints of:

• Swelling of the left lower limb for 5 days

• Progressive calf pain

• Heaviness while walking

• Mild redness over the affected leg

The symptoms developed gradually and worsened over several days.

Further history revealed:

• Recent total knee replacement surgery performed 3 weeks earlier

• Reduced mobility during postoperative recovery

• No history of chest pain or breathlessness

Past medical history included:

• Hypertension for 10 years

• Obesity

• Dyslipidemia

There was no history of:

• Previous venous thromboembolism

• Active malignancy

• Smoking

• Known clotting disorders

Clinical Examination

General Examination

• Blood pressure: 136/84 mmHg

• Pulse rate: 88/min

• Respiratory rate: 18/min

• Temperature: Afebrile

• Oxygen saturation: 98% on room air

Local Examination

Inspection revealed:

• Diffuse swelling of the left lower limb

• Mild erythema over the calf region

• Increased circumference compared with the right leg

Palpation demonstrated:

• Local warmth

• Tenderness along the calf muscles

• Pitting edema extending up to the knee

Calf circumference measurement showed:

• Left calf: 42 cm

• Right calf: 37 cm

Peripheral pulses were palpable bilaterally.

No skin ulceration or gangrene was observed.

Clinical Evaluation

Differential Diagnosis

The following conditions were considered:

• Deep vein thrombosis

• Cellulitis

• Ruptured Baker’s cyst

• Lymphedema

• Superficial thrombophlebitis

The recent surgery, immobilization, unilateral swelling, and calf tenderness strongly suggested DVT.

Investigations

Laboratory Evaluation

Routine investigations revealed:

• Hemoglobin: 13.8 g/dL

• Total leukocyte count: 8,200/mm³

• Platelet count: 245,000/mm³

• Serum creatinine: Normal

• Liver function tests: Normal

D-Dimer Assay

Laboratory testing demonstrated:

• Elevated D-dimer level: 2.8 μg/mL FEU

The elevated level supported the possibility of active thrombosis.

Compression Duplex Ultrasonography

Ultrasound examination demonstrated:

• Non-compressible femoral vein

• Non-compressible popliteal vein

• Intraluminal echogenic thrombus

• Reduced venous flow

These findings confirmed acute deep vein thrombosis.

Computed Tomography Pulmonary Angiography (CTPA)

CTPA was performed to exclude pulmonary embolism and demonstrated:

• No evidence of pulmonary embolism

Thrombophilia Screening

Testing for inherited thrombophilia was deferred because the thrombotic event was provoked by recent surgery and immobilization.

Diagnosis

Based on clinical assessment and imaging findings, a diagnosis of: Acute Proximal Deep Vein Thrombosis of the Left Lower Limb was established.

Management and Outcome

Initial Management

The patient was admitted for anticoagulation therapy.

Treatment included:

• Low-molecular-weight heparin (LMWH)

• Transition to oral anticoagulation with apixaban

• Graduated compression stockings

• Limb elevation

• Early mobilization as tolerated

The patient was educated regarding:

• Medication adherence

• Recognition of bleeding complications

• Importance of follow-up

• Prevention of recurrent thrombosis

Follow-Up and Clinical Course

At 1 Week

• Reduction in calf pain

• Improved ambulation

• No bleeding complications

At 1 Month

• Significant reduction in limb swelling

• Improved quality of life

• Good compliance with anticoagulant therapy

At 3 Months

• Near-complete resolution of edema

• Repeat ultrasonography showed partial recanalization

• No evidence of thrombus extension

At 6 Months

• Complete clinical recovery

• No symptoms of pulmonary embolism

• No recurrence of venous thromboembolism

Anticoagulation was discontinued after six months due to the transient provoking factor.

Discussion

Pathophysiology

Deep vein thrombosis develops through the interaction of factors described in Virchow’s triad.

Venous Stasis

Reduced blood flow occurs during:

• Prolonged immobilization

• Hospitalization

• Paralysis

• Long-distance travel

Endothelial Injury

Damage to the venous endothelium may result from:

• Surgery

• Trauma

• Venous catheterization

Hypercoagulability

Increased clotting tendency may occur due to:

• Malignancy

• Pregnancy

• Hormonal therapy

• Inherited thrombophilia

These mechanisms contribute to thrombus formation within deep veins.

Epidemiology

Important epidemiological features include:

• Annual incidence of approximately 1–2 cases per 1,000 individuals

• Increasing prevalence with advancing age

• Equal occurrence among both genders

• Major contributor to cardiovascular mortality

• Significant healthcare burden worldwide

Venous thromboembolism remains one of the leading preventable causes of hospital-related death.

Clinical Manifestations

Patients with DVT commonly present with:

• Unilateral leg swelling

• Calf pain

• Warmth

• Tenderness

• Erythema

• Limb heaviness

However, some patients may remain asymptomatic.

Severe disease may result in:

• Extensive venous obstruction

• Phlegmasia cerulea dolens

• Pulmonary embolism

• Chronic venous insufficiency

Diagnostic Considerations

Diagnosis is based on:

1. Clinical history
2. Physical examination
3. Wells clinical prediction score
4. D-dimer testing
5. Compression ultrasonography
6. Advanced imaging when required

Compression duplex ultrasonography remains the diagnostic modality of choice for suspected lower-limb DVT.

Treatment Modalities

Anticoagulation Therapy

The cornerstone of DVT management includes:

• Low-molecular-weight heparin

• Direct oral anticoagulants (DOACs)

• Warfarin

Current guidelines favor DOACs in most patients because of efficacy and ease of use.

Mechanical Measures

Supportive interventions include:

• Compression stockings

• Limb elevation

• Early ambulation

Interventional Procedures

Selected patients may require:

• Catheter-directed thrombolysis

• Mechanical thrombectomy

• Inferior vena cava filter placement

These approaches are generally reserved for extensive or high-risk thrombosis.

Complications

Potential complications include:

• Pulmonary embolism

• Recurrent venous thromboembolism

• Post-thrombotic syndrome

• Chronic leg swelling

• Venous ulceration

• Chronic pain

Early diagnosis and treatment substantially reduce these complications.

Prognosis

The prognosis depends on:

• Extent of thrombosis

• Presence of pulmonary embolism

• Timeliness of treatment

• Underlying risk factors

• Patient adherence to therapy

Most patients achieve excellent outcomes with prompt anticoagulation and appropriate follow-up.

Conclusion

Deep vein thrombosis is a potentially serious vascular condition that requires prompt recognition and treatment to prevent life-threatening complications. Careful clinical assessment combined with laboratory evaluation and duplex ultrasonography enables accurate diagnosis. This case demonstrates the successful management of acute proximal deep vein thrombosis following orthopedic surgery through timely anticoagulation therapy, supportive measures, and close follow-up. Early intervention, patient education, and adherence to treatment remain critical for reducing morbidity, preventing recurrence, and improving long-term outcomes.

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