Elsevier

Disease-a-Month

Volume 56, Issue 10, October 2010, Pages 590-600
Disease-a-Month

Isolated Calf Vein Thrombosis Should Be Treated With Anticoagulation

https://doi.org/10.1016/j.disamonth.2010.06.010Get rights and content

Introduction

Acute lower extremity deep venous thrombosis (DVT) is generally considered to involve the proximal veins or to be isolated to the calf veins. The natural history of proximal DVT has been well defined and rigorous evidence-based guidelines for its management have been developed. In contrast, the relative importance of DVT confined to the calf veins remains controversial. The prevalence of isolated calf vein thrombi is 5%-12% in symptomatic patients.1 In asymptomatic patients it may be 15% after hip and knee surgery and 45% after coronary bypass grafting.2, 3, 4, 5 Although all patients should be treated with compression stockings, there is disagreement regarding the need for anticoagulation. Various management strategies, including conventional anticoagulation, treatment with antiplatelet agents, and surveillance duplex screening, have been proposed. However, the incidence of thrombus propagation, pulmonary embolism (PE), and postthrombotic syndrome clearly warrant anticoagulant treatment in appropriate patients.

Section snippets

The Natural History of Isolated Calf Vein Thrombosis

The deep calf venous network consists of 3 paired veins: the posterior tibial, peroneal, and anterior tibial veins, as well as 2 nonpaired muscular veins: the soleal and gastrocnemial veins (Fig 1). With the exception of the soleal vein, they are accompanied by a corresponding artery. Most articles on this subject do not distinguish between proximal calf, distal calf, part of the calf, or whether there is involvement of multiple veins or only a single vein. This methodological inconsistency may

The Treatment of Isolated Calf Vein Thrombosis

In the only randomized prospective trial, 51 patients with isolated calf vein venous thrombosis diagnosed on venography were randomized to 3 months of warfarin or placebo after an initial 5 days of heparin therapy.10 In the placebo group 29% had recurrent DVT, while none of the patients in the treatment group showed recurrence. There were 3 nonfatal pulmonary emboli in the placebo group and 2 in the treated group. All 3 in the placebo group had recurrent DVT. At 1 year, 22/23 (96%) patients in

Ultrasound Imaging of the Calf Veins

Duplex ultrasonography is now the most commonly used diagnostic test for acute DVT. Despite the importance of isolated calf vein thrombosis, some argue that routine ultrasound scanning of the calf veins is not warranted as part of diagnostic protocols for acute DVT. Such arguments are based on claims that the low incidence of thrombi does not justify the time it takes to administer the scan, that propagation and embolization are rare, and that scanning calf veins adds complexity to the

Conclusions

In conclusion, calf vein thrombi should be treated with anticoagulant therapy. The duration of treatment is somewhat more controversial. Several myths exist regarding isolated calf vein thrombi, the first of which is that calf vein thrombosis is an uncommon event. Symptomatic acute idiopathic DVT accounts for 6.2%-43% of all acute DVTs. Calf DVT is the dominant form of DVT in high-risk surgical patients15, 16 and up to 90% of patients with symptomatic DVT have contiguous calf vein involvement.6

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      Among the patients with DVT in their legs, those who had respiratory discomfort or dyspnea underwent single-photon emission computed tomography (SPECT) scan to evaluate PEs. Distal DVT was defined as the presence of a thrombus within the deep calf venous network, which comprises 3 paired veins, namely, the posterior tibial, peroneal, and anterior tibial veins and 2 nonpaired calf muscular veins, namely, the soleal and gastrocnemial veins.7 Proximal DVT was defined as DVT within the deep venous systems of the legs, excluding the deep calf venous network.

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