Deep Venous Thrombosis

29/10/2012 Deep Venous Thrombosis
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Deep Venous Thrombosis

Author: Kaushal (Kevin) Patel, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
Updated: Dec 16, 2011
Background
Deep venous thrombosis (DVT) and pulmonary embolism (PE) are manifestations of a single disease entity,
namely, venous thromboembolism (VTE). The earliest known reference to peripheral venous disease is found on
the Eber papyrus, which dates from 1550 BC and documents the potentially fatal hemorrhage that may ensue from
surgery on varicose veins. In 1644, Schenk first observed venous thrombosis when he described an occlusion in
the inferior vena cava. In 1846, Virchow recognized the association between venous thrombosis in the legs and
PE.
DVT is the presence of coagulated blood, a thrombus, in one of the deep venous conduits that return blood to the
heart. The clinical conundrum is that symptoms (pain and swelling) are often nonspecific or absent. However, if left
untreated, the thrombus may become fragmented or dislodged and migrate to obstruct the arterial supply to the
lung, causing potentially life-threatening PE (See Pathophysiology). See the images below.
Venous thrombus.
Pulmonary embolus.
emedicine.medscape.com/article/1911303-ov erv iew 1/29

DVT most commonly involves the deep veins of the leg or arm, often resulting in potentially life-threatening emboli
to the lungs or debilitating valvular dysfunction and chronic leg swelling. Over the past 25 years, the
pathophysiology of DVT has become much better understood, and considerable progress has been made in its
diagnosis and treatment. (See Pathophysiology.)
DVT is one of the most prevalent medical problems today, with an annual incidence of 80 cases per 100,000.
Each year in the United States, more than 200,000 people develop venous thrombosis; of those, 50,000 cases are
complicated by PE.[1] Lower-extremity DVT is the most common venous thrombosis, with a prevalence of 1 case
per 1000 population. In addition, it is the underlying source of 90% of acute PEs, which cause 25,000 deaths per
year in the United States (National Center for Health Statistics [NCHS], 2006). (See Epidemiology.)
Conclusive diagnosis has historically required invasive and expensive venography, which is still considered the
criterion standard. The diagnosis may also be obtained noninvasively by means of ultrasonographic examination.
(See Workup.)
Early recognition and appropriate treatment of DVT and its complications can save many lives. (See Treatment
and Management.) The goals of pharmacotherapy for DVT are to reduce morbidity, prevent postthrombotic
syndrome (PTS), and prevent PE. The primary agents include anticoagulants and thrombolytics. (See Medication.)
Other than the immediate threat of PE, the risk of long-term major disability from postthrombotic syndrome is
high.[2, 3, 4, 5, 6]
Anatomy
The peripheral venous system functions both as a reservoir to hold extra blood and as a conduit to return blood
from the periphery to the heart and lungs. Unlike arteries, which possess 3 well-defined layers (a thin intima, a
well-developed muscular media, and a fibrous adventitia), most veins are composed of a single tissue layer. Only
the largest veins possess internal elastic membranes, and this layer is thin and unevenly distributed, providing
little buttress against high internal pressures. The correct functioning of the venous system depends on a complex
series of valves and pumps that are individually frail and prone to malfunction, yet the system as a whole performs
remarkably well under extremely adverse conditions.
Primary collecting veins of the lower extremity are passive, thin-walled reservoirs that are tremendously
distensible. Most are suprafascial, surrounded by loosely bound alveolar and fatty tissue that is easily displaced.
These suprafascial collecting veins can dilate to accommodate large volumes of blood with little increase in back
pressure so that the volume of blood sequestered within the venous system at any moment can vary by a factor of
2 or more without interfering with the normal function of the veins. Suprafascial collecting veins belong to the
superficial venous system.
Outflow from collecting veins is via secondary conduit veins that have thicker walls and are less distensible. Most
of these veins are subfascial and are surrounded by tissues that are dense and tightly bound. These subfascial
veins belong to the deep venous system, through which all venous blood must eventually pass through on its way
back to the right atrium of the heart. The lower limb deep venous system is typically thought of as 2 separate
systems, one below the knee and one above.
The calf has 3 groups of paired deep veins: the anterior tibial veins, draining the dorsum of the foot; the posterior
tibial veins, draining the sole of the foot; and the peroneal veins, draining the lateral aspect of the foot. Venous
sinusoids within the calf muscle coalesce to form soleal and gastrocnemius intramuscular venous plexuses, which
join the peroneal veins in the mid calf. These veins play an important role in the muscle pump function of the calf.
Just below the knee, these tibial veins join to become the popliteal vein, which too can be paired on occasion.
Together, the calf’s muscles and deep vein system form a complex array of valves and pumps, often referred to as
the “peripheral heart,” that functions to push blood upward from the feet against gravity. The calf-muscle pump is
analogous to the common hand-pump bulb of a sphygmomanometer filling a blood pressure cuff. Before pumping
has started, the pressure is neutral and equal everywhere throughout the system and the calf fills with blood,
typically 100-150 mL. When the calf contracts, the feeding perforator vein valves are forced closed and the outflow
valves are forced open driving the blood proximally. When the calf is allowed to relax, the veins and sinusoids refill
from the superficial venous system via perforating veins, and the outflow valve is then forced shut, preventing
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retrograde flow. With each “contraction,” 40-60% of the calf’s venous volume is driven proximally.[7]
The deep veins of the thigh begin distally with the popliteal vein as it courses proximally behind the knee and then
passes through the adductor canal, at which point its name changes to the femoral vein. (This important deep vein
is sometimes incorrectly referred to as the superficial femoral vein in a misguided attempt to distinguish it from the
profunda femoris, or deep femoral vein, a short, stubby vein that usually has its origin in terminal muscle tributaries
within the deep muscles of the lateral thigh but may communicate with the popliteal vein in up to 10% of patients.
The term superficial femoral vein should never be used, because the femoral vein is in fact a deep vein and is not
part of the superficial venous system. This incorrect term does not appear in any definitive anatomic atlas, yet it
has come into common use in vascular laboratory practice. Confusion arising from use of the inappropriate name
has been responsible for many cases of clinical mismanagement and death.) In theproximal thigh,the femoral vein
and the deep femoral vein unite to form the common femoral vein, which passes upwards above the groin crease to
become the iliac vein.
The external iliac vein is the continuation of the femoral vein as it passes upward behind the inguinal ligament. At
the level of the sacroiliac joint, it unites with the hypogastric vein to form the common iliac vein. The left common
iliac is longer than the right and more oblique in its course, passing behind the right common iliac artery. This
anatomic asymmetry sometimes results in compression of the left common iliac vein by the right common iliac
artery to produce May-Thurner syndrome, a left-sided iliac outflow obstruction with localized adventitial fibrosis and
intimal proliferation, often with associated deep venous thrombosis. At the level of the fifth lumbar vertebra, the 2
common iliac veins come together at an acute angle to form the inferior vena cava.
Please go to the main article on Inferior Vena Caval Thrombosis for more information.
Pathophysiology
Over a century ago, Rudolf Virchow described 3 factors that are critically important in the development of venous
thrombosis: (1) venous stasis, (2) activation of blood coagulation, and (3) vein damage. These factors have come
to be known as the Virchow triad.
Venous stasis can occur as a result of anything that slows or obstructs the flow of venous blood. This results in an
increase in viscosity and the formation of microthrombi, which are not washed away by fluid movement; the
thrombus that forms may then grow and propagate. Endothelial (intimal) damage in the blood vessel may be
intrinsic or secondary to external trauma. It may result from accidental injury or surgical insult. A hypercoagulable
state can occur due to a biochemical imbalance between circulating factors. This may result from an increase in
circulating tissue activation factor, combined with a decrease in circulating plasma antithrombin and fibrinolysins.
Over time, refinements have been made in the description of these factors and their relative importance to the
development of venous thrombosis. The origin of venous thrombosis is frequently multifactorial, with components of
the Virchow triad assuming variable importance in individual patients, but the end result is early thrombus
interaction with the endothelium. This interaction stimulates local cytokine production and facilitates leukocyte
adhesion to the endothelium, both of which promote venous thrombosis. Depending on the relative balance
between activated coagulation and thrombolysis, thrombus propagation occurs.
Decreased vein wall contractility and vein valve dysfunction contribute to the development of chronic venous
insufficiency. The rise in ambulatory venous pressure causes a variety of clinical symptoms of varicose veins,
lower extremity edema, and venous ulceration.
Development of thrombosis
Thrombosis is the homeostatic mechanism whereby blood coagulates or clots, a process crucial to the
establishment of hemostasis after a wound. It may be initiated via several pathways, usually consisting of
cascading activation of enzymes that magnify the effect of an initial trigger event. A similar complex of events
results in fibrinolysis, or the dissolution of thrombi. The balance of trigger factors and enzymes is complex.
Microscopic thrombus formation and thrombolysis (dissolution) are continuous events, but with increased stasis,
procoagulant factors, or endothelial injury, the coagulation-fibrinolysis balance may favor the pathologic formation
of an obstructive thrombus. Clinically relevant deep venous thrombosis is the persistent formation of macroscopic
thrombus in the deep proximal veins.
For the most part, the coagulation mechanism consists of a series of self-regulating steps that result in the
production of a fibrin clot. These steps are controlled by a number of relatively inactive cofactors or zymogens,
which, when activated, promote or accelerate the clotting process. These reactions usually occur at the
phospholipid surface of platelets, endothelial cells, or macrophages. Generally, the initiation of the coagulation
process can be divided into 2 distinct pathways, an intrinsic system and an extrinsic system (see the image
below).
Coagulation pathw ay.
The extrinsic system operates as the result of activation by tissue lipoprotein, usually released as the result of
some mechanical injury or trauma. The intrinsic system usually involves circulating plasma factors. Both of these
pathways come together at the level of factor X, which is activated to form factor Xa. This in turn promotes the
conversion of prothrombin to thrombin (factor II). This is the key step in clot formation, for active thrombin is
necessary for the transformation of fibrinogen to a fibrin clot.
Once a fibrin clot is formed and has performed its function of hemostasis, mechanisms exist in the body to restore
the normal blood flow by lysing the fibrin deposit. Circulating fibrinolysins perform this function. Plasmin digests
fibrin and also inactivates clotting factors V and VIII and fibrinogen.
Three naturally occurring anticoagulant mechanisms exist to prevent inadvertent activation of the clotting process.
These include the heparin-antithrombin III (ATIII), protein C and thrombomodulin protein S, and the tissue factor
inhibition pathways. When trauma occurs, or when surgery is performed, circulating ATIII is decreased. This has
the effect of potentiating the coagulation process. Studies have demonstrated that levels of circulating ATIII is
decreased more, and stay reduced longer, after total hip replacement (THR) than after general surgical cases (see
the image below).
Postoperative antithrombin III levels.
Furthermore, patients who have positive venograms postoperatively tend to be those in whom circulating levels of
ATIII are diminished (see the image below).

Antithrombin III levels and deep venous thrombosis formation.
Under normal circumstances, a physiologic balance is present between factors that promote and retard
coagulation. A disturbance in this equilibrium may result in the coagulation process occurring at an inopportune
time or location or in an excessive manor. Alternatively, failure of the normal coagulation mechanisms may lead to
hemorrhage.
Thrombus usually forms behind valve cusps or at venous branch points, most of which begin in the calf.
Venodilation may disrupt the endothelial cell barrier and expose the subendothelium. Platelets adhere to the
subendothelial surface by means of von Willebrand factor or fibrinogen in the vessel wall. Neutrophils and platelets
are activated, releasing procoagulant and inflammatory mediators. Neutrophils also adhere to the basement
membrane and migrate into the subendothelium. Complexes form of the surface of platelets and increase the rate
of thrombin generation and fibrin formation. Stimulated leukocytes irreversibly bind to endothelial receptors and
extravasate into the vein wall by means of mural chemotaxis. Because mature thrombus composed of platelets,
leukocytes and fibrin develops, and an active thrombotic and inflammatory process occurs at the inner surface of
the vein, and an active inflammatory response occurs in the wall of the vein.[8, 9]
Studies have shown that low flow sites, such as the soleal sinuses, behind venous valve pockets, and at venous
confluences, are at most risk for the development of venous thrombi.[10, 11] However, stasis alone is not enough to
facilitate the development of venous thrombosis. Experimental ligation of rabbit jugular veins for periods of up to 60
minutes have failed to consistently cause venous thrombosis.[12, 13] Although, patients that are immobilized for
long periods of time seem to be at high risk for the development of venous thrombosis, an additional stimulus is
required to develop DVT.
Evolution of venous insufficiency
Over time, thrombus organization begins with the infiltration of inflammatory cells into the clot. This results in a
fibroelastic intimal thickening at the site of thrombus attachment in most patients and a fibrous synechiae in up to
11%.[14] In many patients, this interaction between vessel wall and thrombus leads to valvular dysfunction and
overall vein wall fibrosis. Histological examination of vein wall remodeling after venous thrombosis has
demonstrated an imbalance in connective tissue matrix regulation and a loss of regulatory venous contractility that
contributes to the development of chronic venous insufficiency.[15, 16] Some form of chronic venous insufficiency
develops in 29-79% of patients with an acute DVT, while ulceration is noted in 4-6%.[17, 18] The risk has been
reported to be 6 times greater in those patients with recurrent thrombosis.[19]
Over a few months, most acute DVTs evolve to complete or partial recanalization, and collaterals develop (see the
images below).[20, 21, 22, 23, 24, 25] Although blood flow may be restored, residual evidence of thrombus or stenosis
is observed in half the patients after 1 year. Furthermore, the damage to the underlying valves and those
compromised by peripheral dilation and insufficiency usually persists and may progress. Venous stasis, venous
reflux, and chronic edema are common in patients who have had a large DVT.[26]

Low er-extremity venogram show s outlining of an acute deep venous thrombosis in the popliteal vein w ith contrast enhancement.
Low er-extremity venogram show s a nonocclusive chronic thrombus. The superficial femoral vein (lateral vein) has the appearance of 2
parallel veins, w hen in fact, it is 1 lumen containing a chronic linear thrombus. Although the chronic clot is not obstructive after it
recanalizes, it effectively causes the venous valves to adhere in an open position, predisposing the patient to reflux in the involved
segment.
The acute effect of an occluded outflow vein may be minimal if adequate collateral pathways exist. As an
alternative, it may produce marked pain and swelling if flow is forced retrograde. In the presence of deep vein
outflow obstruction, contraction of the calf muscle produces dilation of the feeding perforating veins, it renders the
valves nonfunctional (because the leaflets no longer coapt), and it forces the blood retrograde through the perforator
branches and into the superficial system. This high-pressure flow may cause dilation of the superficial (usually
low-pressure) system and produce superficial venous incompetence. In clinical terms, the increased incidence of
reflux in the ipsilateral greater saphenous vein increases 8.7-fold on follow-up of DVT.[20] This chain of events (ie,
obstruction to antegrade flow producing dilation, stasis, further valve dysfunction, with upstream increased
pressure, dilation, and other processes) may produce hemodynamic findings of venous insufficiency.
Another mechanism that contributes to venous incompetence is the natural healing process of the thrombotic vein.
The thrombotic mass is broken down over weeks to months by inflammatory reaction and fibrinolysis, and the
valves and venous wall are altered by organization and ingrowth of smooth muscle cells and production of
neointima. This process leaves damaged, incompetent, underlying valves, predisposing them to venous reflux. The
mural inflammatory reaction breaks down collagen and elastin, leaving a noncompliant venous wall.[20, 21, 22, 23, 24,
25]
Persistent obstructive thrombus, coupled with valvular damage, ensures continuation of this cycle. Over time, the
venous damage may become irreversible. Hemodynamic venous insufficiency is the underlying pathology of
postthrombotic syndrome (PTS), also referred to as postphlebitic syndrome. If numerous valves are affected, flow
does not occur centrally unless the leg is elevated. Inadequate expulsion of venous blood results in stasis and a
persistently elevated venous pressure or venous hypertension. As fibrin extravasates and inflammation occurs, the
superficial tissues become edematous and hyperpigmented. With progression, fibrosis compromises tissue
oxygenation, and ulceration may result. After venous insufficiency occurs, no treatment is ideal; elevation and use
of compression stockings may compensate, or surgical thrombectomy or venous bypass may be attempted.[27,
28, 29, 30]

With anticoagulation alone, as many as 75% of patients with symptomatic DVT present with PTS at 5-10
years.[30, 31] However, the incidence of venous ulceration is far less, at 5%. Of the half million patients with venous
ulcers in the United States, 17-45% report having a history of DVT.[32]
Lower-extremity deep venous thrombosis
Most small thrombi in the lower extremities tend to resolve spontaneously after surgery. In about 15% of cases,
however, these thrombi may extend into the proximal femoral venous system of the leg. Untreated proximal
thrombi represent a significant source of clinically significant pulmonary emboli.
In the absence of rhythmic contraction of the leg muscles, as in walking or moving, blood flow in the veins slows
and even stops in some areas, predisposing patients to thrombosis.[33]
In the postoperative patient, as many as one half of all isolated calf vein thrombi resolve spontaneously within a few
hours, whereas approximately 15% extend to involve the femoral vein. A many as one third of untreated
symptomatic calf vein DVT extend to the proximal veins.[34] At 1-month follow-up of untreated proximal DVT, 20%
regress and 25% propagate. Although calf vein thrombi are rare sources of clinically significant PE, the incidence
of PE with untreated proximal thrombi is 29-50%.[35, 34] Most PEs are first diagnosed at autopsy.[36, 37]
Upper-extremity deep venous thrombosis
The 2 forms of upper-extremity DVT are (1) effort-induced thrombosis (Paget-von Schrötter syndrome) and (2)
secondary thrombosis.
Effort induced thrombosis, or Paget-von Schrötter syndrome, accounts for 25% of cases.[38] Paget in England and
von Schrötter in Germany independently described effort thrombosis more than 100 years ago. In this primary form
of the disease, an underlying chronic venous compressive abnormality caused by the musculoskeletal structures
in the costoclavicular space is present at the thoracic inlet and/or outlet. See the images below.
This contrast-enhanced study w as obtained through a Mediport placed through the chest w all through the internal jugular vein to
facilitate chemotherapy. A thrombus has propagated peripherally from the tip of the catheter in the superior vena cava into both
subclavian veins.

Superior vena cava syndrome in a patient w ith lung cancer. CT scan demonstrates a hypoattenuating thrombus that fills the superior
vena cava. The patient w as treated w ith anticoagulation alone.
In 75% of patients with secondary thrombosis, hypercoagulability and/or indwelling central venous catheters are
important contributing factors. In fact, with the advent of central venous catheters, upper-extremity and
brachiocephalic venous thrombosis has become a more common problem.[39, 40, 41, 42]
For more information on upper-extremity DVT, see the eMedicine article in the Radiology Journal.
Pulmonary embolism
PE develops as venous thrombi break off from their location of origin and travel through the right heart and into the
pulmonary artery, causing a ventilation perfusion defect and cardiac strain. PE occurs in approximately 10% of
patients with acute DVT and can cause up to 10% of in hospital deaths.[43, 44] However, most patients (up to 75%)
are asymptomatic. Traditionally, proximal venous thrombosis are thought to be at highest risk for causing
pulmonary emboli; however, the single largest autopsy series ever performed to specifically to look for the source
of fatal PE was performed by Havig in 1977, who found that one third of the fatal emboli arose directly from the calf
veins.[45]
Etiology
Numerous factors, often in combination, contribute to DVT. These may be categorized as acquired (eg,
medication, illness) or congenital (eg, anatomic variant, enzyme deficiency, mutation). A useful categorization
may be an acute provoking condition versus a chronic condition, as this distinction affects the length of
anticoagulant therapy.
The frequent causes of DVT are due to augmentation of venous stasis due to immobilization or central venous
obstruction. Immobility can be as transient as that occurring during a transcontinental airplane flight or that during
an operation under general anesthesia. It can also be extended, as during hospitalization for pelvic, hip, or spinal
surgery, or due to stroke or paraplegia. Individuals in these circumstances warrant surveillance, prophylaxis, and
treatment if they develop DVT.[46, 47]
Reduced blood flow from increased blood viscosity or central venous pressure
Increased blood viscosity may decrease venous blood flow. This change may be due to an increase in the cellular
component of the blood in polycythemia rubra vera or thrombocytosis or a decrease in the fluid component due to
dehydration.
Increased central venous pressure, either mechanical or functional, may reduce the flow in the veins of the leg.
Mass effect on the iliac veins or inferior vena cava from neoplasm, pregnancy, stenosis, or congenital anomaly
increases outflow resistance.
Anatomic variants contributing to venous stasis
Anatomic variants that result in diminution or absence of the inferior vena cava or iliac veins may contribute to
venous stasis. In iliocaval thromboses, an underlying anatomic contributor is identified in 60-80% of patients. The
best-known anomaly is compression of left common iliac vein at the anatomic crossing of the right common iliac
artery. The vein normally passes under the right common iliac artery during its normal course.
In some individuals, this anatomy results in compression of the left iliac vein and can lead to band or web
formation, subsequent stasis, and left leg DVT. The reasons are poorly understood. Compression of the iliac vein
is also called May-Thurner syndrome or Cockett syndrome.
Inferior vena cava variants are uncommon. Anomalous development is most commonly detected and diagnosed on
cross-sectional imaging or venography. The embryologic evolution of the inferior vena cava is from an enlargement
or atrophy of paired supracardinal and subcardinal veins. Anomalous embryologic development may result in
absence of the normal cava. These variations may increase the risk of symptoms because small-caliber vessels
may be most subject to obstruction. In patients younger than 50 years who have deep venous thrombosis, the
incidence of a caval anomalyervisiewas
emedicine.medscape.com/article/1911303-ov high as 5%.[48] 8/29
incidence of a caval anomaly is as high as 5%.[48]
A double or duplicated inferior vena cava results from lack of atrophy in part of the left supracardinal vein, resulting
in a duplicate structure to the left of the aorta. The common form is a partial paired inferior vena cava that connects
the left common iliac and left renal veins. When caval interruption, such as placement of a filter, is planned, these
alternate pathways must be considered. As an alternative, the inferior vena cava may not develop. The most
common alternate route for blood flow is through the azygous vein, which enlarges to compensate. If a venous
stenosis is present at the communication of iliac veins and azygous vein, back pressure can result in
insufficiency, stasis, or thrombosis.[49]
In rare cases, neither the inferior vena cava nor the azygous vein develops, and the iliac veins drain through internal
iliac collaterals to the hemorrhoidal veins and superior mesenteric vein to the portal system of the liver. Hepatic
venous drainage to the atrium is patent. Because this pathway involves small hemorrhoidal vessels, thrombosis of
these veins can cause severe acute swelling of the legs.
Thrombosis of the inferior vena cava is a rare occurrence and is an unusual result of leg deep venous thrombosis
unless an inferior vena cava filter is present and stops a large embolus in the cava, resulting in obstruction and
extension of thrombosis. Common causes of caval thrombosis include tumors involving the kidney or liver, tumors
invading the inferior vena cava, compression of the inferior vena cava by extrinsic mass, and retroperitoneal
fibrosis.[50, 51]
Mechanical injury to vein
Mechanical injury to the vein wall appears to provide an added stimulus for venous thrombosis. Hip arthroplasty
patients with the associated femoral vein manipulation represent a high-risk group that cannot be explained by just
immobilization, with 57% of thrombi originating in the affected femoral vein rather than the usual site of stasis in
the calf.[52] Endothelial injury can convert the normally antithrombogenic endothelium to become prothrombotic by
stimulating the production of tissue factor, von Willebrand factor, and fibronectin.
Injury may be obvious, such as those due to trauma, surgical intervention, or iatrogenic injury, but they may also
be obscure, such as those due to remote deep venous thrombosis (perhaps asymptomatic) or minor (forgotten)
trauma. Previous DVT is a major risk factor for further DVT. The increased incidence of DVT in the setting of acute
urinary tract or respiratory infection may be due to an inflammation-induced alteration in endothelial function.
Common risk factors for deep venous thrombosis
The presence of risk factors plays a prominent role in the assessing the pretest probability of DVT. Furthermore,
transient risk factors permit successful short-term anticoagulation, whereas idiopathic deep venous thrombosis or
chronic or persistent risk factors warrant long-term therapy.
In the MEDENOX study that evaluated 1102 acutely ill, immobilized admitted general medical patients, multiple
logistic regression analysis found the following factors to be significantly and independently associated with an
increased risk for VTE, most of which were asymptomatic and diagnosed by venography of both lower
extremities [53] :
Presence of an acute infectious disease

Age older than 75 years
Cancer
History of prior VTE
The most common risk factors are obesity, previous VTE, malignancy, surgery, and immobility. Each is found in
20-30% of patients. Hospitalized and nursing home patients often have several risk factors and account for one half
of all DVT (with an incidence of 1 case per 100 population).[36, 54]
The single most powerful risk marker remains a prior history of DVT with as many as 25% of acute venous
thrombosis occurring in such patients.[55] Pathologically, remnants of previous thrombi are often seen within the
specimens of new acute thrombi. However, recurrent thrombosis may actually be the result of primary
hypercoagulable states. Abnormalities within the coagulation cascade are the direct result of discrete genetic
mutations within the coagulation
emedicine.medscape.com/article/1911303-ov erv iew cascade. Deficiencies of protein C, protein S, or antithrombin III account for 9/29
mutations within the coagulation cascade. Deficiencies of protein C, protein S, or antithrombin III account for
approximately 5-10% of all cases of DVT.[56]
Age has been well studied as an independent risk factor for venous thrombosis development. Although a 30-fold
increase in incidence is noted from age 30 to age 80, the effect appears to be multifactorial, with more
thrombogenic risk factors occurring in the elderly than in those younger than 40 years.[55, 57] Venous stasis, as
seen in immobilized patients and paralyzed limbs, also contributes to the development of venous thrombosis.
Autopsy studies parallel the duration of bed rest to the incidence of venous thrombosis, with 15% of patients in
those studies dying within 7 days of bedrest to greater than 80% in those dying after 12 weeks.[10] Within stroke
patients, DVT is found in 53% of paralyzed limbs, compared with only 7% on the nonaffected side.[58]
Malignancy is noted in as many as 30% of patients with venous thrombosis.[55, 59] The thrombogenic mechanisms
involve abnormal coagulation, as evidenced by 90% of cancer patients having some abnormal coagulation
factors.[60] Chemotherapy may increase the risk of venous thrombosis by affecting the vascular endothelium,
coagulation cascades, and tumor cell lysis. The incidence has been shown to increase in those patients
undergoing longer courses of therapy for breast cancer, from 4.9% for 12 weeks of treatment to 8.8% for 36
weeks.[61] Additionally, DVT complicates 29% of surgical procedures done for malignancy.[62]
Postoperative venous thrombosis varies depending on a multitude of patient factors, including the type of surgery
undertaken. Without prophylaxis, general surgery operations typically have an incidence of DVT around 20%,
whereas orthopedic hip surgery can occur in up to 50% of patients.[63] The nature of orthopedic illnesses and
diseases, trauma, and surgical repair or replacement of hip and knee joints predisposes patients to the occurrence
of VTE disease. These complications are predictable and are the result of alterations of the natural equilibrium
mechanisms in various disease states.[64] For more information, see the eMedicine article Deep Venous
Thrombosis Prophylaxis in Orthopedic Surgery in the Orthopedic Surgery Journal.
Based on radioactive labeled fibrinogen, about half of lower extremity thrombi develop intraoperatively.[65]
Perioperative immobilization, coagulation abnormalities, and venous injury all contribute to the development of
surgical venous thrombosis.
Genetic factors
Genetic mutations within the blood’s coagulation cascade represent those at highest risk for the development of
venous thrombosis. Genetic thrombophilia is identified in 30% of patients with idiopathic venous thrombosis.
Primary deficiencies of coagulation inhibitors antithrombin, protein C, and protein S are associated with 5-10% of
all thrombotic events.[66, 67, 68] Altered procoagulant enzyme proteins include factor V, factor VIII, factor IX, factor
XI, and prothrombin. Resistance of procoagulant factors to an intact anticoagulation system has also recently
been described with the recognition of factor V Leiden mutation, representing 10-65% of patients with DVT.[69] In
the setting of venous stasis, these factors are allowed to accumulate in thrombosis prone sites, where mechanical
vessel injury has occurred, stimulating the endothelium to become prothrombotic.[70]
Factor V Leiden is a mutation that results in a form of factor Va that resists degradation by activated protein C,
leading to a hypercoagulable state. Its importance lies in the 5% prevalence in the American population and its
association with a 3-fold to 6-fold increased risk for VTE. Antiphospholipid syndrome is considered a disorder of
the immune system, where antiphospholipid antibodies (cardiolipin or lupus anticoagulant antibodies) are
associated with a syndrome of hypercoagulability. Although not a normal blood component, the antiphospholipid
antibody may be asymptomatic. It is present in 2% of the population, and it may be detected in association with
infections or the administration of certain drugs, including antibiotics, cocaine, hydralazine, procainamide, and
quinine.[67]
Tests for these genetic defects are often not performed in patients with recurrent venous thrombosis because
therapy remains symptomatic. In most patients with these genetic defects, lifetime anticoagulation therapy with
warfarin or low molecular weight heparin (LMWH) is recommended after recurrent DVT without an alternative
identifiable etiology documented. The risk of recurrent DVT is multiplied 1.4-2 times, with the most common
genetic polymorphisms predisposing individuals to DVT. However, the low incidence of factor V Leiden and
prothrombin G20210A may not warrant aggressive prophylaxis. Therefore, genetic testing might not be warranted

until a second event occurs.[71]
Other conditions that can induce hypercoagulability
Other diseases and states can induce hypercoagulability in patients without other underlying risks for DVT. They
can predispose patients to DVT, though their ability to cause DVT without intrinsic hypercoagulability is in
question. The conditions include malignancy, dehydration, and use of medications (eg, estrogens). Acute
hypercoagulable states also occur, as in disseminated intravascular coagulopathy (DIC) resulting from infection or
heparin-induced thrombocytopenia.[72]
Summary of risk factors
A summary of risk factors is as follows:
Age
Immobilization longer than 3 days
Pregnancy and the postpartum period
Major surgery in previous 4 weeks
Long plane or car trips (>4 h) in previous 4 weeks
Cancer
Previous DVT
Stroke
Acute myocardial infarction (AMI)
Congestive heart failure (CHF)
Sepsis
Nephrotic syndrome
Ulcerative colitis
Multiple trauma
CNS/spinal cord injury
Burns
Lower extremity fractures
Systemic lupus erythematosus (SLE) and the lupus anticoagulant
Behçet syndrome
Homocystinuria
Polycythemia rubra vera
Thrombocytosis
Inherited disorders of coagulation/fibrinolysis
Antithrombin III deficiency
Protein C deficiency
Protein S deficiency
Prothrombin 20210A mutation
Factor V Leiden
Dysfibrinogenemias and disorders of plasminogen activation
Intravenous (IV) drug abuse
Oral contraceptives
Estrogens
Heparin-induced thrombocytopenia (HIT)
Epidemiology
DVT and thromboembolism remain a common cause of morbidity and mortality in bedridden or hospitalized
patients, as well as generally healthy individuals. The exact incidence of DVT is unknown because most studies
are limited by the inherent inaccuracy of clinical diagnosis. Existing data that probably underestimate the true
incidence of DVT suggest that about 80 cases per 100,000 population occur annually. Approximately 1 person in
20 develops a DVT in the course of his or her lifetime. About 600,000 hospitalizations per year occur for DVT in the
United States.

In elderly persons, the incidence is increased 4-fold. The in-hospital case-fatality rate for VTE is 12%, rising to
21% in elderly persons. In hospitalized patients, the incidence of venous thrombosis is considerably higher and
varies from 20-70%. Venous ulceration and venous insufficiency of the lower leg, which are long-term
complications of DVT, affect 0.5% of the entire population. Extrapolation of these data reveals that as many as 5
million people have venous stasis and varying degrees of venous insufficiency.
Age distribution for deep venous thrombosis
Deep venous thrombosis usually affects individuals older than 40 years. The incidence of VTE increases with age
in both sexes. The age-standardized incidence of first-time VTE is 1.92 per 1000 person-years.
Prevalence of deep venous thrombosis by sex
The male-to-female ratio is 1.2:1, indicating that males have a higher risk of DVT than females.
Prevalence of deep venous thrombosis by race
From a demographic viewpoint, Asian and Hispanic populations have a lower risk of VTE, whereas whites and
blacks have a higher risk (2.5-4 times higher).
Prognosis
Most DVT is occult and usually resolves spontaneously without complication. The principal long-term morbidity
from DVT is PTS, which complicates about a quarter of cases of symptomatic proximal DVT; most cases develop
within 2 years afterward.
Death from DVT is attributed to massive PE, which causes as many as 300,000 deaths annually in the United
States.[73] PE is the leading cause of preventable in-hospital mortality. The Longitudinal Investigation of
Thromboembolism Etiology (LITE) that combined data from two prospective cohort studies, the Atherosclerosis
Risk in Communities (ARIC) and the Cardiovascular Health Study (CHS) determined the incidence of symptomatic
DVT and pulmonary embolism in 21,680 participants aged 45 years or older who were followed for 7.6 years.[74]
Patient Education
For excellent patient education resources, visit eMedicine’s Circulatory Problems Center and Lung and Airway
Center
Also, see eMedicine’s patient education articles Blood Clot in the Legs, Deep Vein Thrombosis (Blood Clot in the
Leg, DVT), Phlebitis, and Pulmonary Embolism
Contributor Information and Disclosures

Author
Kaushal (Kevin) Patel, MD Vascular Surgeon, Kaiser Permanente Los Angeles Medical Center
Disclosure: Nothing to disclose.
Coauthor(s)
Marc D Basson, MD, PhD, MBA, FACS Professor, Chair, Department of Surgery, Assistant Dean for Faculty
Development in Research, Michigan State University College of Human Medicine
Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha,
American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, and Sigma Xi
John J Borsa, MD Consulting Staff, Department of Radiology, St Joseph Medical Center

John J Borsa, MD is a member of the following medical societies: American College of Radiology, American
Society of Neuroradiology, Cardiovascular and Interventional Radiological Society of Europe, Radiological
Society of North America, Royal College of Physicians and Surgeons of Canada, and Society of Interventional
Radiology
Hearns W Charles, MD Assistant Professor of Radiology, New York University School of Medicine; Attending
Physician, Division of Vascular and Interventional Radiology, Department of Radiology, New York University
Medical Center
Hearns W Charles, MD is a member of the following medical societies: American College of Radiology,
American Roentgen Ray Society, Radiological Society of North America, and Society of Cardiovascular and
Interventional Radiology
Kyung J Cho, MD, FACR William Martel Professor of Radiology, Interventional Radiology Fellowship Director,
University of Michigan Health System
Kyung J Cho, MD, FACR is a member of the following medical societies: American College of Radiology,
American Heart Association, American Medical Association, American Roentgen Ray Society, Association of
University Radiologists, and Radiological Society of North America
Linda J Chun, MD Resident Physician, Department of Surgery, Los Angeles Medical Center, Kaiser
Permanente
Douglas M Coldwell, MD, PhD Professor of Radiology, Director, Division of Vascular and Interventional
Radiology, University of Louisville School of Medicine
Douglas M Coldwell, MD, PhD is a member of the following medical societies: American Association for Cancer
Research, American College of Radiology, American Heart Association, American Physical Society, American
Roentgen Ray Society, Society of Cardiovascular and Interventional Radiology, Southwest Oncology Group,
and Special Operations Medical Association
Disclosure: Sirtex, Inc. Consulting fee Speaking and teaching; DFINE, Inc. Honoraria Consulting
Paul E Di Cesare, MD, FACS Professor and Chair, Department of Orthopedic Sugery, University of California,
Davis, School of Medicine
Paul E Di Cesare, MD, FACS is a member of the following medical societies: American Academy of
Orthopaedic Surgeons, American College of Surgeons, and Sigma Xi
Disclosure: Stryker Consulting fee Consulting
Robert S Ennis, MD, FACS Associate Professor, Department of Orthopedic Surgery, University of Miami
School of Medicine; President, OrthoMed Consulting Services, Inc
Robert S Ennis, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic
Surgeons, American College of Surgeons, and Florida Orthopaedic Society
Luis G Fernandez, MD, KHS, FACS, FASAS, FCCP, FCCM, FICS Assistant Clinical Professor of Surgery
and Family Practice, University of Texas Health Science Center; Adjunct Clinical Professor of Medicine and
Nursing, University of Texas, Arlington; Chairman, Division of Trauma Surgery and Surgical Critical Care, Chief
of Trauma Surgical Critical Care Unit, Trinity Mother Francis Health System; Brigadier General, Texas Medical
Rangers, TXSG/MB
Luis G Fernandez, MD, KHS, FACS, FASAS, FCCP, FCCM, FICS is a member of the following medical
societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American
College of Legal Medicine, American College of Surgeons, American Society of Abdominal Surgeons, American
Society of General Surgeons, American Society of General Surgeons, American Society of Law, Medicine &
Ethics, American Trauma Society, Association for Surgical Education, Association of Military Surgeons of the
US, Chicago Medical Society, Illinois State Medical Society, International College of Surgeons, New York
Academy of Sciences, Pan American Trauma Society, Society of Critical Care Medicine, Society of
Laparoendoscopic Surgeons, Southeastern Surgical Congress, Texas Medical Association, and Undersea and
Hyperbaric Medical Society
Douglas M Geehan, MD Associate Professor, Department of Surgery, University of Missouri at Kansas City
Douglas M Geehan, MD is a member of the following medical societies: American College of Surgeons,
American Institute of Ultrasound in Medicine, American Medical Association, Association for Academic
Surgery, Phi Beta Kappa, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of
Critical Care Medicine
John Geibel, MD, DSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal
Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director,
Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological
Association, American Physiological Society, American Society of Nephrology, Association for Academic
Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the
Alimentary Tract
Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership
Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic
Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M
Miller School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical
Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American
Society for Surgery of the Hand, and Arkansas Medical Society
Craig Greben, MD Assistant Professor of Radiology, Hofstra University School of Medicine; Chief, Division of
Vascular and Interventional Radiology, North Shore University Hospital
Craig Greben, MD is a member of the following medical societies: Society of Cardiovascular and Interventional
Radiology
Lars Grimm, MD, MHS House Staff, Department of Diagnostic Radiology, Duke University Medical Center

Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital
Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society
of Thoracic Surgeons, and Society of University Surgeons
George Hartnell, MBChB Professor of Radiology, Tufts University School of Medicine; Director of
Cardiovascular and Interventional Radiology, Department of Radiology, Baystate Medical Center
George Hartnell, MBChB is a member of the following medical societies: American College of Cardiology,
American College of Radiology, American Heart Association, Association of University Radiologists, British
Institute of Radiology, British Medical Association, Massachusetts Medical Society, Radiological Society of
North America, Royal College of Physicians, Royal College of Radiologists, and Society of Cardiovascular and
Eric K Hoffer, MD Director, Vascular and Interventional Radiology, Associate Professor of Radiology, Section
of Angiography and Interventional Radiology, Dartmouth-Hitchcock Medical Center
Eric K Hoffer, MD is a member of the following medical societies: American Heart Association, Radiological
Society of North America, Society for Cardiac Angiography and Interventions, and Society of Interventional
Radiology
James Quan-Yu Hwang, MD, RDMS, RDCS, FACEP Staff Physician, Emergency Department, Kaiser
Permanente
James Quan-Yu Hwang, MD, RDMS, RDCS, FACEP is a member of the following medical societies: American
Academy of Emergency Medicine, American College of Emergency Physicians, American Institute of
Ultrasound in Medicine, and Society for Academic Emergency Medicine
Disclosure: 3rd Rock Ultrasound, LLC Salary Speaking and teaching; Schlesinger Associates Consulting fee
Consulting; Philips Ultrasound Consulting fee Consulting
Rick Kulkarni, MD Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance,
Division of Emergency Medicine, Harvard Medical School
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of
Emergency Medicine, American College of Emergency Physicians, American Medical Association, American
Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment
Bartholomew Kwan, MBBS, FRCPC, FRCR Staff Radiologist, Department of Medical Imaging, WOHC
Brampton Civic Hospital
Bartholomew Kwan, MBBS, FRCPC, FRCR is a member of the following medical societies: American Roentgen
Ray Society, Cardiovascular and Interventional Radiological Society of Europe, Radiological Society of North
America, Royal College of Physicians and Surgeons of Canada, Royal College of Radiologists, and Society of
William C Manson, MD Director of Emergency Ultrasound, Department of Emergency Medicine, Emory

University School of Medicine

William C Manson, MD is a member of the following medical societies: American College of Emergency
Physicians, American Institute of Ultrasound in Medicine, Emergency Medicine Residents Association, and
Society for Academic Emergency Medicine
Disclosure: The Emergency Ultrasound Course Honoraria Speaking and teaching
Miguel A Schmitz, MD Consulting Surgeon, Department of Orthopedics, Klamath Orthopedic and Sports
Medicine Clinic
Miguel A Schmitz, MD is a member of the following medical societies: American Academy of Orthopaedic
Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and
North American Spine Society
Donald Schreiber, MD, CM Associate Professor of Surgery (Emergency Medicine), Stanford University
School of Medicine
Donald Schreiber, MD, CM is a member of the following medical societies: American College of Emergency
Physicians
Disclosure: Abbott Point of Care Inc Research Grant and Speakers Bureau Speaking and teaching; Nanosphere
Inc Grant/research funds Research; Singulex Inc Grant/research funds Research; Abbott Diagnostics Inc
Grant/research funds None
William A Schwer, MD Professor, Department of Family Medicine, Rush Medical College; Chairman,
Department of Family Medicine, Rush-Presbyterian-St Luke's Medical Center
William A Schwer, MD is a member of the following medical societies: American Academy of Family
Physicians
Gary P Siskin, MD Professor and Chairman, Department of Radiology, Albany Medical College
Gary P Siskin, MD is a member of the following medical societies: American College of Radiology,
Cardiovascular and Interventional Radiological Society of Europe, Radiological Society of North America, and
Society of Interventional Radiology
Wai Hong Wilson Tang, MD Associate Professor of Medicine, Section of Heart Failure and Cardiac
Transplantation Medicine, Cleveland Clinic Foundation
Wai Hong Wilson Tang, MD is a member of the following medical societies: American College of Cardiology,
American Heart Association, Heart Failure Society of America, and International Society for Heart and Lung
Transplantation
Disclosure: Abbott Laboratories Grant/research funds Research Supplies; Medtronic Inc Consulting fee
Consulting; St Jude Medical Consulting fee Consulting
Anthony Watkinson, MD Professor of Interventional Radiology, The Peninsula Medical School; Consultant
and Senior Lecturer, Department of Radiology, The Royal Devon and Exeter Hospital, UK
Anthony Watkinson, MD is a member of the following medical societies: Radiological Society of North America,
Royal College of Radiologists, and Royal College of Surgeons of England

29/10/2012
Specialty Editor Board

Francis Counselman, MD, FACEP Chair, Professor, Department of Emergency Medicine, Eastern Virginia
Medical School
Francis Counselman, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha,
American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine
(AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center
College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor,
Division of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians,
National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management
position; ProceduresConsult.com Royalty Other
Vincent Lopez Rowe, MD Associate Professor of Surgery, Department of Surgery, Division of Vascular
Surgery, University of Southern California Medical Center
Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons,
American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society
for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society
Chief Editor
Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine,
Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve
University School of Medicine
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha,
American Academy of Emergency Medicine, American College of Chest Physicians, American College of
Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic
Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and
Society for Academic Emergency Medicine
Additional Contributors
The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Craig F
Feied, MD, FACEP, FAAEM, FACPh, Douglas M Geehan, MD, Michael A Grosso, MD, Girish R Mood, MBBS,
MD, MRCS, James Naidich, MD, and Jason J Naidich, MD, to the development and writing of the source
articles.
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29/10/2012 Deep Venous Thrombosis

Deep Venous Thrombosis

Updated: Dec 16, 2011

emedicine.medscape.com/article/1911303-ov erv iew 1/29

thrombus in the deep proximal veins.

Coagulation pathw ay.

Postoperative antithrombin III levels.

emedicine.medscape.com/article/1911303-ov erv iew 4/29

Antithrombin III levels and deep venous thrombosis formation.

Evolution of venous insufficiency

emedicine.medscape.com/article/1911303-ov erv iew 5/29

emedicine.medscape.com/article/1911303-ov erv iew 6/29

Lower-extremity deep venous thrombosis

Upper-extremity deep venous thrombosis

emedicine.medscape.com/article/1911303-ov erv iew 7/29

Anatomic variants contributing to venous stasis

incidence of a caval anomaly is as high as 5%.[48]

Mechanical injury to vein

Common risk factors for deep venous thrombosis

Presence of an acute infectious disease

emedicine.medscape.com/article/1911303-ov erv iew 10/29

until a second event occurs.[71]

Other conditions that can induce hypercoagulability

Summary of risk factors

A summary of risk factors is as follows:

emedicine.medscape.com/article/1911303-ov erv iew 11/29

Age distribution for deep venous thrombosis

Prevalence of deep venous thrombosis by sex

Prevalence of deep venous thrombosis by race

Contributor Information and Disclosures

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John J Borsa, MD Consulting Staff, Department of Radiology, St Joseph Medical Center

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Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

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William C Manson, MD Director of Emergency Ultrasound, Department of Emergency Medicine, Emory

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Disclosure: The Emergency Ultrasound Course Honoraria Speaking and teaching

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