Deep vein thrombosis treatment approach

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Resident Survival Guide

Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] ; Kashish Goel, M.D.; Assistant Editor(s)-In-Chief: Justine Cadet; Rim Halaby, M.D. [3]

Deep Vein Thrombosis Microchapters
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This page provides algorithms about the treatment choices. For more details about the medical therapy, click here. For more details about invasive therapy, click here.

Overview

Clinical practice guidelines by the American College of Chest Physicians guide management.

The treatment approach to deep vein thrombosis (DVT) depends on the location of DVT and the presence or absence of contraindications to anticoagulation. In the absence of any contraindication to anticoagulation therapy, the treatment of DVT with parental anticoagulant should be initiated in case of intermediate or high suspicion of DVT even before the diagnostic confirmatory tests are complete. The choice of parental anticoagulation include: low molecular weight heparin (LMWH), fondaparinux, IV unfractionated heparin (UFH), and SC-UFH; however, the administration of LMWH (once daily rather than twice daily) and fondaparinux is recommended over IV-UFH and SCUFH. Parental anticoagulation therapy should be administered for at least 5 days and until the INR is equal or more than 2 for more than 24 hours.

Treatment Approach

Shown below is an algorithm depicting the initial choice of treatment among patients with DVT.

Is the DVT proximal or distal?

Proximal DVT

Isolated distal DVT

Are there any contraindications to anticoagulation?

Does the patient have severe symptoms OR risk factors for the extension of the thrombus?

No

Yes

Yes

No

Begin initial anticoagulation treatment Begin oral anticoagulant as an overlap therapy for the long term treatment

IVC filter Begin conventional course of anticoagulation if the risk of bleeding subsides

Begin initial anticoagulation treatment (if there are no contraindications) Begin oral anticoagulant as an overlap therapy for the long term treatment

Perform serial imaging for 2 weeks

Does the repeated US demonstrate any extension of the thrombus (with or without extension to the proximal veins)

Yes

No

Begin initial anticoagulation treatment (if there are no contraindications) Begin oral anticoagulant as an overlap therapy for the long term treatment

No anticoagulation therapy

Initial Anticoagulation Choices

❑ SC low molecular weight heparin (1st line)

❑ Enoxaparin 1.0 mg/kg every 12 hours OR 1.5 mg/kg once daily

❑ Tinzaparin 175 U/kg once daily

❑ SC fondaparinux (1st line)

❑ 5 mg once daily (if body weight <50 kg)

❑ 7.5 mg once daily (if body weight <50-100 kg)

❑ 10 mg once daily (if body weight >100 kg)

❑ IV unfractionated heparin

❑ 80 U/kg as bolus, followed by 18 U/kg/h, OR

❑ 70 U/kg as bolus, followed by 15 U/kg/h for stroke or cardiac patients

❑ Adjust the dosages according to the aPTT

❑ SC unfractionated heparin

❑ 333 U/kg as bolus, followed by 250 U/kg

Long Term Treatment

Shown below is the long term treatment for DVT. Note that not all patients with isolated distal DVT are started on anticoagulation, only those who are started require long term therapy with anticoagulation. Patients who are planned to receive long term therapy with anticoagulation should be assessed regularly for the risks vs benefits of anticoagulation therapy.

Is the DVT provoked or unprovoked?

Provoked

Unprovoked

What is the predisposing factor?

Is this the first or second episode?

Surgical OR Transient non surgical predisposing factor

Cancer

First episode

Second episode

Therapy for 3 months ❑ VKA (first line) OR ❑ LMWH OR ❑ Dabigatran OR ❑ Rivaroxaban

Extended therapy or until cancer is cured ❑ LMWH (first line) OR ❑ VKA OR ❑ Dabigatran OR ❑ Rivaroxaban

Is the DVT proximal or distal?

What is the risk of bleeding?

Proximal DVT

Isolated distal DVT

Low or moderate risk of bleeding

High risk of bleeding

What is the risk of bleeding?

Therapy for 3 months (irrespective of the risk of bleeding) ❑ VKA (first line) OR ❑ LMWH OR ❑ Dabigatran OR ❑ Rivaroxaban

Extended therapy ❑ VKA (first line) OR ❑ LMWH OR ❑ Dabigatran OR ❑ Rivaroxaban

Therapy for 3 months ❑ VKA (first line) OR ❑ LMWH OR ❑ Dabigatran OR ❑ Rivaroxaban

Low or moderate

High

Extended therapy ❑ VKA (first line) OR ❑ LMWH OR ❑ Dabigatran OR ❑ Rivaroxaban

Therapy for 3 months ❑ VKA (first line) OR ❑ LMWH OR ❑ Dabigatran OR ❑ Rivaroxaban

Assessment of Risk of Bleeding

The risk factors of bleeding with anticoagulation therapy are:

• Age > 75 years
• Alcohol abuse
• Anemia
• Antiplatelet therapy
• Cancer
• Comorbidity and reduced functional capacity
• Diabetes
• Frequent falls
• Liver failure
• Metastatic cancer
• Poor anticoagulant control
• Previous bleeding
• Prior stroke
• Recent surgery
• Renal failure
• Thrombocytopenia

Shown below is a table summarizing the risk of bleed based on the number of risk factors. Note that, although the presence of one risk factor signify moderate risk of bleeding, if the single risk factor is severe (such as severe thrombocytopenia or recent major surgery) then the patient is at high risk of bleeding despite the presence of a single risk factor.

Risk of bleeding	Number of risk factors
Low Risk	0
Moderate Risk	1
High Risk	≥2

ACCP 2012 Guidelines: Recommendations for Initial Approach in Patients with Acute DVT of the Leg (DO NOT EDIT)

Grade 1

"1. In patients with acute DVT of the leg treated with vitamin K antagonist (VKA) therapy, we recommend initial treatment with parenteral anticoagulation (low-molecular-weight heparin [LMWH], fondaparinux, IV unfractionated heparin [UFH], or subcutaneous [SC] UFH) over no such initial treatment. (Level of evidence B)"

Grade 2

"1. In patients with a high clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment while awaiting the results of diagnostic tests. (Level of evidence C)"

"2. In patients with an intermediate clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment if the results of diagnostic tests are expected to be delayed for more than 4 h (Level of evidence C)."

"3. In patients with a low clinical suspicion of acute VTE, we suggest not treating with parenteral anticoagulants while awaiting the results of diagnostic tests, provided test results are expected within 24 h (Level of evidence C)."