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    Deep Vein Thrombosis- Treatment

    Cardiovascular, Hematological / Oncological

    Last Updated Dec 04, 2020
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    By Nazde Edeer

    Context

    • Deep vein thrombosis (DVT) is common, with over 45,000 cases diagnosed in Canada each year.
    • Complications can include pulmonary embolism (PE) and post-thrombotic syndrome.
    • The mainstay of treatment is anticoagulation.
    • Of note, the misleadingly named superficial femoral vein is a part of the deep venous system, and thrombus identified in this vein must be treated.

    Recommended Treatment

    • Most patients with DVT can be treated with oral anticoagulation therapy alone. There are a number of initial treatment regimens recommended by Thrombosis Canada but the two more commonly recommended regimes are:
      • Apixaban 10 mg PO BID for 1 week before reducing dose to 5 mg PO BID.
        • 10 mg BID for 7 days, followed by 5 mg BID. Apixaban is not recommended in patients with CrCl <15 mL/min or for those undergoing dialysis.
      • Rivaroxaban 15 mg PO BID for 3 weeks before reducing dose to 20 mg PO once daily.
        • Same cautions with respect to renal function as with Apixaban.
      • Equally efficacious with less bleeding complications.
    • Duration of therapy is a minimum of three months.
    • Other regimes include:
      • Full-dose low molecular weight heparin (LMWH) overlapping with warfarin for at least 5 days and until the INR > 2.0 for >2 days.
      • Full-dose IV heparin overlapping with warfarin for at least 5 days and until the INR is at least 2.0 for at least 2 days.
      • Full-dose SC LMWH or IV heparin for at least 5-10 days before switching to dabigatran 150 mg PO BID.
      • Full-dose LMWH for the 1st month or so before switching to a DOAC or warfarin.
    • Special Situations
      • Pregnancy/Breastfeeding
        • LMWH alone recommended. Dalteparin or enoxaparin.
        • DOAC’s contraindicated.
      • Malignancy: Case by case decision: risk of thrombosis/ bleeding, specific malignancy, prognosis.
      • Heart Valve Replacements: LMWH and Warfarin only.
      • Massive DVT: For patients with massive lower extremity DVT (Phlegmasia Cerulea Dolens – severe cyanosis and swelling of the affected leg – and Phlegmasia Alba Dolens – thrombosis without ischemic changes as some collateral flow) involving the proximal deep veins mechanical and catheter-directed thrombolysis can be considered within 14 days of symptom onset. Intravenous UFH should be used pre-thrombolytic therapy.
    • Isolated distal DVT
      • Anticoagulation is generally suggested if:
        • Severe symptoms.
        • Risk factors for extension (thrombus greater than 5 cm in length, involvement of multiple deep veins, close to the popliteal vein, no reversible risk factor, previous VTE, in-patient, active cancer, or positive D-dimer),
        • Unable or unwilling to return for serial studies.
        • Has progression of the DVT on repeat imaging.
        • Duration at least 3 months.
    •  Upper extremity DVT (UEDVT)
      • Treatment should generally follow the principles for lower extremity DVT.
      • Thrombolysis may be considered on a case-by-case basis if limb compromise.
    • Superficial vein thrombosis (SVT)
      • If within 3 cm of saphenofemoral junction or the saphenopopliteal junction treat DVT as high risk of progression into the deep venous system. These patients should also receive therapeutic doses of anticoagulation for 3 months.
    • In patients with a contraindication to anticoagulation or increased risk of bleeding a vena cava filter can be considered to reduce the risk of pulmonary embolism.

    Criteria For Hospital Admission

    • Outpatient treatment of DVT is preferred.
    • Factors that may contribute to hospitalization of patients with DVT include severe symptoms, phlegmasia cerulea dolens, hemodynamic instability, high risk of bleeding and renal failure.

    Criteria For Transfer To Another Facility

    • Transfer to an acute care centre may be indicated for patients that are hemodynamically unstable, or require further management such as mechanical and catheter-directed thrombolysis or vena cava filter insertion.

    Criteria For Close Observation And/or Consult

    • Consider internal medicine consult for patients that meet criteria for hospital admission.
    • Referral to a venous thromboembolism or internal medicine clinic should be considered for optimization of anticoagulation choice and regimen.

    Criteria For Safe Discharge Home

    • Criteria for safe discharge home may differ on a case-by-case basis but generally includes patients that:
      • Are hemodynamically stable.
      • Are ambulatory.
      • Have a low risk of bleeding on anticoagulation.
      • Do not have renal failure.
      • Are compliant with their treatment regimen.
      • Have a plan to follow up in the community.

    Quality Of Evidence?

    Justification

    This management strategy has been approved and developed by Thrombosis Canada.

    High

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