Proximal DVT without history of cancer
- Novel oral anticoagulant (NOAC)) preferred over a vitamin K antagonist (coumadin) (Grade 2B recommendation)
- Coumadin preferred to low-molecular weight heparin (LMWH) (Grade 2C recommendation)
- Duration of treatment: 3 months for 1st clot (Grade 1B recommendation)
Proximal DVT with cancer (“cancer-associated thrombosis”)
- LMWH preferred to coumadin or NOAC (Grade 2C recommendation)
- Duration of treatment: 3 months for 1st clot (Grade 1B recommendation)
Isolated Distal (calf) DVT
- Up to 25% will propagate proximally in admitted patients but no robust evidenced in ambulatory patients discharged home
- Absence of severe symptoms and no risk factors for extension
- Serial imaging over 2 weeks preferred to anticoagulation (Grade 2C recommendation)
- No established role for providing antiplatelet therapy (i.e. aspirin) alone in these cases but a reasonable intervention
- Presence of severe symptoms or risk factors for extension
- Anticoagulation preferred to serial imaging (Grade 2C recommendation)
- Anticoagulation choices same as for proximal DVT (Grade 1B recommendation)
Superficial Thrombophlebitis
- Saphenous vein clots above the knee can spread into deep venous system via the saphenous-femoral junction
- Initial treatment with NSAIDs, warm compresses and compression stockings
- Repeat US in 2-5 days and start anticoagulation if clot extending
Catheter-Directed Thrombolysis (CDT)
- No substantial benefits in most patients with proximal DVT
- Likely increases risk of major bleeding
- Possible benefit in post-thrombotic syndrome in patients with iliofemoral DVT and a low risk of bleeding
References:
1) Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, Huisman M, King CS, Morris TA, Sood N, Stevens SM, Vintch JRE, Wells P, Woller SC, Moores L. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb;149(2):315-352.
2) Decousus H et al. Fondaparinux for the treatment of superficial-vein thrombosis in the legs. N Engl J Med 2010; 363:1222-1232.
3) Bashir R et al. Comparative outcomes of catheter-directed thrombolysis plus anticoagulation vs anticoagulation alone to treat lower-extremity proximal deep vein thrombosis. JAMA Intern Med. 2014;174(9):1494-1501.