• proximal DVT
• proximal propagation of a distal DVT
  • some authors advocate that isolated asymptomatic distal DVT can be followed on serial Duplex Ultra-sound, and does not require treatment
  • distal DVT will propagate proximally in less than 10-20% of cases, and has a low risk of PE
  • serial ultrasound can be performed on POD 7 and 14
  • in the review by Laird L and Wille-Jorgensen P (2000), the authors advocate treatment of asymptomatic calf vein thrombosis in order to reduce the chance of throbosis extension as well as post-thrombotic venous syndrome
  • references
  • Risk assessment and novel therapeutic approaches: reducing the incidence and recurrence of deep vein thrombosis in the surgical patient. Conclusion.
  • Is anticoagulation indicated for asymptomatic postoperative calf vein thrombosis?
  • The significance of calf thrombi after total knee arthroplasty.
  • The clinical course of distal deep venous thrombosis after total hip and total knee arthroplasty, as determined with duplex ultrasonography.
  • Incidence and natural history of below-knee deep venous thrombosis in high-risk trauma patients.

Treatment modalities (classes of drugs)

• Anticoagulants
  • Prevent recurrent or ongoing thrombolytic occlusion of the verterobasilar circulation
• Low molecular weight heparins
  • Prepared by selectively treating UFH to isolate low molecular weight fragments
  • Activity measured in units of factor X inactivation and monitoring of aPTT not required
• Vitamin K antagonists
  • Class of oral anticoagulant drug that acts as antagonists to vitamin K
  • Interferes with interaction between vitamin K and coagulation factors II, VII, IX, and X
• Thrombolytics
  • Used to dissolve a pathologic intraluminal thrombus or embolus that has not been dissolved by the endogenous fibrinolytic system
  • Used for prevention of recurrent thrombus formation and rapid restoration of hemodynamic disturbances

Duration of treatment

• standard recommendations range from 3-6 months
• in the study by Ridker PM, et al.,: that long-term, low-intensity warfarin therapy is a highly effective method of preventing recurrent VT
  • patients assigned to placebo or low-intensity warfarin (target INR, 1.5 to 2.0) had a risk reduction of 64 percent p < 0.001)
• in the future, patients with DVT may be tested for thrombophilias (inherited suseptibility), and recommendations for length of treatment are based accordingly
• patients with DVT need to wear fitted compression stockings for at least two years - will reduce incidence of the post-thrombotic syndrome by 50%
• in the report by Agnelli G, et al. (2001), the authors sought to determine the optimal duration of treatment
  • patients with a first episode of idiopathic proximal DVT who had completed 3 months of oral anticoagulant therapy were randomly assigned to the discontinuation of oral anticoagulants or to their continuation for 9 additional months
  • analysis showed that of 134 patients assigned to continued oral anticoagulant therapy, 21 had a recurrence of DVT (15.7 %; average follow-up, 37.8 months), as compared with 21 of 133 patients assigned to the discontinuation of oral anticoagulant therapy (15.8 percent; average follow-up, 37.2 months), resulting in a relative risk of 0.99 (95 % CI, 0.57 to 1.73)
  • incidence of recurrence after the discontinuation of treatment was 5.1 % per patient-year in patients in whom oral anticoagulant therapy was discontinued after 3 months and 5.0 percent per patient-year in patients who received an additional 9 months of oral anticoagulant therapy
  • authors concluded that the clinical benefit associated with extending duration of anticoagulant therapy to one year is not maintained after therapy is discontinued
• references
  • Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism.
  • Three months versus one year of oral anticoagulant therapy for idiopathic deep venous thrombosis. Warfarin Optimal Duration Italian Trial Investigators.

Use of D-dimer to determine length of treatment

• D-dimer and duration of anticoagulation.
• D-dimer Testing to determine the duration of anticoagulation therapy.

Superficial DVT

• superficial thrombophlebitis
• begin treatment with warm compresses, aspirin, and leg elevation
• more aggressive anticoagulation is required with more advanced symptoms
• reference - Treatment for superficial thrombophlebitis of the leg.

Post-thrombotic syndrome

• compression stockings
• references
  • Compression stockings to prevent post-thrombotic syndrome: a role for anticoagulation clinics?
  • Non-pharmaceutical measures for prevention of post-thrombotic syndrome.
  • Use of elastic compression stockings after deep venous thrombosis: a comparison of practices and perceptions of thrombosis physicians and patients.
  • Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial.
  • Review article: anti-embolism stockings.

References

Patient-reported treatment satisfaction with oral rivaroxaban versus standard therapy in the treatment of acute symptomatic deep-vein thrombosis.

Oral rivaroxaban for symptomatic venous thromboembolism.

Rivaroxaban (Xarelto) Criteria for Use for Treatment of Venous Thromboembolism (VTE)