Indications for treatment
- 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
- 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)
- 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
- 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
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 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.
- compression stockings
- 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.