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Venous Thromboembolism

Kenna Koehler

Background

  • Includes both deep vein thrombosis (DVTs) and pulmonary embolism (PE). See “Pulmonary Embolism” section in cardiology for more information on PEs
  • Risk Factors for Provoked DVT/PE
    • Major risk factors: major surgery >30 minutes, hospitalization > 3 days, C-section
    • Minor Risk Factors: Surgery <30 minutes, Hospitalization <3 days, pregnancy, estrogen therapy, reduced mobility >3 days
    • Non-transient risk factors: Malignancy (active), IBD, liver disease, hereditary thrombophilia

Evaluation

  • Asymmetric calf swelling of >2cm sensitivity and specificity for DVT of 60-70%
  • Wells’ Criteria for DVT can help guide diagnostic testing
  • If a patient has a low pre-test probability, a negative D-dimer can rule out DVT
  • In a high pre-test probability patient a negative D-dimer is less helpful
  • Whole-leg ultrasounds with doppler

Management

  • Prophylaxis: Padua score
  • Score > 4 high risk, recommend pharmacologic prophylaxis
    • Subcutaneous Low Molecular Weight Heparin (LMWH) or Subcutaneous Heparin
  • Score <4 is low risk; recommend ambulation and SCDs
  • Treatment (see anticoagulation section)
    • Subcutaneous low molecular weight heparin (LMWH)
    • Oral factor Xa inhibitors (rivaroxaban, apixaban)
    • Intravenous unfractionated heparin
    • Warfarin (with bridge therapy)
  • Duration of treatment
    • Provoked: 3 months or until provoking factor (trauma, surgery, malignancy) is removed
    • Unprovoked: Typically requires life-long anticoagulation along with assistance from hematology
  • Anticoagulation in malignancy:
    • LMWH or DOAC (most evidence for apixaban and rivaroxaban) while malignancy still active
    • Avoid rivaroxaban and edoxaban in GI malignancies (increased rates of bleeding)

Additional Information

  • Should we get a follow up ultrasound?
    • A follow up ultrasound at the CONCLUSION of anticoagulation can help establish a post-treatment baseline and provide a baseline study for future comparison that can be critical for the diagnosis of recurrent/new DVT (which is very difficult to determine radiographically without a comparison imaging study)
  • What about IVC filters?
    • Select circumstances for these: In patients with acute DVT or PE and in whom anti-coagulation is absolutely contraindicated (thrombocytopenia, recent intra-cranial bleed, recent GI bleed) placement of a retrievable IVC filter should be discussed with Hematology and IR
Last update: 2022-06-24 23:35:57