Treatment Acute Proximal DVT
ÎThe ACCP suggests anticoagulant therapy alone over catheter-directed thrombolysis (CDT) (2-C).
Remark: Patients who are most likely to benefit from CDT (see full text guideline), who attach a high value to prevention of postthrombotic syndrome (PTS), and a lower value to the initial complexity, cost, and risk of bleeding with CDT, are likely to choose CDT over anticoagulation alone.
ÎAn IVC filter inserted as an alternative to anticoagulation: The ACCP suggests a conventional course of anticoagulant therapy if the risk of bleeding resolves (2-B).
Remark: The ACCP does not consider that a permanent IVC filter, of itself, is an indication for extended anticoagulation.
Acute Isolated Distal DVT
ÎWithout severe symptoms or risk factors for extension: The ACCP suggests serial imaging of the deep veins for 2 weeks over initial anticoagulation (2-C).
ÎWith severe symptoms or risk factors for extension (Table 1): The ACCP suggests initial anticoagulation over serial imaging of the deep veins (2-C).
• Patients at high risk for bleeding are more likely to benefit from serial imaging. • Patients who place a high value on avoiding the inconvenience of repeat imaging and a low value on the inconvenience of treatment and on the potential for bleeding are likely to choose initial anticoagulation over serial imaging.
Remarks:
ÎManaged with initial anticoagulation: The ACCP recommends using the same approach as for patients with acute proximal DVT (1-B).
ÎManaged with serial imaging: The ACCP recommends no anticoagulation if the thrombus does not extend (1-B). The ACCP suggests anticoagulation if the thrombus extends but remains confined to the distal veins (2-C) The ACCP recommends anticoagulation if the thrombus extends into the proximal veins (1-B).
ÎWhen provoked by surgery or by a nonsurgical transient risk factor, the ACCP suggests treatment with anticoagulation for 3 months over treatment for a shorter period (2-C) and recommends treatment with anticoagulation for 3 months over treatment for a longer time-limited period (eg, 6 or 12 months) (1-B) or extended therapy (1-B regardless of bleeding risk).a
a b 2
Duration of treatment of patients with isolated distal DVT refers to patients in whom a decision has been made to treat with anticoagulant therapy. However, it is anticipated that not all patients who are diagnosed with isolated distal DVT will be prescribed anticoagulants.
Choice of treatment in patients with and without cancer is sensitive to the individual patient's tolerance for daily injections, need for laboratory monitoring, and treatment costs.
