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Deep vein thrombosis

What's new

Updates 2023 ASH guidelines for the evaluation and management of venous thromboembolism.

Background

Overview

Definition
DVT is the formation of thrombus within the deep veins of lower extremity characterized by lower extremity pain and swelling and calf tenderness.
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Pathophysiology
DVT is caused by thrombus formation due to venous stasis, endothelial injury, and blood hypercoagulability.
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Disease course
Thrombus formation due to venous stasis, endothelial injury, and blood hypercoagulability in the lower extremities results in DVT, which causes clinical manifestations of lower extremity pain, swelling, and calf tenderness. Disease progression may lead to postphlebitis syndrome and pulmonary hypertension; acute complication may result in PE that might prove fatal.
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Prognosis and risk of recurrence
The 90-day mortality rates of asymptomatic proximal DVT and asymptomatic distal DVT are 13.75% and 3.39%, respectively.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of deep vein thrombosis are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024,2022,2013), the American Society of Hematology (ASH 2023,2020,2018), the European Association for the Study of the Liver (EASL 2022), the American College of Chest Physicians (ACCP 2021,2016), the European Society ...
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Classification and risk stratification

Anatomic classification: as per SVS 2012 guidelines, use precise anatomic terminology to characterize the most proximal extent of venous thrombosis as involving the iliofemoral veins, with or without extension into the IVC, the femoropopliteal veins, or isolated to the calf veins, rather than a simple characterization of a thrombus as proximal or distal.
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Diagnostic investigations

Assessment of pretest probability: as per AAFP 2022 guidelines, use the Wells' score for diagnosing acute DVT in patients with acute unilateral lower extremity edema.
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  • Diagnostic imaging

  • Evaluation for occult PE

  • Evaluation for occult malignancy

  • Evaluation for thrombophilia

Medical management

Setting of care: as per ESVS 2021 guidelines, offer outpatient management in most patients with DVT.
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  • Indications for anticoagulation

  • Choice of anticoagulation (initial management, provoked thrombosis)

  • Choice of anticoagulation (initial management, unprovoked thrombosis)

  • Choice of anticoagulation (extended therapy)

  • Duration of anticoagulation (provoked thrombosis)

  • Duration of anticoagulation (unprovoked thrombosis)

  • Aspirin for extended treatment

  • Thrombolytic therapy

Nonpharmacologic interventions

Compression stockings, early use: as per ESVS 2021 guidelines, offer early compression at 30-40 mmHg with either multilayer bandaging or compression hosiery, applied within 24 hours, to reduce pain, edema, and residual venous obstruction in patients with proximal DVT.
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  • Compression stockings (medically managed patients)

  • Compression stockings (after thrombus removal)

Therapeutic procedures

Thrombus removal and venous stenting
As per ESVS 2021 guidelines:
Consider performing early thrombus removal in selected patients with symptomatic iliofemoral DVT.
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Do not perform early thrombus removal in patients with DVT limited to femoral, popliteal, or calf veins.
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  • Anticoagulation after thrombus removal

  • IVC filter placement

  • Anticoagulation after IVC filter placement

  • IVC filter removal

Surgical interventions

Surgical thrombectomy: as per SVS 2012 guidelines, consider performing open surgical venous thrombectomy in selected patients being candidates for anticoagulation, if thrombolytic therapy is contraindicated.
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Specific circumstances

Pregnant patients, antepartum thromboprophylaxis
As per ASH 2023 guidelines:
Consider obtaining testing for the known familial thrombophilia in females with a family history of VTE and known homozygous factor V Leiden, a combination of factor V Leiden and prothrombin G20210A, or antithrombin deficiency in the family. Consider administering antepartum thromboprophylaxis in patients with the same familial thrombophilia.
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Consider either obtaining testing for the known familial thrombophilia or omitting testing for thrombophilia to guide antepartum prophylaxis in females with a family history of VTE and known protein C or protein S deficiency in the family.
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  • Pregnant patients (postpartum thromboprophylaxis)

  • Pregnant patients (evaluation)

  • Pregnant patients (setting of care)

  • Pregnant patients (anticoagulation)

  • Pregnant patients (catheter-directed thrombolysis)

  • Pregnant patients (IVC filter placement)

  • Pediatric patients

  • Underweight or overweight patients

  • Patients with CKD

  • Patients with liver cirrhosis

  • Patients with thrombophilia

  • Patients with iliofemoral DVT (evaluation)

  • Patients with cancer-associated thrombosis (initial management)

  • Patients with cancer-associated thrombosis (extended therapy)

  • Patients with catheter-related thrombosis (catheter removal)

  • Patients with iliofemoral DVT (anticoagulation)

  • Patients with iliofemoral DVT (IVC filter placement)

  • Patients with iliofemoral DVT (systemic thrombolysis)

  • Patients with iliofemoral DVT (endovascular thrombectomy)

  • Patients with iliofemoral DVT (surgical thrombectomy)

  • Patients with iliofemoral DVT (venous stenting)

  • Patients with iliofemoral DVT (management of post-thrombotic syndrome)

  • Patients with iliofemoral DVT (follow-up)

  • Patients with upper extremity DVT

  • Patients with catheter-related thrombosis (anticoagulation)

Preventative measures

Thrombophilia testing for minor provoking factors: as per ASH 2023 guidelines, avoid obtaining testing for factor V Leiden or prothrombin G20210A (low-risk thrombophilia) to guide thromboprophylaxis in patients with a family history of factor V Leiden (with or without VTE) and having a minor provoking risk factor for VTE, such as immobility or minor injury, illness, or infection.
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  • Thrombophilia testing before hormone therapy (combined oral contraceptives)

  • Thrombophilia testing before hormone therapy (hormone replacement therapy)

  • Thromboprophylaxis in hospitalized patients

Follow-up and surveillance

Surveillance imaging: as per ESVS 2021 guidelines, consider obtaining repeated ultrasound assessment after 5-7 days in patients with suspected DVT with a likely pretest probability and negative compression ultrasound.
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  • Management of recurrent thrombosis