Guideline 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 Society of Hematology (ASH 2023; 2020; 2018), the European Association for the Study of the Liver (EASL 2022), the European Society for Vascular Surgery (ESVS 2021), the American College of Chest Physicians (ACCP 2021; 2016), the Society for Vascular Medicine (SVM/AHA/ACC/ACS/ACCP/SIR 2020), the International Initiative on Thrombosis and Cancer (ITAC 2019), the Interdisciplinary Expert Panel on Iliofemoral Deep Vein Thrombosis (InterEPID 2015), the British Committee for Standards In Haematology (BCSH 2015), the International Society on Thrombosis and Haemostasis (ISTH 2014), the American Association of Family Physicians (AAFP 2013), and the Society for Vascular Surgery (SVS 2012). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 15 15 16 Definition Deep vein thrombosis is the formation of thrombus within the deep veins of lower extremity characterized by lower extremity pain and swelling and calf tenderness. 15 https://web.pathway.md/diseases/recy7Y18EJ5OGaopy 1/17 6/29/23, 10:06 PM Deep vein thrombosis Pathway Epidemiology Deep vein thrombosis is caused by thrombus formation due to venous stasis, endothelial injury, and blood hypercoagulability. 15 Disease course Thrombus formation due to venous stasis, endothelial injury, and blood hypercoagulability in the lower extremities results in deep vein thrombosis, 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. 15 Prognosis and risk of recurrence The 90-day mortality rates of asymptomatic proximal deep vein thrombosis and asymptomatic distal deep vein thrombosis are 13.75% and 3.39%, respectively. 16 Calculator Calculator Calculat Caprini Score for venous thromb DASH score for recurrent VTE Geneva Guidelines 1. Classification and risk stratification Anatomic classification: 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. A 2. Diagnostic investigations Assessment of pretest probability: obtain clinical assessment of the pretest probability as part of the diagnostic process in patients with suspected deep vein thrombosis. B Diagnostic imaging: As per ESVS 2021 guidelines, obtain ultrasound as the first-line modality in patients with suspected deep vein thrombosis requiring imaging. B Show 4 more As per AAFP 2013 guidelines, obtain MRV of the lower extremity and pelvis in patients with unilateral left leg swelling and negative results on duplex ultrasound if the clinical suspicion for DVT is high (in the context of suspected May-Thurner syndrome). B https://web.pathway.md/diseases/recy7Y18EJ5OGaopy 2/17 6/29/23, 10:06 PM Deep vein thrombosis Pathway As per SVS 2012 guidelines, obtain adjunctive imaging modalities (such as CTV or MRV) in patients with suspected iliofemoral venous thrombosis not confirmed with standard diagnostic modalities such as venous ultrasound imaging. B Evaluation for occult pulmonary embolism: do not evaluate for occult PE routinely in patients with deep vein thrombosis in the absence of symptoms or signs. D Evaluation for occult malignancy: As per ESVS 2021 guidelines, perform clinical examination and obtain sex-specific cancer screening, as opposed to routine extensive screening, for occult malignancy in patients with unprovoked deep vein thrombosis. A As per BCSH 2015 guidelines, consider obtaining CT (and mammography in females) for screening of cancer in > 40 years old patients with unprovoked VTE. Set a lower threshold for screening patients with bilateral deep vein thrombosis, very high D-dimers, or an early recurrence of VTE. C Landmark trials: SOME In patients who had a first unprovoked VTE, limited occult-cancer screening plus CT was not superior to limited occult-cancer screening with respect to occult cancer diagnosis at 1 year. Carrier M et al. N Engl J Med. 2015 Aug 20. Evaluation for thrombophilia: do not obtain thrombophilia testing in patients with provoked deep vein thrombosis. D Show 3 more 3. Medical management Setting of care: As per ESVS 2021 guidelines, offer outpatient management in most patients with deep vein thrombosis. A As per ASH 2020 guidelines, consider offering home-based rather than hospital treatment in patients with uncomplicated deep vein thrombosis. C Indications for anticoagulation: As per ACCP 2021 guidelines, consider obtaining serial imaging (repeated ultrasound once weekly or with worsening symptoms) of the deep veins for 2 weeks rather than initiating anticoagulation in patients with acute isolated distal deep vein thrombosis of the leg and without severe symptoms or risk factors for extension. C Show 3 more As per ESVS 2021 guidelines, consider deciding on the initiation of anticoagulation treatment in patients with calf deep vein thrombosis based on the patient's symptoms, risk factors for progression, and bleeding risk. C Administer a 3-month anticoagulant therapy in patients with symptomatic calf deep vein thrombosis requiring anticoagulation. B https://web.pathway.md/diseases/recy7Y18EJ5OGaopy 3/17 6/29/23, 10:06 PM Deep vein thrombosis Pathway Choice of anticoagulation, initial management, provoked thrombosis: As per ACCP 2021 guidelines, administer apixaban, dabigatran, edoxaban, or rivaroxaban rather than vitamin K antagonists for the treatment phase (first 3 months) in patients with deep vein thrombosis of the leg. B As per ESVS 2021 guidelines: Administer direct OACs rather than vitamin K antagonists for the principal treatment phase of patients with provoked proximal deep vein thrombosis. A Administer direct OACs rather than LMWH followed by vitamin K antagonists in patients with calf deep vein thrombosis requiring anticoagulation. B As per ASH 2020 guidelines: Consider administering direct OACs rather than vitamin K antagonists in patients with deep vein thrombosis and/or PE. C Insufficient evidence to recommend one direct OAC over another in patients with deep vein thrombosis and/or PE. I Choice of anticoagulation, initial management, unprovoked thrombosis: As per ACCP 2021 guidelines, administer oral Xa inhibitors (apixaban, edoxaban, rivaroxaban) rather than LMWH for the initiation and treatment phases in patients with acute deep vein thrombosis and cancer (cancer-associated thrombosis). B Show 2 more Landmark trials: CLOT In patients with cancer who had acute, symptomatic proximal deep vein thrombosis, PE, or both, subcutaneous dalteparin was superior to oral anticoagulation with respect to recurrent VTE at 6 months. Lee AY et al. N Engl J Med. 2003 Jul 10. As per ESVS 2021 guidelines: Administer LMWH for the initial and principal treatment in patients with cancer-associated deep vein thrombosis. A Consider administering approved direct OACs for the initial and principal treatment in selected patients with cancer-associated deep vein thrombosis, with the malignancy not located in the gastrointestinal or genitourinary systems. B As per ESVS 2021 guidelines, administer direct OACs rather than LMWH followed by a vitamin K antagonist for the principal treatment phase in patients with unprovoked proximal deep vein thrombosis. A Choice of anticoagulation, extended therapy: As per ACCP 2021 guidelines, administer reduced-dose direct OACs rather than aspirin in patients requiring extended-phase anticoagulation. B Show 3 more As per ESVS 2021 guidelines, consider administering direct OACs rather than vitamin K antagonists in patients with unprovoked proximal deep vein thrombosis requiring extended https://web.pathway.md/diseases/recy7Y18EJ5OGaopy 4/17 6/29/23, 10:06 PM Deep vein thrombosis Pathway anticoagulation beyond 3 months. C Show 2 more As per ASH 2020 guidelines: Target an INR range of 2-3 over a lower range (such as 1.5-1.9) in patients with deep vein thrombosis and/or PE completed primary treatment and continuing vitamin K antagonist therapy for secondary prevention. B Consider using a standard- or a lower-dose direct OAC in patients with deep vein thrombosis and/or PE completed primary treatment and continuing direct OAC for secondary prevention. C Duration of anticoagulation, provoked thrombosis: As per ASH 2023 guidelines, avoid obtaining thrombophilia testing to determine the duration of anticoagulant treatment after primary short-term treatment in patients with VTE provoked by surgery. D Show 2 more As per ACCP 2021 guidelines, complete a 3-month treatment phase of anticoagulation in patients with acute deep vein thrombosis in the absence of contraindications. Assess the need for extended-phase therapy upon completion of the 3-month treatment phase of therapy. B Show 2 more As per ESVS 2021 guidelines, complete a 3-month rather than a shorter A or longer duration of anticoagulation treatment in patients with provoked proximal deep vein thrombosis and a major transient risk factor. B Show 2 more As per ASH 2020 guidelines, consider completing a shorter (3-6 months) over a longer (6-12 months) course of anticoagulation for primary treatment in patients with deep vein thrombosis and/or PE, whether provoked by a transient risk factor or by a chronic risk factor. C Show 3 more Duration of anticoagulation, unprovoked thrombosis: As per ASH 2023 guidelines: Avoid obtaining thrombophilia testing to guide the duration of anticoagulant treatment after primary short-term treatment in patients with unprovoked VTE. D Avoid obtaining thrombophilia testing to guide anticoagulant treatment duration after primary short-term treatment in patients with an unspecified type of VTE. D As per ACCP 2021 guidelines, complete a 3-month treatment phase of anticoagulation in patients with acute deep vein thrombosis in the absence of contraindications. Assess the need for extended-phase therapy upon completion of the 3-month treatment phase of therapy. B Show 3 more As per ESVS 2021 guidelines, reassess the bleeding risk before continuing anticoagulation beyond 3 months in patients with unprovoked deep vein thrombosis. B Show 3 more https://web.pathway.md/diseases/recy7Y18EJ5OGaopy 5/17 6/29/23, 10:06 PM Deep vein thrombosis Pathway As per ASH 2020 guidelines, consider completing a shorter (3-6 months) over a longer (6-12 months) course of anticoagulation for primary treatment in patients with unprovoked deep vein thrombosis and/or PE. C Show 2 more Aspirin for extended treatment: As per ACCP 2021 guidelines, consider initiating aspirin to prevent recurrent VTE in patients with unprovoked proximal deep vein thrombosis after stopping anticoagulant therapy and not having contraindications to aspirin. C Landmark trials: ASPIRE In patients who had completed initial anticoagulant therapy after a first episode of unprovoked VTE, aspirin was not superior to placebo with respect to the incidence of recurrent VTE. Brighton TA et al. N Engl J Med. 2012 Nov 22. As per ESVS 2021 guidelines, do not use aspirin for extended antithrombotic therapy in patients with unprovoked deep vein thrombosis. D As per ASH 2020 guidelines: Consider initiating anticoagulation over aspirin in patients with deep vein thrombosis and/or PE completed primary treatment and continuing to receive secondary prevention. C Consider suspending aspirin for the duration of anticoagulation therapy in patients with deep vein thrombosis and/or PE with stable CVD initiating anticoagulation and previously taking aspirin for cardiovascular risk modification. C Thrombolytic therapy: As per ACCP 2021 guidelines, consider initiating anticoagulant therapy alone over interventional (thrombolytic, mechanical, or pharmacomechanical) therapy in patients with acute deep vein thrombosis of the leg. C As per ASH 2020 guidelines: Consider initiating anticoagulation therapy alone over thrombolytic therapy in addition to anticoagulation in most patients with proximal deep vein thrombosis. C Consider performing catheter-directed thrombolysis over systemic thrombolysis in patients with extensive deep vein thrombosis, if thrombolysis is performed. C 4. Nonpharmacologic interventions Compression stockings (early use): 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 deep vein thrombosis. A Compression stockings, medically managed patients: As per ACCP 2021 guidelines, avoid using compression stockings routinely for the prevention of post-thrombotic syndrome in patients with acute deep vein thrombosis of the https://web.pathway.md/diseases/recy7Y18EJ5OGaopy 6/17 6/29/23, 10:06 PM Deep vein thrombosis Pathway leg. D As per ESVS 2021 guidelines: Consider offering below-knee compression stockings in patients with proximal deep vein thrombosis to reduce the risk of post-thrombotic syndrome. B Limit the use of below-knee stockings to 6 or 12 months in patients with proximal deep vein thrombosis and limited symptoms and signs, as described in the Villalta score. A As per ASH 2020 guidelines, avoid using compression stockings routinely in patients with deep vein thrombosis, with or without an increased risk for post-thrombotic syndrome. D Compression stockings, after thrombus removal: As per AAFP 2013 guidelines, offer compression stockings in patients following deep vein thrombosis to prevent post-thrombotic syndrome. A As per SVS 2012 guidelines, offer knee-high compression stockings (30-40 mmHg), to be worn for 2 years after the procedure, in patients with deep vein thrombosis managed with thrombus removal techniques. B 5. Therapeutic procedures Thrombus removal and venous stenting: As per ESVS 2021 guidelines: Consider performing early thrombus removal in selected patients with symptomatic iliofemoral deep vein thrombosis. B Do not perform early thrombus removal in patients with deep vein thrombosis limited to femoral, popliteal, or calf veins. D As per SVS 2012 guidelines, perform early thrombus removal as the treatment of choice in patients with limb-threatening venous ischemia due to iliofemoral deep vein thrombosis (phlegmasia cerulea dolens), with or without associated femoropopliteal vein thrombosis. A Show 3 more Anticoagulation after thrombus removal: As per ESVS 2021 guidelines: Initiate anticoagulation in patients with deep vein thrombosis treated by early thrombus removal, with or without stenting, with a duration of at least as long as if the patients were treated by anticoagulation alone and at the discretion of the treating physician. B Decide on the choice of therapy in patients with iliofemoral deep vein thrombosis undergoing early thrombus removal based on the judgment of the treating physician. B As per SVS 2012 guidelines, administer a standard course of conventional anticoagulation in patients managed with early thrombus removal. A Inferior vena cava filter placement: As per ACCP 2021 guidelines: Do not use IVC filters in addition to anticoagulation therapy in patients with acute deep vein thrombosis of the leg. D Place an IVC filter in patients with acute proximal deep vein thrombosis of the leg and a contraindication to anticoagulation. B https://web.pathway.md/diseases/recy7Y18EJ5OGaopy 7/17 6/29/23, 10:06 PM Deep vein thrombosis Pathway Landmark trials: PREPIC In patients with proximal deep vein thrombosis who were at risk for PE, IVC filter implantation was superior to no IVC filter implantation with respect to symptomatic or asymptomatic PE at 12 days. Decousus H et al. N Engl J Med. 1998 Feb 12. As per ESVS 2021 guidelines: Place a temporary IVC filter in patients with proximal deep vein thrombosis having contraindications to anticoagulation during the initial or principal treatment phase. B Do not use IVC filters routinely in patients anticoagulated for deep vein thrombosis. D As per ASH 2020 guidelines, consider initiating anticoagulation alone rather than anticoagulation plus placement of an IVC filter in patients with proximal deep vein thrombosis and significant preexisting cardiopulmonary disease, as well as in patients with PE and hemodynamic compromise. C As per SIR 2020 guidelines, consider placing an IVC filter based on various clinical risk factors in patients with deep vein thrombosis without PE, if anticoagulation is contraindicated. C Show 8 more As per SVS 2012 guidelines: Do not use IVC filters (permanent or temporary) routinely in conjunction with catheter- directed pharmacologic thrombolysis of the iliofemoral venous segments. D Discuss the relative risks and benefits of periprocedural retrievable IVC filters in patients: undergoing pharmacomechanical thrombolysis with thrombus extending into the IVC with markedly limited cardiopulmonary reserve. B Anticoagulation after IVC filter placement: As per SIR 2020 guidelines, insufficient evidence to recommend for or against anticoagulation in patients having indwelling IVC filters with no other indication for anticoagulation. I As per ACCP 2016 guidelines, consider administering a conventional course of anticoagulant therapy in patients with acute proximal deep vein thrombosis of the leg and an IVC filter inserted as an alternative to anticoagulation, if the risk of bleeding resolves. C Inferior vena cava filter removal: consider removing/converting IVC filters routinely in patients with indwelling retrievable/convertible filters if the risk of PE has been mitigated or if patients are no longer at risk for PE unless risk outweighs benefit. E Show 5 more 6. Surgical interventions https://web.pathway.md/diseases/recy7Y18EJ5OGaopy 8/17 6/29/23, 10:06 PM Deep vein thrombosis Pathway Surgical thrombectomy: consider performing open surgical venous thrombectomy in selected patients being candidates for anticoagulation, if thrombolytic therapy is contraindicated. C 7. Specific circumstances Pregnant patients (antepartum thromboprophylaxis): 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. C 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. C Pregnant patients (postpartum thromboprophylaxis): consider obtaining testing for the known familial thrombophilia in females with a first-degree family history of VTE and known homozygous factor V Leiden, a combination of factor V Leiden and prothrombin G20210A, antithrombin deficiency, protein C deficiency, or protein S deficiency in the family. Consider administering postpartum thromboprophylaxis in patients with the same familial thrombophilia. C Show 2 more Pregnant patients, evaluation: As per ESVS 2021 guidelines, do not measure D-dimer levels and use the Wells score in pregnant patients with suspected deep vein thrombosis. D As per ASH 2018 guidelines, consider obtaining additional investigations, including serial compression ultrasound or MRV, after an initial negative ultrasound of the iliac veins in pregnant patients with suspected deep vein thrombosis. C Pregnant patients (setting of care): consider managing pregnant patients with low-risk acute VTE initially with outpatient therapy. C Pregnant patients, anticoagulation: As per ASH 2023 guidelines, consider obtaining thrombophilia testing to guide anticoagulant treatment duration after primary treatment in patients with VTE provoked by pregnancy or postpartum. Consider continuing anticoagulant treatment indefinitely in patients with thrombophilia and discontinuing it in patients without thrombophilia. C As per ESVS 2021 guidelines, initiate therapeutic doses of LMWH in pregnant patients with deep vein thrombosis during pregnancy for at least 3 months and for at least 6 weeks postpartum. B As per ASH 2018 guidelines: Initiate anticoagulant therapy with LMWH B , either once daily or BID, B in pregnant patients with acute VTE. A Avoid obtaining routine monitoring of anti-factor Xa levels to guide dosing in pregnant patients receiving therapeutic doses of LMWH. D https://web.pathway.md/diseases/recy7Y18EJ5OGaopy 9/17 6/29/23, 10:06 PM Deep vein thrombosis Pathway Pregnant patients (catheter-directed thrombolysis): avoid performing catheter-directed thrombolysis in addition to anticoagulation in pregnant patients with acute lower extremity deep vein thrombosis. D Pregnant patients (IVC filter placement): consider placing a temporary IVC filter in pregnant patients with deep vein thrombosis < 2 weeks before the anticipated date of delivery. C Pediatric patients: refer pediatric patients with deep vein thrombosis to clinicians with specific expertise in pediatric thrombosis and hemostasis. B Underweight or overweight patients: adjust the dose of UFH, LMWHs, and fondaparinux in underweight or overweight patients with deep vein thrombosis requiring anticoagulation. B Patients with chronic kidney disease: Consider monitoring anticoagulation levels and reducing the dosage in patients with deep vein thrombosis and CKD as most anticoagulants are excreted through kidneys. C Obtain periodic reassessments of renal function in patients with deep vein thrombosis and CKD treated with LMWH, fondaparinux, or a direct OAC. B Patients with liver cirrhosis: recognize that the risk of deep vein thrombosis/PE is at least as high in patients with cirrhosis as in the general population. B Show 6 more Patients with thrombophilia: As per ACCP 2021 guidelines, consider administering adjusted-dose vitamin K antagonists (target INR 2.5, with an overlapping period of parenteral anticoagulation) over direct OAC therapy during the treatment phase in patients with confirmed antiphospholipid syndrome being treated with anticoagulant therapy. C As per ESVS 2021 guidelines, initiate full-dose extended anticoagulant therapy with periodic reevaluation in patients with deep vein thrombosis and high-risk thrombophilia (such as antiphospholipid syndrome, homozygous FVL mutation, or deficiencies of protein C or S, or antithrombin). B Show 3 more Patients with iliofemoral DVT (evaluation): decide on the initial choice of tests based on the pretest probability of deep vein thrombosis. B Show 3 more Patients with cancer-associated thrombosis, initial management: As per ACCP 2021 guidelines: Administer oral Xa inhibitors (apixaban, edoxaban, rivaroxaban) rather than LMWH for the initiation and treatment phases in patients with acute deep vein thrombosis and cancer (cancer-associated thrombosis). B Consider preferring apixaban and LMWH in patients with luminal gastrointestinal malignancies due to the lower risk of major gastrointestinal bleeding. As per ESVS 2021 guidelines: Administer LMWH for the initial and principal treatment in patients with cancer-associated deep vein thrombosis. A Consider administering approved direct OACs for the initial and principal treatment in selected patients with cancer-associated deep vein thrombosis, with the malignancy not https://web.pathway.md/diseases/recy7Y18EJ5OGaopy 10/17 6/29/23, 10:06 PM Deep vein thrombosis Pathway located in the gastrointestinal or genitourinary systems. B Patients with cancer-associated thrombosis (extended therapy): Consider continuing anticoagulation beyond 3 months in patients with symptomatic calf deep vein thrombosis and active cancer. C Switch from LMWH to an OAC after 3-6 months of treatment for extended treatment in patients with active cancer-associated deep vein thrombosis. B Consider administering approved direct OACs for the extended treatment in selected patients with cancer-associated deep vein thrombosis, with the malignancy not located in the gastrointestinal or genitourinary systems. B Patients with catheter-related thrombosis, catheter removal: As per ESVS 2021 guidelines, consider removing the catheter in patients with catheter- related thrombosis when: it is not needed it is not functional anticoagulation is contraindicated symptoms are not resolving with anticoagulation the thrombosis is limb- or life-threatening. C As per ITAC 2019 guidelines, consider keeping the central venous catheter in place if it is functional, well positioned, and not infected, under close surveillance while administering anticoagulation therapy. Insufficient evidence to recommend specific duration of anticoagulation. C As per ISTH 2014 guidelines: Remove the non-functional, infected or incorrectly positioned catheter and consider initiating anticoagulation with LMWH for catheter-related thrombosis in patients with cancer. E Consider removing the central venous catheter without anticoagulation if therapeutic anticoagulation cannot be safely administered due to the active risk of hemorrhage. E Patients with iliofemoral DVT (anticoagulation): initiate anticoagulation for a minimum of 3 months in all patients in the acute care setting. A Show 4 more Patients with iliofemoral DVT (IVC filter placement): consider placing an IVC filter in patients with acute iliofemoral deep vein thrombosis with contraindications to systemic anticoagulation. B Show 2 more Patients with iliofemoral DVT (systemic thrombolysis): do not administer systemic thrombolysis in patients with iliofemoral deep vein thrombosis. D Patients with iliofemoral DVT (endovascular thrombectomy): Consider performing clot removal by endovenous techniques in patients with symptomatic acute iliofemoral deep vein thrombosis, to prevent or reduce post-thrombotic syndrome, ideally in patients with onset of symptoms within 21 days, good functional status, reasonable life expectancy, and low risk of bleeding. C Consider using endovenous techniques as first-line therapy for early thrombus removal. C https://web.pathway.md/diseases/recy7Y18EJ5OGaopy 11/17 6/29/23, 10:06 PM Deep vein thrombosis Pathway Patients with iliofemoral DVT (surgical thrombectomy): Perform urgent surgical thrombectomy, B or endovascular thrombus removal as an alternative option, in patients with phlegmasia cerulea dolens. B Consider performing open surgical venous thrombectomy in selected patients with iliofemoral deep vein thrombosis without phlegmasia cerulea dolens if the patient is a candidate for thrombus removal but has contraindications to thrombolytic therapy. C Patients with iliofemoral DVT (venous stenting): Consider performing stenting of the iliac venous system with self-expanding metallic stents at the time of clot removal in cases of clinically significant stenosis or extrinsic compression. C Do not place stents in the infrainguinal veins. D Patients with iliofemoral DVT (management of post-thrombotic syndrome): consider offering class II (30-40 mmHg) below-knee elastic compression stockings as soon as possible following initiation of anticoagulant therapy and continue for a minimum of 2 years. B Show 2 more Patients with iliofemoral DVT (follow-up): Obtain periodic clinical assessments in patients receiving extended anticoagulant therapy to reassess the risks and benefits of continuing the therapy. B Obtain longitudinal follow-up in all patients with an inserted optional recovery IVC filter. B Patients with upper extremity DVT: As per ESVS 2021 guidelines, obtain ultrasound as the initial imaging modality in patients with suspected upper extremity deep vein thrombosis. B Show 4 more As per ACCP 2016 guidelines: Consider initiating anticoagulant therapy alone over thrombolysis in patients with acute deep vein thrombosis of the upper extremity involving the axillary or more proximal veins. C Administer the same intensity and duration of anticoagulant therapy in patients with acute DVT of the upper extremity undergoing thrombolysis as in patients not undergoing thrombolysis. B Patients with catheter-related thrombosis, anticoagulation: As per ESVS 2021 guidelines, consider initiating LMWH or LMWH followed by vitamin K antagonists for a minimum of 3 months in patients with catheter-related thrombosis. C As per ITAC 2019 guidelines, initiate anticoagulation with LMWH for a minimum of 3 months and as long as the central venous catheter is in place for the treatment of symptomatic catheter-related thrombosis in patients with cancer. B As per ISTH 2014 guidelines, consider initiating anticoagulation with LMWH without removal of the catheter if the central venous catheter is functional and required for ongoing therapy. E Show 7 more 8. Preventative measures https://web.pathway.md/diseases/recy7Y18EJ5OGaopy 12/17 6/29/23, 10:06 PM Deep vein thrombosis Pathway Thrombophilia testing for minor provoking factors: 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. D Show 4 more Thrombophilia testing before hormone therapy (combined oral contraceptives): do not obtain thrombophilia testing to guide the use of combined oral contraceptives in females in the general population. D Show 3 more Thrombophilia testing before hormone therapy (hormone-replacement therapy): avoid obtaining thrombophilia testing to guide the use of hormone-replacement therapy in patients from the general population. D Show 3 more 9. Follow-up and surveillance Surveillance imaging: consider obtaining repeated ultrasound assessment after 5-7 days in patients with suspected deep vein thrombosis with a likely pretest probability and negative compression ultrasound. C Show 3 more Management of recurrent thrombosis: As per ESVS 2021 guidelines, consider switching the type of anticoagulation, increasing the dose of LMWH or direct OAC to a therapeutic dose, or switching to vitamin K antagonists with a higher INR target in patients with recurrent deep vein thrombosis occurring while compliant with treatment. C As per ASH 2020 guidelines: Consider administering LMWH rather than direct OACs in patients with breakthrough deep vein thrombosis and/or PE occurring during therapeutic vitamin K antagonist therapy. C Continue antithrombotic therapy indefinitely rather than stopping anticoagulation after completion of primary treatment in patients with a recurrent unprovoked deep vein thrombosis and/or PE. B As per ACCP 2016 guidelines: Switch to LMWH, at least temporarily, in patients with recurrent VTE while on OACs (vitamin K antagonists, dabigatran, rivaroxaban, apixaban, or edoxaban) deemed to be compliant with treatment. B Increase the dose of LMWH by about one-quarter to one-third in patients with recurrent VTE while on long-term LMWH deemed to be compliant with treatment. B Clinical findings Symptoms Past medical history Buttock pain Antiphospholipid syndrome https://web.pathway.md/diseases/recy7Y18EJ5OGaopy 13/17 6/29/23, 10:06 PM Deep vein thrombosis Pathway Calf pain Beh et's syndrome Fever Celiac disease Groin pain FVL mutation Leg cramping Granulomatosis with polyangiitis Leg pain IBD Leg swelling Immobility Inserted central venous catheter Medication history Malignancy Obesity Hormonal contraceptives PE Past surgical history Protein C deficiency Protein S deficiency Recent surgery Prothrombin G20210A mutation Rheumatoid arthritis Vital signs Superficial vein thrombosis Tachycardia Thromboangiitis obliterans Integument exam Past obstetric history Leg discoloration Pregnancy Leg telangiectasia Social history Tobacco use Vascular exam Bancroft's sign Homans' sign Leg edema Lisker's sign Louvel's sign Lowenberg's sign Peabody's sign Pratt's sign Rose's sign Lab findings serum D dimer Studies 2019 PREVENT In adults patients within 48 hours after admission to an ICU, pneumatic compression was not superior to control with respect to incident proximal deep vein thrombosis. Yaseen M Arabi et al. N Engl J Med. 2019 Apr 4. 2019 AVERT https://web.pathway.md/diseases/recy7Y18EJ5OGaopy 14/17 6/29/23, 10:06 PM Deep vein thrombosis Pathway In ambulatory patients with cancer who were at intermediate-to-high risk for VTE and were initiating chemotherapy, apixaban was superior to placebo with respect to the rate of VTE within 180 days. Carrier M et al. N Engl J Med. 2019 Feb 21. Show 22 more References 1. Saskia Middeldorp, Robby Nieuwlaat, Lisa Baumann Kreuziger et al. American Society of Hematology 2023 Guidelines for Management of Venous Thromboembolism: Thrombophilia Testing. Blood Adv. 2023 May 17;bloodadvances.2023010177. Open 2. Kathryn P Trayes, James S Studdiford, Sarah Pickle et al. Edema: Diagnosis and Management. Am Fam Physician. 2013 Jul 15;88 2 102 10. Open 3. Stavros K Kakkos, Manjit Gohel, Niels Baekgaard et al. Editor's Choice European Society for Vascular Surgery ESVS 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg. 2021 Jan;61 1 9 82. Open 4. Scott M Stevens, Scott C Woller, Lisa Baumann Kreuziger et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021 Dec;160 6):e545-e608. Open 5. Kearon C, Akl EA, Ornelas J et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb;149 2 315 352. Open 6. Meissner MH, Gloviczki P, Comerota AJ et al. Early thrombus removal strategies for acute deep venous thrombosis: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2012 May;55 5 1449 62. Open 7. John A Kaufman, Geoffrey D Barnes, Rabih A Chaer et al. Society of Interventional Radiology Clinical Practice Guideline for Inferior Vena Cava Filters in the Treatment of Patients with Venous Thromboembolic Disease: Developed in collaboration with the American College of Cardiology, American College of Chest Physicians, American College of Surgeons Committee on Trauma, American Heart Association, Society for Vascular Surgery, and Society for Vascular Medicine. J Vasc Interv Radiol. 2020 Oct;31 10 1529 1544. Open 8. David Liu, Erica Peterson, James Dooner et al. Diagnosis and management of iliofemoral deep vein thrombosis: clinical practice guideline. CMAJ. 2015 Nov 17;187 17 1288 1296. Open 9. Thomas L Ortel, Ignacio Neumann, Walter Ageno et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv. 2020 Oct 13;4 19 4693 4738. Open 10. Henry G Watson, David M Keeling, Mike Laffan et al. Guideline on aspects of cancer-related venous thrombosis. Br J Haematol. 2015 Sep;170 5 640 8. Open 11. J I Zwicker, G Connolly, M Carrier et al. Catheter-associated deep vein thrombosis of the upper extremity in cancer patients: guidance from the SSC of the ISTH. J Thromb Haemost. 2014 May;12 5 796 800. Open 12. Bates SM, Rajasekhar A, Middeldorp S et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy. Blood Adv. 2018 Nov 27;2 22 3317 3359. Open https://web.pathway.md/diseases/recy7Y18EJ5OGaopy 15/17 6/29/23, 10:06 PM Deep vein thrombosis Pathway 13. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol. 2022 May;76 5 1151 1184. Open 14. Dominique Farge, Corinne Frere, Jean M Connors et al. 2019 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. Lancet Oncol. 2019 Oct;20 10):e566-e581. Open 15. Emeka Kesieme, Chinenye Kesieme, Nze Jebbin et al. Deep vein thrombosis: a clinical review. J Blood Med. 2011; 2 59 69. Open 16. Paul T Vaitkus, Alain Leizorovicz, Alexander T Cohen et al. Mortality rates and risk factors for asymptomatic deep vein thrombosis in medical patients. Thromb Haemost. 2005 Jan;93 1 76 9. Open 17. Dhall SS, Hadley MN, Aarabi B et al. Deep venous thrombosis and thromboembolism in patients with cervical spinal cord injuries. Neurosurgery. 2013 Mar;72 Suppl 2 244 54. Open 18. Mahajerin A, Petty JK, Hanson SJ et al. Prophylaxis against venous thromboembolism in pediatric trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society. J Trauma Acute Care Surg. 2017 Mar;82 3 627 636. Open 19. Gould MK, Garcia DA, Wren SM et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141 2 Suppl):e227S-e277S. Open 20. Falck-Ytter Y, Francis CW, Johanson NA et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141 2 Suppl):e278S-e325S. Open 21. Practice Committee of the American Society for Reproductive Medicine. Combined hormonal contraception and the risk of venous thromboembolism: a guideline. Fertil Steril. 2017 Jan;107 1 43 51. Open 22. American Physical Therapy Association. Choosing Wisely APTA recommendations. Choosing Wisely. 2014. Open 23. Society for Vascular Medicine. Choosing Wisely SVM recommendations. Choosing Wisely. 2013. Open 24. Shrey Modi, Ryan Deisler, Karen Gozel et al. Wells criteria for DVT is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma patients. World J Emerg Surg. 2016 Jun 8;11 24. Open 25. Shannon M Bates, Ian A Greer, Saskia Middeldorp et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141 2 Suppl):e691S- e736S. Open 26. Shrey Modi, Ryan Deisler, Karen Gozel et al. Wells criteria for DVT is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma patients. World J Emerg Surg. 2016 Jun 8;11 24. Open 27. J P Galanaud, C A Holcroft, M A Rodger et al. Comparison of the Villalta post-thrombotic syndrome score in the ipsilateral vs. contralateral leg after a first unprovoked deep vein thrombosis. J Thromb Haemost. 2012 Jun;10 6 1036 42. Open