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Thrombus
Experts in Europe have published a consensus document on the diagnosis and management of acute deep vein thrombosis (DVT).
The document provides advice on DVT diagnosis, initial management (first 5–21 days), long-term management (first 3–6 months), extended management (beyond 6 months), and special situations such as cancer, pregnancy, and DVT at unusual sites.
The document, published in the European Heart Journal, was produced by the European Society of Cardiology (ESC) Working Group on Aorta and Peripheral Vascular Diseases and Working Group on Pulmonary Circulation and Right Ventricular Function.
First, the document highlights the importance of clinical assessment and imaging with venous ultrasound for DVT diagnosis.
“The signs and the symptoms of DVT differ from one patient to another and are unspecific but are still very important and recommended for the initial evaluation of patients with suspected DVT,” said lead author of the document Lucia Mazzolai, MD, PhD, of Lausanne University Hospital in Switzerland.
“Ultrasound is recommended as the first-line diagnostic tool when lower or upper limb DVT is suspected. We also propose venous ultrasound in patients with confirmed PE [pulmonary embolism] as initial reference in case of DVT recurrence or further patient stratification in selected individuals.”
For initial and long-term management, the document includes advice according to the location of DVT, which can be proximal (popliteal, femoral, or iliac veins) or isolated distal (in the calf veins only).
Anticoagulation for patients with isolated distal DVT is under debate, and the document’s authors said patients should be stratified based on their individual risk.
Regarding the type of anticoagulant therapy to use in the first line of initial and long-term management, Dr Mazzolai said there has been a paradigm shift in recent years.
“We propose direct oral anticoagulants as first-line treatment for non-cancer patients,” she said. “We also recommend catheter-directed thrombolysis as an adjuvant treatment only in select patients.”
For the extended management phase, the authors recommend personalized decisions on the continuation of anticoagulation, based on risk/benefit balance.
In addition, a venous ultrasound should be performed when anticoagulation is discontinued. This can serve as a baseline comparative exam in case DVT recurs.
Regarding special situations, the authors said that, after 6 months, patients with cancer need personalized management. The decision on whether or not to continue anticoagulation, and with which drug, should be based on the patient’s risk/benefit ratio, tolerability, preference, and cancer activity.
Pregnant patients with suspected lower limb DVT should have venous ultrasound as the first-line diagnostic imaging test. Low-molecular-weight heparin is recommended for initial and long-term treatment of DVT during pregnancy.
“This is the first European document that addresses all aspects of modern DVT management because it discusses diagnosis, treatment, and follow-up, plus special situations like cancer, pregnancy, and unusual DVT sites,” Dr Mazzolai said.
“Together with the 2014 ESC guidelines on PE, clinicians now have comprehensive recommendations on the management of VTE [venous thromboembolism].”
