Phlegmasia cerulea dolens. From PMID: 17229945
Thanks to Dr. van den Burg and Julien Nguyen, PGY2 for a comprehensive introduction to lower extremity DVT management!
Learning points from today:
- When to treat?
- Assess for contraindications.
- No bleeding risk score developed specifically for anticoagulation in VTE, but for HASBLED score is being used for anticoagulation in atrial fibrillation. (PMID: 20299623)
- All proximal DVT should be treated (popliteal, femoral, iliac vein)
- Symptomatic distal DVT generally treated.
- Asymptomatic distal DVT may undergo serial U/S surveillance.
- For how long do we treat?
- 3 months for active episode of VTE.
- Treating beyond 3 months (i.e., indefinitely) is for “secondary prevention,” typically done if active cancer or 2+ unprovoked VTE.
- See this great Blood article for a great review of the literature regarding treatment duration. (PMID: 24497538)
- Treatment options
- Factor Xa inhibitors:
- Parenteral: Some LMWH (enoxaparin, dalteparin, tinzaparin, nadroparin)
- Oral: rivaroxaban, apixaban, edoxaban.
- Direct thrombin inhibitors (No “x” in generic name):
- Parenteral: bivalirudin, argatroban, desirudin.
- Oral: dabigatran.
- Coumadin
- Factor Xa inhibitors:
- Idarucizumab as a reversal agent for dabigatran is undergoing expedited FDA approval. (PMID: 26095746, 26095632)
- Consider IR and/or vascular surgery consult for catheter-directed thrombolysis or thrombectomy if evidence of ischemia due to decreased venous outflow (e.g., phlegmasia cerulea dolens, phlegmasia alba dolens).