see also: [[Pulmonary Embolism]], [[thrombophilia]] see: [Dunn - Management of DVT](x-devonthink-item://2EB4C597-F867-4D2B-B50E-508365503F16), [Hayes' DVT in pregnancy](x-devonthink-item://23836EE4-5E41-4FBD-B372-3095756470DB), [Dunn - upper limb venous thrombosis](x-devonthink-item://6DDEF867-FB81-4136-B87B-31FA554F1AB0), [Superficial thrombophlebitis](x-devonthink-item://30DC1E92-26DC-44EC-B248-85E91B6EBC3C) #haem **Virchad's triad** - stasis - hyper-coaguability - endothelaial damage **Signs** - swelling - erythema **Wells criteria for DVT** # anticoagulation benefits: - ↓ risk of PE to 5% risks: - bleeding from therapeutic anticoagulation - fatal < 0.5% - major 2% | agent | indications | | -------- | ------------------------------------------------------------------------------------------------------- | | DOAC | - non-malignancy DVT<br>- xarelto ↑ menstrual bleeding more than LMWH<br>- do not need bridging therapy | | heparin | - DOACs work just as well<br>- s/c heparin and LMWH equally effective<br>- can bridge to warfarin | | warfarin | - use in pts with lupas anticoagulant <br>- valvular AF | **Treatment table** | type of thrombosis | treatment | dispo | | ----------------------------------------------- | -------------------------------------------- | ----- | | superficial thrombophlebitis ↑ progression risk | LMWH / DOAC | home | | superficial thrombophlebitis ↓ progression risk | no anticoagulation<br>repeat USS in 4-7 days | home | | below knee DVT ↑ risk | no anticoagulation<br>repeat USS in 4-7 days | home | | below knee ↓ risk | observation | home | | proximal no massive iliofemoral | DOAC | home | | proximal massive iliofemoral | consider thrombolysis / heparin / LMWH | admit | | ↑ bleeding risk | caval filter if not high clot burden | admit | | [[drugs in pregnancy\|pregnancy]] | LMWH | | | lupus | LMWH → warfarin | | | malignancy | LMWH / DOAC | | | valvular AF or mechanical prosthetic valve | warfarin <br>LMWH if INR subtherapeutic | | ## duration of therapy - 3 months in most cases - life-long when - thrombophilia present - unprovoked VTE in males ## isolated below knee thrombosis - 7-10% incidence of propagation; PE in 2-3 % - death in <1% - anticoagulation not indicated if *low risk of propagation* - ↑ risk of progression at similar risk of increasing bleeding complications high risk of propagation: - ongoing immobility - pregnancy - septic phlebitis - high risk VTE history - active cancer - \>5cm in length - \> 7mm in maximal diameter - involves multiple veins - close to proximal veins ## superficial thrombophlebitis anticoagulation if: - presence of DVT - affected vein ≥ 5cm in length - thrombosis close to the saphenofemoral / saphenopopliteal junction - ongoing risk factors for thrombosis not required for superficial phlebitis of the saphenous vein following endovascular ablation therapy