From the Guidelines
For a 73-year-old female with non-occlusive deep vein thrombosis (DVT) in the femoral and popliteal veins extending to the short saphenous vein, I recommend immediate anticoagulation therapy. According to the most recent and highest quality study 1, anticoagulation alone is the recommended treatment for patients with acute DVT who do not have contraindications. Start with direct oral anticoagulant (DOAC) therapy, preferably apixaban 10 mg twice daily for 7 days, followed by 5 mg twice daily for at least 3 months. Alternatively, rivaroxaban 15 mg twice daily for 21 days followed by 20 mg once daily is appropriate. If DOACs are contraindicated, use low molecular weight heparin (enoxaparin 1 mg/kg twice daily) bridging to warfarin with a target INR of 2-3.
Some key points to consider in the management of this patient include:
- Ensuring the patient elevates the affected leg when seated to reduce swelling
- Applying compression stockings (20-30 mmHg) once acute pain subsides to prevent post-thrombotic syndrome
- Maintaining adequate hydration to prevent dehydration and promote blood flow
- Monitoring for bleeding complications, particularly given her age and the increased risk of bleeding with anticoagulation therapy
- Encouraging ambulation as tolerated rather than bed rest to promote blood flow and prevent further clot formation
The American College of Radiology recommends anticoagulation alone for patients with acute iliofemoral DVT with mild symptoms 1. However, the most recent study from 2024 1 suggests that anticoagulation alone is sufficient for most patients with acute DVT, and that interventional therapy is not necessary unless there are contraindications to anticoagulation.
It is also important to note that the patient's age and comorbidities should be taken into account when determining the best course of treatment. However, according to the available evidence, anticoagulation therapy is the most effective way to prevent thrombus propagation and pulmonary embolism, and to reduce long-term complications like post-thrombotic syndrome. After the initial 3 months, reassess for extended therapy based on risk factors for recurrence versus bleeding risk.
From the Research
Management of DVT
- The patient is a 73-year-old female with a non-occlusive thrombus in the femoral vein, which commences 10 cm above the knee crease and extends throughout the popliteal vein and the short saphenous vein.
- The management of DVT typically involves anticoagulation therapy to prevent the progression of the thrombus and reduce the risk of pulmonary embolism 2.
- The use of direct oral anticoagulants (DOACs) has been shown to be effective in reducing treatment failure and improving outcomes in patients with acute lower extremity DVT 2.
- The choice of anticoagulant therapy may depend on various factors, including the patient's medical history, renal function, and the presence of any contraindications to anticoagulation 3, 4.
Anticoagulation Therapy
- Low-molecular-weight heparin (LMWH) has been shown to be effective in reducing the risk of recurrent DVT and improving outcomes in patients with acute DVT 5.
- The use of LMWH for more than 10 days has been associated with a reduced risk of early reocclusion in patients with iliac venous stenting 3.
- DOACs, such as factor Xa inhibitors, have been shown to have a favorable effect on clot lysis and recanalization compared to warfarin 4.
Thrombus Resolution and Post-Thrombotic Syndrome
- The resolution of thrombus and prevention of post-thrombotic syndrome are important goals in the management of DVT 4, 6.
- The use of anticoagulant therapy, including DOACs and LMWH, may help to reduce the risk of post-thrombotic syndrome and improve outcomes in patients with DVT 2, 5.
- The anatomical distribution of the thrombus, including the involvement of the common femoral vein and deep femoral vein, may also play a role in the development of post-thrombotic syndrome 6.