What is the management of chronic deep vein thrombosis (DVT)?

From the Guidelines

The management of chronic deep vein thrombosis (DVT) should focus on anticoagulation therapy, with extended-duration therapy being considered for patients with idiopathic VTE or recurrent VTE, as it decreases the relative risk for recurrence by 64% to 95% 1. The cornerstone of treatment for chronic DVT is anticoagulation therapy, which can be achieved with low molecular weight heparin (LMWH) or oral anticoagulants.

• LMWH is safe and efficacious for the long-term treatment of VTE in selected patients, particularly those with cancer, and may be preferable for patients with cancer 1.
• The duration of anticoagulation therapy depends on the risk factors for recurrence, with 3 months being sufficient for provoked DVT, and at least 6-12 months or indefinitely for unprovoked or recurrent DVT.
• Clinicians should weigh the benefits, harms, and patient preferences in deciding on the duration of anticoagulation, considering the risk of recurrence and the risk of anticoagulant-related bleeding 1.
• In addition to anticoagulation therapy, compression therapy using graduated compression stockings (30-40 mmHg at the ankle) can help reduce post-thrombotic syndrome and should be worn daily for at least two years.
• Lifestyle modifications, including regular exercise, leg elevation, weight management, and avoiding prolonged immobility, are also important adjuncts in the management of chronic DVT.

From the Research

Chronic DVT Management

• The management of chronic deep vein thrombosis (DVT) primarily involves anticoagulation therapy to reduce symptoms, thrombus extension, and recurrence, as well as to prevent mortality 2, 3.
• Anticoagulation therapy for proximal DVT is clearly recommended for at least 3 months, while for isolated distal DVT, it should be considered, especially in the presence of high thromboembolic risk factors 3, 4.
• Non-Vitamin K antagonists oral anticoagulants (NOACs) are considered as first-line therapy in the anticoagulation therapy for DVT and are recommended as the preferred anticoagulant agents by most scientific societies due to their simplicity, rapid onset and offset of action, and good efficacy and safety profile compared to Vitamin K Antagonists (VKAs) 3.
• Thrombolytic therapy offers an alternative in the treatment of patients with DVT, particularly for those with iliofemoral venous thrombosis, aiming to dissolve the thrombus, restore patency, and preserve valve function, thus reducing the incidence and severity of post-thrombotic syndrome 5.
• The optimal anticoagulant and duration of therapy are determined by clinical assessment, taking into account the thromboembolic and bleeding risk in each patient on a case-by-case basis 3, 4.
• Current guidelines recommend anticoagulation for a minimum of three months, with extension beyond this period individualized based on a risk/benefit analysis, especially in special situations such as active cancer and pregnancy 4.
• Low-molecular-weight heparin (LMWH) is at least as effective and safe as intravenous unfractionated heparin (UFH) for the treatment of DVT, offering the advantage of less frequent dosing and no need for monitoring, making outpatient treatment possible 6.