How should I manage a patient with a history of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) on Eliquis (apixaban) with an Inferior Vena Cava (IVC) filter in place, who now has bilateral common femoral vein and femoral vein DVT and symptoms of swelling and pain in both legs?

Management of Bilateral Femoral DVT with IVC Filter in Place on Apixaban

Continue therapeutic anticoagulation with apixaban at treatment dose (5 mg twice daily) and proceed with CT venogram to assess IVC filter thrombosis, while considering catheter-directed thrombolysis only if the patient has severe symptoms, high risk for post-thrombotic syndrome, and low bleeding risk. 1

Immediate Anticoagulation Management

The presence of an IVC filter does NOT indicate a need for extended or intensified anticoagulation beyond standard treatment. 1 The American College of Chest Physicians explicitly states that a permanent IVC filter, of itself, is not an indication for extended anticoagulation. 1

• Verify the patient is on therapeutic apixaban dosing: For acute DVT treatment, the dose should be 10 mg twice daily for the first 7 days, then 5 mg twice daily. 2 If the patient is already beyond 7 days of treatment from the prior VTE, continue 5 mg twice daily. 2

• Do not increase anticoagulation intensity based solely on the presence of the IVC filter or suspected filter thrombosis. 1 The guidelines recommend against routine use of IVC filters in addition to anticoagulants, as filters increase DVT recurrence risk without mortality benefit. 1

Diagnostic Workup

• Complete the CT venogram as planned to assess for IVC filter thrombosis and extent of thrombus propagation. 1

• Assess for pulmonary embolism if not already done, as bilateral proximal DVT carries significant PE risk. 2

Thrombolysis Consideration

Anticoagulation alone is preferred over catheter-directed thrombolysis (CDT) for most patients with acute proximal DVT. 1

However, CDT may be considered if:

• The patient has iliofemoral DVT (which includes common femoral involvement) 1
• The patient places high value on preventing post-thrombotic syndrome 1
• The patient has low bleeding risk 1
• Symptoms are severe and limb-threatening 1

The evidence for CDT is weak (Grade 2C), and most patients should receive anticoagulation alone. 1 Systemic thrombolysis and operative thrombectomy are also generally not recommended over anticoagulation alone. 1

Symptomatic Management

• Encourage early ambulation rather than bed rest, unless edema and pain are severe. 1

• Apply compression therapy to manage leg swelling and reduce post-thrombotic syndrome risk. 1

• Elevate legs and provide analgesics as needed for symptom control.

Duration of Anticoagulation

Since this represents recurrent VTE (the patient has history of DVT and PE):

• Minimum 3 months of anticoagulation is required from this new event. 1

• Extended (indefinite) anticoagulation should be strongly considered given the recurrent unprovoked nature, provided bleeding risk is low to moderate. 1 For recurrent VTE, extended-duration therapy (>12 months or indefinite) was associated with fewer recurrences than termination after 6 months. 1

• After 3 months, reassess the risk-benefit ratio for extended therapy based on bleeding risk. 1 If low or moderate bleeding risk, extended anticoagulation with apixaban 5 mg twice daily is recommended. 1

• For extended prophylaxis after initial treatment, apixaban 2.5 mg twice daily is an option after at least 6 months of treatment. 2 However, given recurrent VTE, continuing 5 mg twice daily may be more appropriate. 1

IVC Filter Management

• The IVC filter itself may be contributing to thrombosis. 1 Filters are associated with a 2-fold increase in recurrent DVT. 1

• Consider filter removal if it is a retrievable filter and anticoagulation can be safely continued. 1 The guidelines recommend against routine IVC filter use in addition to anticoagulants. 1

• If the filter is permanent, this does not change anticoagulation duration recommendations. 1

Critical Pitfalls to Avoid

• Do not discontinue or reduce anticoagulation due to the presence of the IVC filter—the filter does not protect against DVT recurrence and may actually increase it. 1

• Do not routinely pursue CDT without careful patient selection, as anticoagulation alone is the standard of care with strong evidence. 1

• Do not assume the IVC filter provides adequate PE protection—therapeutic anticoagulation remains essential. 1

• Monitor for filter complications including filter thrombosis, migration, and caval perforation. 1