When do we repeat imaging for a patient with Deep Vein Thrombosis (DVT) on Eliquis (apixaban)?

Repeat Imaging for DVT on Eliquis

For patients with proximal DVT already on anticoagulation with Eliquis (apixaban), routine repeat imaging is not recommended unless there is a specific clinical indication such as worsening symptoms, concern for treatment failure, or suspected recurrence. 1

When Repeat Imaging is NOT Indicated

• Routine surveillance imaging is not warranted in patients with confirmed proximal DVT who are receiving appropriate anticoagulation therapy 1
• Patients on therapeutic anticoagulation do not require repeat imaging to document clot resolution, as this does not change management 1
• The only exception is obtaining a new baseline ultrasound at the end of treatment to facilitate future comparison if recurrent DVT is suspected 1

When Repeat Imaging IS Indicated

For Distal (Calf) DVT Managed Without Initial Anticoagulation

• Serial imaging weekly for 2 weeks is recommended for patients with isolated distal DVT who are NOT initially anticoagulated 1
• Repeat imaging should be performed sooner if symptoms worsen 1
• If thrombus extends into proximal veins on follow-up imaging, anticoagulation must be started 1
• If thrombus remains confined to distal veins or resolves, continue surveillance or consider anticoagulation based on extension 1

For Patients Already on Anticoagulation with Clinical Concerns

Repeat imaging is appropriate when:

• Worsening or new symptoms develop despite anticoagulation (leg swelling, pain, warmth) 1
• Suspected treatment failure or thrombus extension occurs 1
• Concern for recurrent DVT at a new site or at the site of previous thrombosis 1
• Persistent symptoms without clear etiology after negative initial imaging 1

Specific Timing for Repeat Imaging

• For suspected recurrent DVT with equivocal findings: Repeat ultrasound in 1-3 days and again at 7-10 days to assess for acute changes 1
• For acute calf DVT on treatment: Repeat scan in 1 week if symptoms progress, or at 2 weeks if not treated initially 1
• For technically limited initial study: Repeat in 5-7 days 1

Special Considerations for Iliocaval DVT

• If whole-leg swelling persists with normal compression ultrasound, or if abnormal spectral Doppler waveforms are present at the common femoral vein, consider CT or MR venography to evaluate for iliocaval thrombosis 1
• Continuous or asymmetrical common femoral Doppler spectra suggest a more central obstructive process requiring advanced imaging 1

Common Pitfalls to Avoid

• Do not order routine "follow-up" ultrasounds in asymptomatic patients on therapeutic anticoagulation—this adds no clinical value and increases costs 1
• Do not confuse chronic thrombus with acute DVT—distinguishing recurrent DVT from chronic scarring requires serial imaging over 1-3 and 7-10 days if findings are equivocal 1
• Do not rely solely on D-dimer in patients already anticoagulated, though a negative D-dimer may help exclude recurrence in ambiguous cases 1, 2