How should I manage a patient with an acute deep‑vein thrombosis who is actively bleeding?

Managing Deep Vein Thrombosis in a Patient with Active Bleeding

When a patient with acute DVT is actively bleeding, place an inferior vena cava (IVC) filter immediately and withhold all anticoagulation until the bleeding risk resolves, then restart anticoagulation as soon as safely possible. 1

Immediate Management – IVC Filter Placement

• An IVC filter is the only intervention indicated when anticoagulation is absolutely contraindicated due to active bleeding. This is a strong recommendation across all major guidelines. 1, 2
• Retrievable (temporary) filters are strongly preferred over permanent filters because they can be removed once anticoagulation becomes safe, reducing long-term complications such as recurrent lower-extremity DVT. 1
• IVC filters do not treat the existing DVT; they only prevent pulmonary embolism by trapping emboli before they reach the lungs. The DVT itself will not resolve without anticoagulation. 1, 2

Absolute Contraindications to Anticoagulation (When to Use IVC Filter)

Active bleeding that meets any of these criteria mandates withholding anticoagulation: 1, 3

• Active major or life-threatening bleeding that cannot be reversed or controlled
• Critical-site bleeding: intracranial hemorrhage, pericardial bleeding, retroperitoneal hemorrhage, intra-ocular bleeding, intraspinal bleeding 1, 3
• Active bleeding requiring >2 units of blood transfusion in 24 hours 1
• Recent intracranial or CNS hemorrhage (within the past 4 weeks) 1, 3
• Severe uncontrolled malignant hypertension 1
• Persistent severe thrombocytopenia (platelet count <20,000/µL) 1, 3

Timing of Anticoagulation Resumption

• Restart anticoagulation as soon as the bleeding risk is reduced or controlled, because the risk of recurrent DVT and fatal pulmonary embolism rises rapidly without treatment. 1
• There is no fixed time interval; the decision depends on the bleeding source, severity, and whether it has been definitively controlled (e.g., surgical hemostasis, endoscopic intervention, or spontaneous resolution). 1
• Once anticoagulation is restarted, the IVC filter should be removed promptly (typically within 2–4 weeks) to minimize filter-related complications such as filter thrombosis, migration, or recurrent DVT. 1

Choice of Anticoagulant When Restarting Therapy

• Unfractionated heparin (UFH) continuous IV infusion is the preferred initial agent when resuming anticoagulation after major bleeding, because it has a short half-life (60–90 minutes), can be titrated rapidly, and is fully reversible with protamine sulfate if rebleeding occurs. 1, 2
• UFH dosing: 80 units/kg IV bolus followed by 18 units/kg/h continuous infusion, adjusted to maintain aPTT 1.5–2.5 × control. 2, 4
• Low-molecular-weight heparin (LMWH) should be avoided initially because it has a longer half-life (4–6 hours), cannot be titrated as precisely, and is only partially reversible with protamine. 2
• Direct oral anticoagulants (DOACs) should not be used immediately after major bleeding because they cannot be rapidly reversed in most centers (andexanet alfa is expensive and not universally available), and their fixed dosing does not allow titration. 2, 5

Transition to Long-Term Anticoagulation

• Once the patient has been stable on UFH for 48–72 hours without rebleeding, transition to a DOAC (apixaban or rivaroxaban preferred) or warfarin overlapped with LMWH, depending on the clinical context. 2, 4
• If the bleeding risk remains elevated (e.g., recent gastrointestinal bleeding, intracranial hemorrhage within 4–8 weeks, or ongoing antiplatelet therapy for coronary stents), continue UFH or switch to LMWH with close monitoring rather than a DOAC. 1

Special Populations

Cancer-Associated DVT with Active Bleeding

• Place an IVC filter and withhold anticoagulation until bleeding resolves. 1, 3
• When restarting, use UFH initially, then transition to LMWH (enoxaparin 1 mg/kg twice daily or dalteparin 200 units/kg once daily) rather than a DOAC, because LMWH is superior to warfarin in cancer patients and can be dose-adjusted more easily than DOACs. 3
• Avoid edoxaban and rivaroxaban in patients with gastrointestinal or genitourinary malignancies because they carry a higher risk of major bleeding; use apixaban or LMWH instead. 2, 3

Intracranial Hemorrhage

• Anticoagulation is absolutely contraindicated for at least 4 weeks after intracranial hemorrhage. 1
• The risk of recurrent intracranial hemorrhage is estimated to double with anticoagulation, and the mortality rate of recurrent ICH exceeds 50%. 1
• If DVT or pulmonary embolism occurs during this period, place an IVC filter and delay anticoagulation for 4–8 weeks, then reassess the risk-benefit balance with neurology and hematology consultation. 1

Severe Thrombocytopenia (<50,000/µL)

• Withhold anticoagulation and place an IVC filter if the platelet count is <20,000/µL. 1, 3
• If the platelet count is 20,000–50,000/µL, anticoagulation may be cautiously initiated with UFH at reduced doses (e.g., 10–12 units/kg/h without bolus) under close hematology supervision, but an IVC filter should be strongly considered. 1

Critical Pitfalls to Avoid

• Never delay IVC filter placement while attempting to "optimize" the patient; active bleeding is an absolute indication for a filter, and delaying placement increases the risk of fatal pulmonary embolism. 1
• Never use LMWH or fondaparinux as the initial anticoagulant after major bleeding because their longer half-lives and limited reversibility make them unsafe in this setting. 2
• Never leave a temporary IVC filter in place indefinitely; filters must be removed within 2–4 weeks of anticoagulation resumption to prevent long-term complications. 1
• Never restart anticoagulation without confirming that the bleeding source has been controlled (e.g., endoscopic hemostasis, surgical repair, or spontaneous cessation with stable hemoglobin). 1
• Never use DOACs in patients with severe renal impairment (CrCl <30 mL/min) because drug accumulation markedly increases bleeding risk; use UFH or warfarin instead. 2

Monitoring After Anticoagulation Resumption

• Check hemoglobin and hematocrit daily for the first 3–5 days after restarting anticoagulation to detect occult rebleeding. 1
• Monitor aPTT every 6 hours initially when using UFH to maintain the therapeutic range (1.5–2.5 × control). 2, 4
• Reassess the IVC filter within 2 weeks to plan removal once anticoagulation is stable. 1