From the Guidelines
Management of deep vein thrombosis (DVT) involving all deep veins including the left common femoral vein requires prompt anticoagulation therapy, and in patients with moderate to severe symptoms, catheter-directed thrombolysis (CDT) or pharmacomechanical thrombectomy (PMT) with or without stent placement should be considered in addition to anticoagulation, especially if symptoms are present for less than 14 days. The initial treatment should include a direct oral anticoagulant (DOAC) such as rivaroxaban, apixaban, or edoxaban, as these are recommended over vitamin K antagonist (VKA) as treatment-phase anticoagulant therapy, according to the Chest guideline and expert panel report 1. Alternatively, low molecular weight heparin (LMWH) such as enoxaparin can be used, followed by warfarin with a target INR of 2-3. For this extensive DVT involving the common femoral vein, anticoagulation should continue for at least 3-6 months.
Key Considerations
- Compression stockings (30-40 mmHg) should be worn during the day to reduce swelling and prevent post-thrombotic syndrome.
- Early mobilization is encouraged as tolerated.
- The patient should be evaluated for underlying causes such as malignancy, thrombophilia, or anatomical abnormalities like May-Thurner syndrome, particularly if this is unprovoked or recurrent.
- The American College of Radiology recommends that anticoagulation alone or in conjunction with CDT/PMT with or without stent placement is usually appropriate for a patient with acute iliofemoral DVT with moderate to severe symptoms present for less than 14 days, otherwise healthy 1.
Treatment Approach
- Anticoagulation therapy should be initiated promptly, with a DOAC being the preferred initial treatment.
- In patients with significant swelling, pain, or risk of venous gangrene, catheter-directed thrombolysis or pharmacomechanical thrombectomy should be considered, especially if symptoms are present for less than 14 days.
- The treatment approach should be individualized based on the patient's symptoms, medical history, and risk factors for bleeding or recurrence.
From the Research
Management of DVT Involving All Deep Veins Including Left Common Femoral
- The management of deep vein thrombosis (DVT) involving all deep veins, including the left common femoral vein, is crucial to prevent complications such as pulmonary embolism and post-thrombotic syndrome 2.
- The approach to making a diagnosis of DVT currently involves an algorithm combining pretest probability, D-dimer testing, and compression ultrasonography 2.
- The goals of treatment are to prevent extension of thrombi, pulmonary embolism, recurrence of thrombi, and the development of complications such as pulmonary hypertension and post-thrombotic syndrome 2.
- The mainstay of treatment is anticoagulant therapy, with options including low-molecular-weight heparin, unfractionated heparin, and vitamin K antagonists, as well as direct oral anticoagulants (DOACs) such as rivaroxaban, apixaban, and dabigatran 2, 3.
Treatment Options for DVT
- DOACs have been shown to be effective in the treatment of acute venous thromboembolism (VTE), with a decreased risk of major bleeding compared to traditional anticoagulant therapy 3.
- A study comparing warfarin to DOACs for the treatment of distal deep vein thrombosis (DDVT) found that DOACs were associated with a lower incidence of pulmonary embolism and major bleeding 4.
- Catheter-based, invasive therapies are also available for the treatment of iliofemoral DVT, which involves the common femoral vein and/or iliac vein 5.
Patient Assessment and Treatment
- Patient assessment and treatment for DVT should involve a comprehensive evaluation of risk factors, including prolonged immobility, malignancy, recent surgery, and family history 6.
- Nurse-led diagnostic pathways and specialist services have been developed to speed up the diagnosis and treatment of DVT, highlighting the importance of timely and effective care 6.