Generally, anticoagulant therapy for at least 3 months is required for patients with DVT. ![]() Interventional therapies, including thrombolysis, are rarely indicated. DVT may also be unprovoked (idiopathic) and occur in the absence of any identifiable extrinsic risk factors.ĭVTs commonly cause asymmetrical leg swelling, unilateral leg pain, dilation or distension of superficial veins, and red or discolored skin, but can also be asymptomatic.Īssessment of pre-test probability (using a validated score such as Wells) is key if DVT is suspected, and should be used in combination with an algorithmic diagnostic approach to avoid unnecessary imaging when the likelihood of DVT is low.ĭiagnosis requires confirmation of a blood clot in a deep vein in the leg, pelvis, or vena cava by venous ultrasound imaging (or other imaging techniques such as computed tomography scan).ĭVT is usually treated with anticoagulants such as unfractionated heparin, low molecular weight heparin, fondaparinux, rivaroxaban, apixaban, edoxaban, dabigatran, and/or warfarin. Patients who develop DVT commonly have risk factors, such as active cancer, trauma, major surgery, hospitalisation, immobilisation, pregnancy, or oral contraceptive use. Deep vein thrombosis (DVT) is the development of a blood clot within a vein deep to the muscular tissue planes. Post-thrombotic syndrome affects 13% (see 'Complications', below).Recurrent thrombosis affects between 2% and 5% of patients.Reported mortality rates have varied from 15-50%, largely dependent on the underlying cause.About 10-20% develop pulmonary embolism.PrognosisĪssociated with significant morbidity and mortality due to potential risks of pulmonary embolism, post-thrombotic syndrome and loss of vascular access. Many patients are also at risk of lower-limb thrombosis, which warrants anticoagulant prophylaxis in its own right. The use of anticoagulant prophylaxis in patients who are acutely ill and those who undergo central venous catheterisation may prevent upper-extremity DVT. A trial of compression bandages or sleeves to reduce symptoms is recommended for post-thrombotic syndrome of the arm (chronic venous insufficiency that may cause pain, oedema, pigmentation, skin changes and venous ulcers).If the catheter is not removed then anticoagulation should be continued as long as the central venous catheter remains but there should be a minimum of three months of treatment.For those patients with upper-extremity DVT that is associated with a central venous catheter, it is recommended that the catheter should not be removed if it is functional and there is an ongoing need for the catheter.For patients who undergo thrombolysis, the same intensity and duration of anticoagulant therapy should be used as for those patients who do not undergo thrombolysis.Anticoagulation should be for a minimum of three months. Anticoagulant therapy is recommended in preference to thrombolysis.Rivaroxaban and apixaban can also be used. Low molecular weight heparin or fondaparinux are preferred. Acute treatment with parenteral anticoagulation (low molecular weight heparin, fondaparinux, intravenous/subcutaneous unfractionated heparin) is recommended.In idiopathic cases one should consider investigations to look for an occult malignancy or thrombophilia.Imaging investigations to detect thoracic outlet syndrome should depend on the degree of clinical suspicion of this cause.It is probably useful where it occurs idiopathically, with a family history of thrombosis or history of recurrent miscarriage or previous DVT. It is uncertain whether routine thrombophilic screening in patients with this condition is worthwhile.In patients with suspected upper-extremity DVT in whom initial ultrasound is negative for thrombosis despite a high clinical suspicion of DVT, CT scan or magnetic resonance phlebography is recommended.D-dimer testing is less useful than in lower-limb thrombosis, particularly in hospitalised patients with central venous catheters or malignancy.Ultrasound (compression with either Doppler or colour Doppler) is recommended as the investigation of choice.
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