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www.uptodate.com2016UpToDate

Overviewofthetreatmentoflowerextremitydeepveinthrombosis(DVT)
Authors: GregoryYHLip,MD,FRCPE,FESC,FACC,RussellDHull,MBBS,MSc
SectionEditors: LawrenceLKLeung,MD,JessMandel,MD
DeputyEditor: GeraldineFinlay,MD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Oct2016.|Thistopiclastupdated:Jul22,2016.
INTRODUCTIONDeepveinthrombosis(DVT)andacutepulmonaryembolism(PE)aretwomanifestationsofvenousthromboembolism(VTE).VTE
contributestosignificantmorbidityandmortalitybothinthecommunityandinhospital.ThemainstayoftherapyforDVTisanticoagulation,providedthere
isnocontraindication.Followinginitialanticoagulation,patientswithDVTareanticoagulatedfurthertopreventfuturerecurrences,embolism,and
thrombosisrelateddeath.
AnoverviewofthetreatmentoflowerextremityDVT(distalandproximal),includingindicationsforanticoagulation,alternatetherapies,andtreatmentof
specialpopulationsofpatientswithDVT,arediscussedinthistopic.Initial,longterm,andextended(indefinite)anticoagulationforDVT,aswellasthe
treatmentofPE,upperextremityDVT,andthediagnosisandpreventionofDVT,arediscussedindetailseparately.(See"Venousthromboembolism:
Initiationofanticoagulation(first10days)"and"Venousthromboembolism:Anticoagulationafterinitialmanagement"and"Rationaleandindicationsfor
indefiniteanticoagulationinpatientswithvenousthromboembolism"and"Overviewofthetreatment,prognosis,andfollowupofacutepulmonary
embolisminadults"and"Diagnosisofsuspecteddeepveinthrombosisofthelowerextremity"and"Preventionofvenousthromboembolicdiseasein
acutelyillhospitalizedmedicaladults"and"Preventionofvenousthromboembolicdiseaseinsurgicalpatients".)
NOMENCLATUREForthepurposesofdiscussioninthistopic,thefollowingtermsapply:
Thetermunprovokeddeepveinthrombosis(DVT)impliesthatnoidentifiableprovokingenvironmentaleventforDVTisevident[1].Incontrast,a
provokedDVTisonethatisusuallycausedbyaknownevent(eg,surgery,hospitaladmission).VTEeventscanbeprovokedbytransientmajorrisk
factors(ie,majorsurgery>30minutes,hospitalizationorimmobility3days,cesariansection),transientminorriskfactors(minorsurgery<30
minutes,hospitalization<3days,pregnancy,estrogentherapy,reducedmobility3days)orpersistentriskfactors.Persistentriskfactorsinclude
reversibleconditions(eg,curablemalignancy,inflammatoryboweldiseasethatresolves)andirreversibleconditionssuchasinheritable
thrombophilias,chronicheartfailure,andmetastaticendstagemalignancy.(See"Overviewofthecausesofvenousthrombosis".)
ProximalDVTisonethatislocatedinthepopliteal,femoral,oriliacveins.IsolateddistalDVThasnoproximalcomponent,islocatedbelowtheknee,
andisconfinedtothecalfveins(peroneal,posterior,anteriortibial,andmuscularveins)(table1).
SymptomaticDVTreferstothepresenceofsymptomsthatusuallyleadstotheradiologicconfirmationofDVT,whereasasymptomaticDVTrefersto
theincidentalfindingofDVTonimaginginapatientwithoutsymptoms(eg,computedtomography).(See"Approachtothediagnosisandtherapyof
lowerextremitydeepveinthrombosis",sectionon'Initialapproach'and"Diagnosisofsuspecteddeepveinthrombosisofthelowerextremity".)
Initialanticoagulationreferstoanticoagulanttherapythatisadministeredduringthefirstfewdays(upto10days)followingadiagnosisofDVT.Long
termanticoagulanttherapyistypicallyadministeredforafinitetimebeyondtheinitialperiod,usuallythreetosixmonths,andoccasionallyupto12
months.Extendedanticoagulationreferstotherapythatisadministeredindefinitely.(See"Venousthromboembolism:Initiationofanticoagulation
(first10days)"and"Venousthromboembolism:Anticoagulationafterinitialmanagement"and"Rationaleandindicationsforindefiniteanticoagulation
inpatientswithvenousthromboembolism".)
DirectfactorXaandthrombininhibitorshavebeenreferredtousingavarietyofnamesincludingnewer/noveloralanticoagulants,nonvitaminK
antagonistoralanticoagulants(NOAs,NOACs),directoralanticoagulants(DOACs),andtargetspecificoralanticoagulants(TOACs,TSOACs)[2,3].
Throughoutthistopic,werefertotheseagentsbytheirpharmacologicclass,directfactorXaandthrombininhibitors.(See"Directoral
anticoagulants:Dosingandadverseeffects".)
INDICATIONSAnticoagulationisthemainstayoftherapyforpatientswithdeepveinthrombosis(DVT)(algorithm1).Anticoagulationisindicatedforall
patientswithproximalDVTandselectcasesofdistalDVT.Thedecisiontoanticoagulatemustweighthebenefitsofanticoagulationagainsttheriskof
bleedingforanindividual.Theprimaryobjectiveofanticoagulationisthepreventionoffurtherthrombosisandofearlyandlatecomplications.Majorearly
complicationsofDVTincludefurtherclotextension,acutepulmonaryembolus(PE),majorbleeding(fromanticoagulation),anddeath.Latecomplications
includerecurrentclot,postthrombotic(postphlebitic)syndrome,andchronicthromboembolicpulmonaryhypertension.(See"Overviewofthetreatment,
prognosis,andfollowupofacutepulmonaryembolisminadults"and"Postthrombotic(postphlebitic)syndrome"and"Clinicalmanifestationsand
diagnosisofchronicthromboembolicpulmonaryhypertension".)
TheindicationtoanticoagulateisstrongerforpatientswithproximalDVT(popliteal,femoral,iliacvein)thanwithdistalDVT(calfvein)becausetheriskof
complicationsishigher,especiallyembolizationanddeath.Asanexample,olderstudiesreportedthatover90percentofacutePEarisefromthe
proximalveins[4,5].Anotherprospectiveanalysisof1643patientsanticoagulatedforacuteDVT(OPTIMEV)reportedthatthemortalityrateofproximal
DVTishigherthanthatofdistalDVT(8versus4percent)[6].
TheindicationstoanticoagulatearebaseduponadefinitivediagnosisofDVT,usuallymadeoncompressiveultrasound(CUS)ofthelowerextremities.In
patientswithasymptomaticproximalordistalDVTfoundincidentallybyanotherimagingmodality,usuallycomputedtomography(CT),thediagnosis
shouldbesoughtusingCUSbeforeanticoagulationduetothepoorersensitivityandspecificityofCT.(See"Diagnosisofsuspecteddeepveinthrombosis
ofthelowerextremity".)
ProximalDVTProximallowerextremityDVTisthrombusthatislocatedinthepopliteal,femoral,oriliacveins(table1).Anticoagulanttherapyis
indicatedforallpatientswithproximalDVT,regardlessofthepresenceofsymptomsandprovidedthereisnocontraindicationtoanticoagulation
(algorithm1).Thisapproachissupportedbyaseminalrandomizedtrialthatdemonstratedasurvivalbenefitwithanticoagulationaswellasrandomized
trialsandmetaanalysesofpatientstreatedwithvariabledurationsofanticoagulanttherapy.

AccurateestimatesofrecurrentthrombosisanddeathinpatientswithproximalDVTwhoarenottreatedwithanticoagulanttherapyareunknown.Inthe
seminaltrial,performedin1960,thatcomparedanticoagulationwithobservationinpatientswithacuteDVT,anticoagulationresultedinadramatic
reductioninrecurrence,whichtranslatedintoamortalitybenefit[7].Sincethen,mostothertrialshavecomparedvariousdosesanddurationsof
anticoagulanttherapyforDVTtoprovideanestimateoftheriskofrecurrence[8].Nonetheless,thesedataallsupportlowratesofrecurrentvenous
thromboembolism(VTE)anddeathinpatientstreatedwithanticoagulanttherapyforproximalDVT,withthegreatestbenefitoccurringwithinthefirstfew
daysorweeksoftheinitialevent.Asanexample,one2010metaanalysisof13prospectivecohortstudiesand56randomizedclinicaltrialsreported
ratesofrecurrentVTEandfatalVTEduringthefirstthreemonthsofanticoagulanttherapyas3.4and0.4percent,respectively[8].
ForpatientswithproximalDVT,theabsenceofsymptoms(ie,incidentalproximalDVT)doesnotaltertheindicationforanticoagulation.Althoughthe
safetyandefficacyofanticoagulanttherapyinpatientswithasymptomaticproximalveinDVTcomparedwithsymptomaticDVTisunknown,weand
otherspreferthatthispopulationofpatientsbemanagedinthesamemannerassymptomaticpatients[9].Thispreferenceisbasedupontherationale
thatproximalDVThasahighriskofembolizationanduponindirectevidencefrompatientswithsymptomaticproximalDVTthatreportareductioninthe
riskofrecurrencewithanticoagulation.
DistalDVTIsolateddistalDVTencompassesthromboseslocatedbelowthekneeinthecalfveins(ie,thepoplitealveinisnotinvolved).Mostcalfvein
DVTsarelocatedintheposteriortibialandperonealveinswhileanteriortibialandmuscularveinDVTsareuncommon(table1).Notably,isolateddistal
DVTcannotbedetectedbyroutineproximalveincompressionultrasonography(proximalCUS)andalthoughitcanbedetectedbywholeleg
ultrasonography,thelatterisdifficulttoperformandinterpretanditsuseisinstitutiondependentthus,toovercomethisdisadvantageserialproximal
CUScanbeusedtodetectthrombusthatextendsintotheproximalveins.(See"Diagnosisofsuspecteddeepveinthrombosisofthelowerextremity".)
ThetreatmentofisolateddistalDVTvariesamongcentersandcliniciansandrepresentsamajorchallengetherapeutically.Whilesomeexpertsprefer
thatallpatientswithisolateddistalDVTbeanticoagulated,weandotherexpertsagreethataselectminoritycanavoidanticoagulation.Thispreferenceis
basedupontherationalethatpatientswithisolateddistalDVTareatlowerriskofembolization(approximatelyhalftherisk)thanthosewithproximalDVT
andthatinsomepatients,thedistalDVTsresolvespontaneouslywithouttherapy[921].Whenthedecisionismadetoanticoagulatepatientswith
isolateddistalDVT,fulltherapeuticanticoagulationshouldbeadministeredsimilartothosewithproximalDVT.
AnticoagulationWhileinthepastwholelegultrasoundfrequentlyidentifiedasymptomaticpatientswithisolateddistalDVT,ashifttowards
presentationwithsymptomaticDVThasoccurredsuchthatweandothersusesymptomsaswellasotherclinicalfeaturestohelpusdecidewhototreat.
Ingeneral,thefollowingindicationsforanticoagulationapply:
SymptomaticIngeneral,mostcliniciansagreethatanticoagulationisindicatedinmostpatientswithsymptomaticisolateddistalDVT,provided
theriskofbleedingislow[9,2224].However,someexpertschoosenottotreatselectpatientswhoareconsideredaverylowriskofembolization
andaresuitablecandidatesforsurveillancesuchpatientsincludethosewithminorthrombosisinthemuscularveins,thosewithanegativeDdimer
level,thosewithnondiagnosticultrasonographyresults,thosewithminorsymptomswhoarewithoutriskfactorsforextension(seelistin
"Asymptomatic"bullet,below),andthoseathighriskofbleeding.(See'Surveillancewithserialultrasound'below.)
AsymptomaticAdditionalindicationsforanticoagulationinasymptomaticpatientsorinpatientswithsymptomaticDVTwhooptfor
surveillanceinclude(see'Surveillancewithserialultrasound'below):
PatientswithdocumentedDVTextensionintoortowardtheproximalveinsduringsurveillance
Patientsconsideredbytheircliniciantobeatriskofextensiontotheproximalveins.Thisincludespatientswith:
UnprovokedDVT
Ddimer>500mg/mL
Extensivethrombosisinvolvingmultipleveins(eg,>5cminlength,>7mmindiameter)
Thrombosisclosetotheproximalveins
Persistent/irreversibleriskfactorssuchasactivecancer
PriorDVTorPE
Prolongedimmobility
Inpatientstatus
Supportforthisapproachisbasedupontheriskofextensionintotheproximalveins(ie,thepoplitealveinorhigher)wheretheindicationto
anticoagulateisstrongerduetothehigherriskofembolizationandtheprovenefficacyinthispopulationofanticoagulationinreducingclot
extension[9].Asexamples:
Naturalhistorystudiessuggestthatwhenleftuntreated,approximatelyonethirdofpatientswithsymptomaticisolateddistalDVTwilldevelop
extensionintotheproximalveins,mostoftenwithinthefirsttwoweeksafterdiagnosis[1019].
OnemetaanalysisthatincludedtworandomizedandsixnonrandomizedcohortstudiesofpatientswithisolateddistalDVTreportedthat,compared
withthosewhowerefollowedwithserialultrasound,proximalthrombuspropagationwaslesslikelytooccurinthosereceivinganticoagulation(odds
ratio0.29,95%CI0.140.62)[20].However,themethodologicqualityofmoststudieswaspoorandthenumberofoutcomeeventsthatoccurred(ie,
deaths,PE,proximalDVTextension,bleeding)wassmall,whichlimitedtheanalysis.
SurveillancewithserialultrasoundSelectpatientswithisolateddistalDVTmaybesubjectedtosurveillancewithserialultrasoundtolookfor
extensionoflowerextremityclotintotheproximalveins.Candidatesthatmaybesuitableforthisapproacharediscussedabove.(See'DistalDVT'
above.)
SupportforthisapproachisderivedfromstudiesthatsuggestthattheriskofembolizationinpatientswithisolateddistalDVTislowandapproximately
halfthatofproximalDVT[25].Asanexample,severalretrospectiveandprospectiveobservationalstudiesreportedthatlimitedthrombosisconfinedto
themuscularveins,comparedwithextensivethrombosisofmultiplecalfveins,appearstohavealowriskofextensionwithouttherapy(about3versus15
percent)[912,14,17,18,23].Inaddition,ifextensiondoesnotoccurwithintwoweeks,itisunlikelytooccur.
Theoptimalfrequency,duration,andmethodofsurveillanceareunknown.Wegenerallysurveypatientseveryweekfortwoweekswithproximal
compressiveultrasound(CUS)forclotextensionorresolution.
Ifthrombusresolves,noanticoagulationisrequired.

 Ifthrombusextensionisobservedintotheproximalveins,patientsshouldbeanticoagulatedortreatedwithaninferiorvenacavafilterifa
contraindicationtoanticoagulationexists.
Ifthrombusextendstowardtheproximalveinsbutremainsconfinedtothecalf,wesuggestanticoagulationratherthancontinuedsurveillancewith
CUS.
Forpatientsinwhomclotdoesnotresolvebutremainsstable,longerperiodsofsurveillancemayberequired.
Forsurveillance,wepreferproximalratherthanwholelegCUSbecauseitissufficientforthedetectionofproximalDVT,wheretheindicationfor
anticoagulationisstrong.
ASSESSINGBLEEDINGRISKAllpatientsshouldbeassessedbeforeandduringanticoagulanttherapyforbleedingrisk(table2andtable3).
Patients,especiallythoseondirectfactorXaandthrombininhibitorsandthose>75years,shouldalsobeassessedforthesignsandsymptomsof
conditionsthatmayaffectthehalflifeoftheadministeredanticoagulant(eg,renalfailure,weightloss,pregnancy).Inallpatients,thedecisionto
anticoagulateshouldbeindividualizedandthebenefitsofvenousthromboembolism(VTE)preventioncarefullyweighedagainsttheriskofbleeding.
Absoluteandrelativecontraindicationstoanticoagulationarediscussedseparately.(See'Patientswithcontraindicationstoanticoagulation'below.)
Theadministrationofanticoagulationisalwaysassociatedwithanincreasedriskofbleeding,whichisinturndependentuponthedegreeof
anticoagulationandthepresenceofpreexistingfactorsforbleeding.Toolsareavailableforestimatingtheriskofbleedinginanticoagulatedindividuals
(eg,HASBLEDscore)(calculator1).However,noneofthesetoolshasbeenvalidatedinpatientsanticoagulatedforVTEandnooneindexcanreliably
predictbleedingriskinaparticularpatientsuchthatforpracticalpurposes,manycliniciansuseagestaltestimateforassessingbleedingrisk.Details
regardingtheuseofscoringsystemsthatestimatetheriskofbleedingarediscussedseparately.(See"Rationaleandindicationsforindefinite
anticoagulationinpatientswithvenousthromboembolism",sectionon'Assessingtheriskofbleeding'and"Managementofwarfarinassociatedbleeding
orsupratherapeuticINR",sectionon'Bleedingrisk'.)
Mostcliniciansagreethatpatientswithathreemonthbleedingriskoflessthan2percent(lowrisk)shouldbeanticoagulated.Inaddition,mostclinicians
agreethatpatientswithathreemonthbleedingriskofmorethan13percent(highrisk)shouldnotbeanticoagulated[9].Forpatientswithanestimated
bleedingriskbetweenthesevalues,thereisnoagreementregardingthepreferredapproachsuchthatthedecisiontoanticoagulateinthispopulation
mustbeindividualizedaccordingtothevaluesandpreferencesofthepatientaswellastheriskbenefitratio,whichmaychangeovertime.Asan
example,thebenefitsofanticoagulationaregreaterduringtheinitialperiodofanticoagulationthanattheendofafiniteperiodofthreemonths.Patients
whowishtoavoidtheriskofbleedingonanticoagulationshouldbeconsideredforaninferiorvenacavafilter.(See"Rationaleandindicationsfor
indefiniteanticoagulationinpatientswithvenousthromboembolism",sectionon'Ourapproach'and"Placementofvenacavafiltersandtheir
complications"and'Inferiorvenacavafilter'below.)
ANTICOAGULATION
Initialanticoagulation(first10days)Initialanticoagulationreferstosystemicanticoagulationadministeredforthefirstfewdays(upto10days)
followingadiagnosisofdeepveinthrombosis(DVT)[9,24,26].Inmostpatients,anticoagulationshouldbestartedimmediatelyasadelayintherapymay
increasetheriskofpotentiallylifethreateningembolization[27,28].
SelectionofagentOptionsincludesubcutaneouslowmolecularweight(LMW)heparin,subcutaneousfondaparinux,theoralfactorXainhibitors
rivaroxabanorapixaban,orunfractionatedheparin(UFH).Adecisionbetweentheseagentsisusuallymadebaseduponclinicianexperienceaswellas
therisksofbleeding,patientcomorbidities,preferences,cost,andconvenience(table4).Warfarincannotbeadministeredaloneasaninitial
anticoagulantforDVTbecauseofthedelayindepletionofthevitaminKdependentcoagulationfactors.Selectinganinitialanticoagulant,dosingfor
parenteralandoralanticoagulants,andempiricanticoagulationinthegeneralpopulationaswellasinpatientswithmalignancyandpregnancy,are
discussedindetail,separately.(See"Venousthromboembolism:Initiationofanticoagulation(first10days)"and"Treatmentofvenousthromboembolism
inpatientswithmalignancy"and"Deepveinthrombosisandpulmonaryembolisminpregnancy:Treatment".)
OutpatienttherapyNotallpatientswhohaveacuteDVTneedtobeadmittedtothehospitalforsystemicanticoagulation.Thedecisiontotreat
DVTintheoutpatientsettingshouldbemadeinthecontextofthepatient'sunderstandingoftheriskbenefitratio,preferences,andclinicalcondition.
Factorsdeterminingwhomaybeconsideredforoutpatienttherapyarenotwelldefined.However,severalrandomizedtrialsandmetaanalysesthathave
comparedoutpatienttherapywithLMWheparintoinpatienttherapywithIVUFHsuggestthattreatmentathomewithLMWheparinissafeandeffective
inselectpatients[9,2942].Anticoagulanttherapyshouldnotbedelayedwhilethedecisionisbeingmadetotreatthepatientathome.
WhenconsideringoutpatientadministrationofLMWheparin,patientselectioniscritical:
Outpatienttherapycanbeconsideredwhenpatientshaveallofthefollowingfeatures(table5):
Hemodynamicallystable
Alowriskofbleeding
Norenalinsufficiency
Apracticalsysteminplaceathomefortheadministrationandsurveillanceofanticoagulanttherapy(eg,goodlivingconditions,caregiver
support,phoneaccess,understandingandabilitytoreturntothehospitalshoulddeteriorationoccur)
Outpatienttherapyisnotappropriateinpatientswith[43]:
MassiveDVT(eg,iliofemoralDVT,phlegmasiaceruleadolens)
Concurrentsymptomaticpulmonaryembolism(PE)
Highriskofbleedingonanticoagulanttherapy
Comorbidconditionsorotherfactorsthatwarrantinhospitalcare
Forpatientsinwhomoutpatienttherapyisselected,wesuggesttheuseofLMWheparinoverlappedwithwarfarin(dualtherapy),pretreatmentwith
LMWheparinfollowedbytheadministrationofeitherdabigatranoredoxaban(dualtherapy),oranticoagulationwitheitherrivaroxabanorapixaban
(monotherapyie,noneedforheparinpretreatment).Selectinganagentshouldbeindividualizedandisdependentupontheriskofbleeding,patient
comorbidities,preferences,cost,andconvenience.Datathatsupporttheseapproachesarediscussedbelow:

 LMWheparinpluswarfarinEvidencetosupportthiscombinationisderivedfromrandomizedtrialsandmetaanalysesthathavecomparedLMW
heparindeliveredathomefollowingimmediatedischargefromtheemergencyoroutpatientdepartmentorfollowingabriefinpatientstay(eg,one
day).However,thesetrialshavebeenintrinsicallyflawedbecauseofdifferencesintheLMWheparinused,followuptherapy(warfarinandLMW
heparin),anddifferencesinrandomizationtohometherapy,whichwasnotexplicitlyperformedinmanystudies.(See"Venousthromboembolism:
Anticoagulationafterinitialmanagement",sectionon'Lowmolecularweightheparin'.)
Asexamples:
One2012metaanalysisofsixrandomizedtrialstotaling1708patientswithacuteDVTcomparedoutpatientuseofLMWheparinwithinpatient
IVUFH[9].OutpatienttherapywithLMWheparinwasassociatedwithreductionsintherateofrecurrentvenousthromboembolism(VTErisk
reduction[RR]0.61,95%CI0.420.9),majorbleeding(RR0.67,95%CI0.331.36),andmortality(RR0.72,95%CI0.451.15).Another2007
metaanalysisofsixolderstudiesreportedsimilarresults[40].
A2003metaanalysisofeighttrialsthatalsoincludedpatientswithbriefinpatientstays(24hoursorless)foracuteDVTreportedthatcompared
withinpatientstreatedwithheparin,thosetreatedasanoutpatienthadsimilarratesofrecurrentDVT(4versus6percent)andmajorbleeding
(0.5versus1percent)[36].
LMWheparinfollowedbydabigatranoredoxabanRandomizedtrialsthatsupportefficacyofthiscombinationonlystudiedefficacyfor
dabigatran(directthrombininhibitor)andedoxaban(factorXainhibitor)whenpatientsweretreatedwiththeseagentsfollowinga5to10daycourse
ofheparin(usuallyLMWheparinie,dualtherapy).Consequently,wesuggestthatdabigatranandedoxabannotberoutinelyusedasa
monotherapyforinitialanticoagulationinoutpatientsbutcanbeusedinthissettingprovidedthataninitialcourseofheparinhasbeenadministered,
similartotheoriginalstudyprotocolsthatprovedtheirefficacy[44,45].Thesestudiesandhowtotransitionfromheparintotheseagentsare
discussedindetailseparately.(See"Venousthromboembolism:Anticoagulationafterinitialmanagement",sectionon'DirectthrombinandfactorXa
inhibitors'.)
RivaroxabanorapixabanmonotherapyRandomizedtrialsofrivaroxabanandapixabanreportedefficacyofbothofthesefactorXainhibitorsas
thesoleinitialanticoagulant(monotherapy)[46,47].Althoughshortperiods(<48hours)ofheparinwereallowedpriortorandomization,our
experiencewiththeseagentsisinkeepingwiththedatathatsuggestmonotherapywiththeseagentsissafeandeffectivewhenadministeredtothe
outpatientpopulation(ie,withoutheparinpretreatment).Thesestudiesarediscussedindetailseparately.(See"Venousthromboembolism:
Anticoagulationafterinitialmanagement",sectionon'DirectthrombinandfactorXainhibitors'.)
Subcutaneousunfractionatedheparin(UFH)hasnotbeenadequatelystudiedinthispopulationandassuchcannotberoutinelyrecommended.(See
"HeparinandLMWheparin:Dosingandadverseeffects".)
Costsavingsduetotheavoidanceofaninpatientstayisafrequentlycitedadvantageofoutpatientanticoagulation,andisestimatedtorangefrom$500
to$2500perpatient[36,4854].Randomizedtrialsandmetaanalysesofnonrandomizedtrialshavesuggestedthatthecostofoutpatienttherapywith
LMWheparinissimilarto,orlowerthan,thecostofstrategiesthatutilizeunfractionatedheparin,regardlessofthetreatmentsetting(eg,inpatientversus
outpatient)[48,49,5557].Thesedatashouldbeinterpretedwithcautionasmanystudieswerebiasedandwerelimitedintheirsensitivityanalysis.
TheoutpatienttreatmentofPEisdiscussedseparately.(See"Overviewofthetreatment,prognosis,andfollowupofacutepulmonaryembolismin
adults",sectionon'Outpatientanticoagulation'.)
Longtermanticoagulation(10daysto3months)Longtermanticoagulanttherapyisadministeredbeyondtheinitialfewdaysofanticoagulation
forafiniteperiodoftypicallythreetosixmonths,andupto12monthsinsomecases(eg,phlegmasiaceruleadolens,apersistingbutreversiblerisk
factor).Insomepatientsthisisthesameagentthatwasselectedforinitialanticoagulation(eg,LMWheparin,rivaroxabanandapixaban),butinothers,
theinitialagentandtheselectedlongtermagentbelongtodifferentclasses,suchthattransitioningfromoneagenttoanotherisnecessary(eg,heparin
towarfarin,heparintoedoxabanordabigatran).Fullanticoagulationshouldbeensuredduringtransitionperiodsandinterruptionsshouldbeminimized
duringthefirstthreemonthsoflongtermanticoagulationbecausethisistheperiodthathasthehighestriskofrecurrentthrombosis.(See"Venous
thromboembolism:Anticoagulationafterinitialmanagement".)
SelectionofagentOptionsforlongtermanticoagulationareeitheroralorsubcutaneous.OralanticoagulantsincludedirectfactorXainhibitors
(rivaroxaban,apixaban,oredoxaban),thrombininhibitors(dabigatran),andvitaminKantagonists(warfarin)subcutaneousanticoagulantsincludeLMW
heparin,andfondaparinux.WhilethefactorXaandthrombininhibitorsarepreferred,adecisionbetweentheseagentsisusuallymadebasedupon
clinicianexperienceaswellastherisksofbleeding,patientcomorbidities,preferences,cost,andconvenience(table4).Becauseindividualpatients
perceiveburdensdifferently,patient'svaluesandpreferencesareparticularlycriticalinselectingalongtermagentforanticoagulationinacuteDVT.
Selectinganagentanddosinginthegeneralpopulationaswellasinpatientswithmalignancyandpregnancy,arediscussedindetailseparately.(See
"Venousthromboembolism:Anticoagulationafterinitialmanagement",sectionon'Selectionofagent'and"Deepveinthrombosisandpulmonary
embolisminpregnancy:Treatment"and"Treatmentofvenousthromboembolisminpatientswithmalignancy".)
DurationoftherapyAdecisionregardingtheoptimaldurationofanticoagulationmusttakeintoaccountthepresenceorabsenceofprovoking
events,riskfactorsforrecurrenceandbleeding,andtheindividualpatient'spreferencesandvalues.Althoughthereisagreementontheminimum
lengthoftimeapatientwithafirstepisodeofDVTshouldbetreated(ie,threemonths),theoptimallengthoftimeisnotknown.Formostpatientswitha
firstepisodeofDVT(provokedandunprovoked,proximalanddistal),anticoagulantsshouldbeadministeredforthreemonthsratherthanforshorter
periods(eg,fourorsixweeks)(algorithm1).Mostexpertsalsoagreethatextendinganticoagulationbeyondthreemonthsisconsideredinselect
populations.Durationoftherapyandindicationsforindefiniteanticoagulationarediscussedindetailseparately.(See"Venousthromboembolism:
Anticoagulationafterinitialmanagement",sectionon'Durationoftreatment'and"Rationaleandindicationsforindefiniteanticoagulationinpatientswith
venousthromboembolism",sectionon'Ourapproach'.)
IndefiniteanticoagulationThedecisiontoanticoagulatepatientswithDVTindefinitelyshouldbebaseduponanestimateoftheriskofrecurrence
andbleedinginthecontextoftheclinicalnatureoftheepisodeoftheDVT(eg,provokedorunprovokedDVT,reversibleorirreversibleriskfactors)as
wellasthepatient'svaluesandpreferences(eg,occupation,lifeexpectancy,burdenoftherapy).Whilethereisconsensusregardingtheneedto
anticoagulateselectpatientswithacuteDVTindefinitely,thereisnoagreeduponbestapproach[9,24,58,59].Patientsinwhomindefiniteanticoagulation
shouldbeconsideredandagentselectionforthispopulationarediscussedseparately.(See"Rationaleandindicationsforindefiniteanticoagulationin
patientswithvenousthromboembolism"and"Venousthromboembolism:Anticoagulationafterinitialmanagement",sectionon'Durationoftreatment'.)

SPECIALPOPULATIONSSpecialpopulationsofpatientswithacutedeepveinthrombosis(DVT)requirespecificconsiderationincludingthoselisted
inthissection(table4).
PatientswithcontraindicationstoanticoagulationForpatientswithacuteproximalDVTinwhomanticoagulationiscontraindicatedorinwhom
theriskofbleedingisestimatedbythecliniciantooutweightheriskofvenousthromboembolism(VTE),aninferiorvenacava(IVC)filtershouldbe
placedpromptly.PatientswithacutedistalDVTinwhomanticoagulationiscontraindicatedmaybemanagedwithsurveillanceultrasonography.The
indicationsanddetailsofIVCfilterplacementarediscussedseparately.(See'Inferiorvenacavafilter'below.)
Absolutecontraindicationstoanticoagulationinclude:
Activebleeding
Severebleedingdiathesis
Plateletcount<50,000/microL
Recent,planned,oremergenthighbleedingrisksurgery/procedure
Majortrauma
Historyofintracranialhemorrhage(ICH)particularlyrecentICH
Relativecontraindicationstoanticoagulationinclude:
Recurrentbleedingfrommultiplegastrointestinaltelangiectasias
Intracranialorspinaltumors
Plateletcount<150,000/microL
Largeabdominalaorticaneurysmwithconcurrentseverehypertension
Stableaorticdissection
Recent,planned,oremergentlowbleedingrisksurgery/procedure
PatientswitharemotehistoryofICH(eg,duetoaneurysmsuccessfullyablated),maybecandidatesforanticoagulation.
Specialconsiderationshouldalsobegiventoavoidinganticoagulation,whenfeasible,inolderpatients(eg,>65years)withahistoryofmultiplefallsand
thepresenceofmorethanonefactorthatelevatesthebleedingrisk.Suchpatientsareathighriskofbleedingorhaveahighriskofacatastrophicresult
shouldableedoccur.Consequently,thedecisiontoanticoagulateinthesepopulationsshouldbeevenmorecautioustoallowthebenefitsofVTE
preventiontobecarefullyweighedagainsttheriskofbleeding.
Patientswitharecentepisodeofminorbleedingsuchasepistaxisorheavymenstrualbleedingarenotgenerallyconsideredhighriskforbleedingand
anticoagulationcanusuallybeadministeredsafelyinthispopulation.
Themanagementofanticoagulationperioperativelyandassessingtheriskofbleedingarediscussedseparately.(See'Assessingbleedingrisk'above
and"Rationaleandindicationsforindefiniteanticoagulationinpatientswithvenousthromboembolism",sectionon'Assessingtheriskofbleeding'and
"Perioperativemanagementofpatientsreceivinganticoagulants".)
PatientswithmalignancyInpatientswithcancer,treatmentofDVTisassociatedwithhighermorbidity,duetohigherthanusualratesofboth
recurrentthrombosisandanticoagulantassociatedbleeding.ForpatientswithmalignancyandDVTwhohaveareasonablelifeexpectancyandwhodo
nothavesevererenalinsufficiency(creatinineclearance<30mL/minute),oracontraindicationtoanticoagulation,lowmolecularweight(LMW)heparinis
preferredforbothinitialandlongtermanticoagulationratherthanotheragents.Furtherdiscussionofthetreatmentofvenousthromboembolismin
patientswithmalignancyisdiscussedindetail,separately.(See"Treatmentofvenousthromboembolisminpatientswithmalignancy".)
PregnancyPregnancyisariskfactorforthedevelopmentofDVT.AdjusteddosesubcutaneousLMWheparinisthepreferredagentforinitialand
longtermanticoagulationinpregnantwomenwithacuteDVT.Thisagentispreferred,becauseithasamorefavorablesafetyprofile,especiallywhen
comparedwithwarfarin.Warfarinfreelycrossestheplacentalbarrierandcanproduceanembryopathywhengivenbetweenthesixthandninthweeksof
pregnancy.Intravenousandsubcutaneousformsofunfractionatedheparin(UFH)arealternativestoLMWheparin.FondaparinuxandoralfactorXaand
directthrombininhibitorshavenotbeenadequatelytestedinpregnantwomenwithacuteDVTandassuchshouldnotbeadministered.Thetreatmentof
DVTanduseofanticoagulantsinpregnancyarediscussedindetailseparately.(See"Deepveinthrombosisandpulmonaryembolisminpregnancy:
Treatment"and"Useofanticoagulantsduringpregnancyandpostpartum".)
PhlegmasiaceruleadolensAlthoughuncommon,itisimportanttoidentifypatientswithphlegmasiaceruleadolens(PCDmassiveiliofemoralDVT)
becausetheyshouldbeconsideredformoreaggressivemanagement,usuallythrombolysisand/orthrombectomy.Intravenous(IV)UFHisusuallythe
anticoagulantofchoicewhileadecisiontopursuemoreaggressivetherapyisbeingconsidered.PatientswithextensiveDVTbutwithoutsignsofPCDdo
notroutinelyreceivethrombolysisbutshouldbeanticoagulatedandmonitoredcloselyforthedevelopmentofPCD.
ClinicalpresentationPCDispartofaclinicalspectrumthatrangesfromphlegmasiaalbadolenstovenousgangrene[6063].PCDresultsfrom
acutemassivevenousthrombosisthatcausesanobstructionofthevenousdrainageofanextremity(upperorlower)andisassociatedwithahigh
degreeofmorbidity.Patientsusuallypresentwithsuddenseverepain,swelling,cyanosis,edema,venousgangrene,andcompartmentsyndromethat
togetherimpairarterialsupply,suchthatcirculatorycollapseandshockfrequentlyensue.Delayintreatmentmayresultindeathorlossofthepatient's
limb.
PCDoccursatanyagebutismorecommonduringthefifthandsixthdecades[60,61,64].Theincidenceishigherinfemalesthaninmales.Malignancyis
themostcommontriggeringfactorandispresentinapproximately20to40percentofpatients.Otherassociatedriskfactorsincludethetypicalrisk
factorsforthrombosis(eg,inheritedthrombophilias,surgery,trauma,venacavalfilterinsertion,pregnancy).Approximately10percentofpatientshave
idiopathicPCD.
Inthelowerextremities,leftsidedinvolvementisthreetofourtimesmorecommonthanrightsidedinvolvement[61].UpperextremityPCDisunusual
andoccursinlessthan5percentofpatients.
Manifestationsmaybegradualorfulminant.Mostcasesareprecededbyphlegmasiaalbadolens,withsymptomsofedema,pain,andblanching(alba)
withoutcyanosis.Asitprogresses,massivefluidsequestrationmayleadtoblebandbullaeformationandeventuallycyanosis(cerulea)andvenous

gangreneensue.Thepainisconstant,severe,andusuallystartsatthefemoraltriangleandprogressestotheentireextremity.Cyanosisisthe
pathognomonicfindingofPCD,progressingfromdistaltoproximalareas.
ManagementPCDistheonlyacceptedindicationforthrombolysisand/orthrombectomyinpatientswithDVT,especiallyinthosewithsignsof
ischemiaorgangrene.Accordingly,catheterdirectedthrombolysisorrapidremovaloftheoccludingthrombususingmanualtechniques(eg,surgicalor
catheterdirectedthrombectomy)shouldbeseriouslyconsideredinthispopulationofpatients[6571].Thus,itisprudenttoobtainaninterventional
radiologyand/orvascularsurgeryconsultationforpatientswithPCD,especiallythosewithimpendinggangrene.Theselectedintervention(s)willdepend
uponavailableexpertise.Detaileddiscussionofthrombolytictherapyandthrombectomyforthispopulationarediscussedseparately.(See"Fibrinolytic
(thrombolytic)therapyinacutepulmonaryembolismandlowerextremitydeepveinthrombosis",sectionon'Lowerextremitydeepveinthrombosis'and
'Thrombolytictherapyandthrombectomy'below.)
Importantly,delayedimplementationoftheseproceduresshouldnotprohibittheadministrationofinitialsystemicanticoagulationwithIVUFH.Our
preferenceforIVUFHastheinitialanticoagulantisbaseduponclinicalexperienceandlackofdatatosupportlowmolecularweightheparinordirectoral
anticoagulantsinthispopulation,aswellasthepotentialneedtoacutelydiscontinueanticoagulationwhen/ifthedecisionismadetoproceedwith
thrombolysisorthrombectomy.Oncethethreatofischemiaisresolved,mostexpertssimilartothegeneralpopulationtreatwithanticoagulantsfor
minimumofthreemonths,similartothegeneralpopulationhowever,theselectionofagentforlongtermtherapyandtotaldurationoftherapyshouldbe
individualized[9].(See"Venousthromboembolism:Anticoagulationafterinitialmanagement"and"Rationaleandindicationsforindefiniteanticoagulation
inpatientswithvenousthromboembolism".)
HeparininducedthrombocytopeniaForpatientswithaDVTandadiagnosisofheparininducedthrombocytopenia(HIT),allformsofheparin
shouldbediscontinued.ThisincludesUFH,LMWheparin,heparinflushes,heparinbondedcatheters,andheparincontainingmedications.Immediate
anticoagulationwithanonheparinanticoagulant(eg,argatroban,danaparoid,fondaparinux)isindicated,unlessthereisastrongcontraindicationto
anticoagulation.ThediagnosisandmanagementofpatientswithHITarediscussedindetail,separately.(See"Clinicalpresentationanddiagnosisof
heparininducedthrombocytopenia"and"Managementofheparininducedthrombocytopenia".)
ADDITIONALTHERAPIESAdditionalconsiderationsforpatientsdiagnosedwithacutedeepveinthrombosis(DVT)includeambulationandgraduated
compressionstockingsforthepreventionofpostthromboticsyndrome(postphlebitic)(PTS)aswellasthrombolytictherapyandinferiorvenacavafilter
placement,whicharediscussedinthesectionsbelow.
AmbulationDespitepriorconcernsregardingthepotentialforembolization,earlyambulationissafeinpatientswithacuteDVTandshouldbe
encouragedassoonasisfeasible.
Severalsmallrandomizedstudiesandmetaanalyseshaveshownthatearlyambulationdoesnotincreasetheriskofrecurrentorfatalpulmonary
embolism(PE)[29,30,7280].TheriskofPEduringmoreaggressiveformsofexercise,physicaltherapy,orrehabilitationisunknown.However,inthis
settingwetypicallygraduallyincreaseexercisetrainingastoleratedbythepatient.Symptomssuchaspainorlegedemamaylimitambulation.
Compressionstockingsmaybeusefulforsymptomaticreliefandthepromotionofambulation.
CompressionstockingsforthepreventionofPTSIngeneral,weprefertoavoidtheroutineuseofelasticgraduatedcompressionstockings
(GCS)thatprovide30to40mmHgofanklepressureforthepreventionofPTS.Thispreferenceisbaseduponrandomizedstudiesthathavenotshown
clearconsistentbenefit.However,ifthedecisionismadetousecompressionstockings,theyshouldbestartedafteranticoagulanttherapy,withintwo
weeksofthediagnosis,andcontinuedfortwoyears.
EvidenceevaluatingelasticGCSforthepreventionofPTSisconflictingwithsmallertrialssuggestingbenefitandonelargerandomizedtrialreportingno
benefit[9,55,8191].Mosttrialswerehamperedbymethodologicflawsincludingimpreciseestimationofrecurrenceanddifferingcriteriaforthe
assessmentofPTS(GinsbergorVillaltacriteria).Inaddition,manytrialswerenotblindedandhadvariableinitialrandomizationperiods(zerototwo
weeks)andcontrolgroups(nostockings,stockingswith5mmHgpressureattheankles,GCSonetotwosizestoobig).
SmallrandomizedtrialsofpatientswithacuteDVT(firstorrecurrent)thatusedtheVillaltacriteriaforPTS,suggestedthatGCSthatapplyanankle
pressureof30to40mmHgstartedwithintwoweeksandcontinuedfortwoyearstoreducetheoccurrenceofPTSby50percentwithoutincreasing
thefrequencyofrecurrentVTE[82,83].PatientsmostlikelytobenefitincludedthosewithaproximalDVT,priorDVT,andthosewithsymptoms.
Incontrast,arandomizedplacebocontrolledtrialof806patientswithfirstproximalDVTreportednodifferenceintherateofPTSwithGCSas
measuredbythelessstringentGinsbergcriteria(legpainandswellingonemonthormore14versus13percent)[89].Asimilarlackofbenefitwas
reportedwhenthemorerigorousVillaltacriteriawereapplied.Baseduponthisstudy,weandotherexpertsdonotroutinelyapplyGCSforthe
preventionofPTS.
AlthoughGCSarenotharmful,manypatientsalsodeclinetheirusebecausetheyareuncomfortable,costly,inconvenient,andoftenrequireahealthcare
giverfortheirapplication.However,asubsetofpatientswithrecurrentDVTormoderatetoseveresymptomsmayconsiderthepotentialbenefitsofGCS
tooutweightheseinconveniences.Insuchpatients,thepurposeofGCSisoftenfocusedonsymptomreductionratherthanpreventionofPTS.
WhenthedecisionismadetowearGCS,theyshouldbestartedafteranticoagulanttherapy.Thisistoavoidthetheoreticalriskofpromotingembolismto
thelungfromfreshclotinthelowerextremity.GCSshouldbecontinuedfortwoyears,replacedeverysixmonths,andmayrequirerefittingoncelocal
swellingisreduced.Alternativeapproachesofcompressivebandages,applicationofGCSforlimitedperiods(eg,forthedurationofanticoagulation)or
followingthrombolytictherapyhavenotbeenadequatelyevaluated.
ContraindicationstoGCSincludeskinulceration,severearterialinsufficiency,allergytothestockingmaterial,andinabilitytoapplystockings.
TheuseofcompressionstockingsasatherapyforPTSisdiscussedseparately.(See"Postthrombotic(postphlebitic)syndrome".)
ThrombolytictherapyandthrombectomyFormostpatientswithacutelowerextremityDVT,anticoagulanttherapyaloneissufficientsuchthatthe
routineuseofthrombolytictherapy(systemicandcatheterdirected)and/orthrombectomy(surgicalorcatheterdirected)isnotindicated.Thrombolysis
and/orthrombectomyareusuallyreservedforpatientswithphlegmasiaceruleadolensormassiveiliofemoralDVTorforpatientswhofailtherapeutic
anticoagulation.Additionally,suitablecandidatesforthrombolysisshouldhavesymptomsfor<14days(ie,freshclotorganizedclotwillnotundergolysis),
goodfunctionalstatus,andlowbleedingrisk[9].
ThrombolytictherapyisnotroutinelyadministeredformostpatientswithDVT.Whencomparedwithparenteralanticoagulation,althoughthrombolysisis
associatedwithmorerapidandcompletelysis,reducedratesofPTS,andhigherratesofpreservedvenousvalvefunction,ratesofrecurrentvenous

thromboembolismandmortalityareunchanged.Inaddition,theriskofmajorbleedingassociatedwithsystemicthrombolysisisconsideredbymost
expertstobeunacceptablyhighwhenweighedagainstthebenefitsofdecreasedPTS.
Thrombolyticagentscanbeadministeredsystemicallyorviaacatheterinsertedintotheaffectedlowerextremityvein(catheterdirectedthrombolysis).It
isgenerallyconsideredthatcomparedwithsystemicthrombolysis,catheterdirectedthrombolysiscanachieveclotlysismorerapidlyandwithlower
doses,therebyreducingtheriskofbleeding.Onetheoreticaladvantageofthrombolysisisamorecompleteremovalofclotfromsmallervenulesthat
cannotberemovedsurgically,afeaturethatmaybeimportantforpatientswithPCDwhohaveseverevenousgangrene[92,93].(See'Phlegmasia
ceruleadolens'above.)
Mechanicalthrombectomy(usingcatheterextractionorfragmentation)orsurgicalthrombectomymayalsobeconsideredasanalternativeoradjunctive
therapytothrombolysis.Itisthoughtthatcombinedcatheterdirectedprocedures(eg,thrombolysisplusfragmentation)mayfurtherminimizetheriskof
bleeding[9].
ThrombolytictherapyandtheregimensusedforacutePEandDVTarediscussedindetail,separately.(See"Fibrinolytic(thrombolytic)therapyinacute
pulmonaryembolismandlowerextremitydeepveinthrombosis",sectionon'Lowerextremitydeepveinthrombosis'and"Overviewofthetreatment,
prognosis,andfollowupofacutepulmonaryembolisminadults",sectionon'Embolectomy'.)
InferiorvenacavafilterInferiorvenacava(IVC)filters,asstandaloneoradjunctivetherapy,arenotroutinelyinsertedinpatientswithacuteDVT.
Typically,IVCfilters(table6)areusedinpatientswithacuteproximalDVTandPEwhohaveanabsolutecontraindicationtoanticoagulanttherapy(eg,
recentsurgery,hemorrhagicstroke,activebleeding)[94].Althoughnotconsideredabsoluteindications,placementofanIVCfilterisalsooften
consideredasanadjunctivetherapyinpatientswithrecurrentembolismdespiteadequateanticoagulation,aswellasinpatientsinwhomanadditional
emboliceventwouldbepoorlytolerated(eg,thosewithpoorcardiopulmonaryreservefrommassivePEorunderlyingcardiopulmonarydisease,
hemodynamicallyunstablepatients),althoughthisapproachisunproven.TheefficacyofIVCfilterplacementinpatientswithsymptomaticisolateddistal
DVTisunknownandnotgenerallyperformed.FiltersaretypicallyplacedintheinfrarenalportionoftheIVCassuch,theirmajorpurposeisthe
preventionofembolizationoflowerextremityclottothelung.Ingeneral,wepreferretrievablefiltersbutthecompliancewithretrievaltendstobelow.
(See"Placementofvenacavafiltersandtheircomplications".)
ForpatientsinwhomanIVCfilterisplaced,weandothersagreethatoncetheriskofbleedingisassessedaslowthataconventionalcourseof
anticoagulationtherapyshouldbeadministeredandthefilterremoved,whenfeasible[9].(See'Initialanticoagulation(first10days)'above.)
Themanytypesoffiltersthatareavailable,someofwhichareapprovedbyregulatoryagencies,arelistedinthetable(table6).However,thereareno
datatosuggestthatonetypeoffilterissuperiortoanother.
InpatientswithacuteDVTwhohaveacontraindicationtoanticoagulation,retrospectiveandobservationalcaseseriesreportthatratesofrecurrentPE
followingfilterinsertionarelow(2to4percentinmostseries)[9497].Althoughsomecohortstudiesofpatientswithcontraindicationstoanticoagulation
reportlowershorttermfatalityratesinpatientswithIVCfilters,thereisnoevidencethatIVCfilterspreventPErelateddeath[94,98,99].
WhenIVCfiltersareusedasanadjunctivetherapytoanticoagulation,reportssuggestnoconvincingefficacy.Asexamples:
Inoneofthelargesttrialstodate(PREPIC1)thatexaminedtheeffectivenessofIVCfilters,400patientswithproximalDVTwererandomly
assignedtoeitherstandardanticoagulationaloneoranticoagulationplusinsertionofanIVCfilter[100].Duringthefirst12daysafterrandomization,
significantlyfewerpatientsintheIVCfiltergroupdevelopedaPE(1versus5percent).However,afteratwoyearfollowupperiod,therewereno
significantdifferencesinsurvivalorsymptomaticPEbetweenthetwogroups,andasignificantlyhigherrateofDVTwasobservedamongpatients
whohadreceivedanIVCfilter(21versus12percent).Aneightyearfollowupofthesamepopulationofpatientsconfirmedthesefindingsthatfilter
placementwasassociatedwithasuccessfulreductionintherateofPE(15versus6percent)butanincreaseintherateofDVT(35versus28
percent)[101].Nodifferenceinmortalitywasreported.
Asimilarlydesignedrandomizedtrial(PREPIC2)reportedoutcomesin399patientswithseverePE(eg,olderpatients>75years,activecancer,
signsofrightventricledysfunction,chronicrespiratoryinsufficiency)whoreceivedeitherstandardanticoagulationaloneoranticoagulationplusan
IVCfilterthatwasretrievedatthreemonths[102].TheadditionofanIVCfiltertoanticoagulationdidnotaltertherateofPErecurrence(1.5versus3
percent),DVTrecurrence(0.5percent),ormortality(7.5versus6percent)atthreemonths.ThelackofbenefitassociatedwithIVCfilterplacement
persistedbysixmonths.Therateoffiltercomplications(eg,thrombosis)waslow(<2percent).
DataderivedfromtheNationalInpatientSamplereportedthatcomparedwiththrombolytictherapyalone,theinsertionofavenacavafilterwas
associatedwithalowerinhospitalcasefatalityrateamongunstablepatientswhoreceivedthrombolytictherapy(8versus18percent)aswellas
unstablepatientswhodidnotreceivethrombolytictherapy(33versus51percent)[99,103].FiltersdidnotimproveinhospitalcasefatalityrateifDVT
wasdiagnosedinhemodynamicallystablepatients.Althoughadatabaseanalysisofover13,000patientswithPEwhoweretreatedwitheither
thrombolyticoranticoagulanttherapydemonstratedareductioninhospitalmortalityinthosewhowereadjunctivelytreatedwithanIVCfilter
comparedwiththosewhodidnotreceiveafilter(3versus5percent),thisstudywaslimitedbymethodologicflaws[104].
SeveralstudiesreporthigherratesofDVTwithIVCfilterinsertion,particularlyinthoseinwhomanticoagulationiscontraindicatedandthosewithknown
DVT[95,102,105107].Asexamples:
Acomprehensivereviewofretrospectivecaseseriesreportedthatvenousthrombosisatthesiteofinsertionoccursin10percentofpatientswhen
anIVCfilterwasplacedwhenanticoagulationwascontraindicated[95].
Anadditionalprospectiveobservationalstudyofpatientsinwhompermanentfilterswereplacedreportedthatfilterthrombosisoccurredin30
percent,DVTin20percent,andPEin5percent[105].
Asystematicreviewof11studiesinpatientsinwhomapermanentfilterwasplacedforprimaryorsecondarypreventionreportedhighratesofthe
signsandsymptomsofPTS(50and20percent,respectively)[105,106].
InPREPIC1,whichwascomprisedofpatientswithDVTwhowerefullyanticoagulated,therateofDVTassociatedwithadjunctiveIVCfilterinsertion
was21and35percent,attwoandeightyears,respectively.Incontrast,inPREPIC2,whichwascomprisedofpatientswithPEwhowerefully
anticoagulated,ratesofDVTinassociationwitharetrievablefilterwerelessthan1percent[102].
AlthoughretrievablefiltershavethetheoreticalpotentialtoeliminatetheriskofDVT,thereisnodirectevidencetosupportthishypothesisanddatafrom
observationalcaseseriessuggestlowcompliancewiththeirinsertionaswellaslowretrievalratesinpractice[108111].

Severalpracticalfactorsthatmayinfluencethedecisiontoplaceafiltershouldbeconsideredineverypatient:
Thesiteoforiginoftheemboliceventmustbesuchthatthefilterwillprovideabeneficialeffect.Forexample,infrarenalcavalfilterplacementwillnot
beofprophylacticvalueiftheembolioriginatedintherenalveins,acardiacchamber,ortheupperextremityveins.
IVCfilterplacementisassociatedwithitsownsetofcomplications(eg,guidewireentrapment,localhemorrhage,fracture,embolization)and
mortality(0.12to0.3percent)suchthatweighingtheserisksagainstthoseofrecurrenceisprudent.(See"Placementofvenacavafiltersandtheir
complications",sectionon'Complications'and"Placementofvenacavafiltersandtheircomplications",sectionon'Mortality'.)
ForpatientswithPEwhodonothaveprovenclotinthelowerextremitieswhoalsohaveacontraindicationtoanticoagulation,venacavafiltersareoften
placed.Thisisbecauseclotcanquicklyreforminthelegveinsafterembolizationandmayalsoremainundetectedinthepelvisorcalfveinswiththe
potentialtoembolize.(See"Overviewofthetreatment,prognosis,andfollowupofacutepulmonaryembolisminadults",sectionon'Inferiorvenacava
filters'.)
TheplacementandcomplicationsofIVCfiltersarediscussedseparately.(See"Placementofvenacavafiltersandtheircomplications".)
MONITORINGANDFOLLOWUPPatientsshouldbemonitoredforthecomplicationsofdeepveinthrombosis(DVT)aswellasthoseof
anticoagulation.Theseincludefurtherclotextension,recurrence,embolization,postthrombotic(postphlebitic)syndrome,chronicthromboembolic
pulmonaryhypertension,bleeding,thrombocytopenia,andthrombosisrelatedorbleedingrelateddeath.
Duringanticoagulationpatientsshouldalsobemonitoredforthedevelopmentofconditionsthataffectthehalflifeoftheanticoagulantused(eg,renal
failure,pregnancy,weightgain/loss).
Themostcommonlaboratorytestusedtomonitorwarfarinistheprothrombintime(PT)ratiousuallyexpressedastheinternationalnormalizedratio
(INR).ThegoalINRis2to3(target2.5).Lowmolecularweightheparin,fondaparinux,andthefactorXaanddirectthrombininhibitorsdonotrequire
routinelaboratorymonitoring,althoughinrarecircumstancesthismaybeusedtoincreasetheprobabilityoftherapeuticanticoagulationwithaspecific
agent.(See"HeparinandLMWheparin:Dosingandadverseeffects",sectionon'Laboratorymonitoring/measurement'and"Clinicaluseofcoagulation
tests",sectionon'Factoractivitylevels'and"Directoralanticoagulants:Dosingandadverseeffects".)
Monitoringpatientsfortherapeuticefficacyandbleedingisdiscussedseparately.(See"Venousthromboembolism:Anticoagulationafterinitial
management",sectionon'Monitoring'and"Rationaleandindicationsforindefiniteanticoagulationinpatientswithvenousthromboembolism",sectionon
'Makingthedecisiontoindefinitelyanticoagulate'.)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsandBeyondtheBasics.TheBasicspatient
educationpiecesarewritteninplainlanguage,atthe5thto6thgradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthave
aboutagivencondition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyondthe
Basicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10thto12thgradereadingleveland
arebestforpatientswhowantindepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopicstoyourpatients.(Youcanalso
locatepatienteducationarticlesonavarietyofsubjectsbysearchingonpatientinfoandthekeyword(s)ofinterest.)
Basicstopics(see"Patienteducation:Deepveinthrombosis(bloodclotsinthelegs)(TheBasics)")
BeyondtheBasicstopics(see"Patienteducation:Deepveinthrombosis(DVT)(BeyondtheBasics)"and"Patienteducation:Warfarin(Coumadin)
(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Anticoagulationisthemainstayoftherapyforpatientswithacutelowerextremitydeepveinthrombosis(DVT).Initialanticoagulationrefersto
anticoagulanttherapythatisadministeredimmediatelyandforupto10daysfollowingadiagnosisofDVTtoprovideprotectionfromrecurrent
thrombosisinthisperiodofhighestrisk.Longterm(finite)anticoagulationisadministeredforaminimumofthreemonthsandextendedfor6to12
monthsinsomecases.Asmallpopulationofpatientswillrequireindefiniteanticoagulation.(See'Nomenclature'above.)
FormostpatientswithacutesymptomaticproximalDVT,werecommendanticoagulationratherthannoanticoagulation(Grade1B),providedthe
riskofbleedingisnothigh.InpatientswithasymptomaticproximalDVT,wesuggestanticoagulationidenticaltothatforpatientswithsymptomatic
DVT.FormostpatientswithsymptomaticisolateddistalDVT,wesuggestanticoagulationratherthanserialcompressionultrasonography(Grade
2C).ForselectpatientswithisolateddistalDVT(eg,thoseathighriskofbleeding,negativeDdimerlevel,asymptomaticorminorsymptoms,without
riskfactorsforextension,and/orminorthrombosisofthemuscularveins),wesuggestsurveillancewithserialultrasoundoveratwoweekperiod
ratherthananticoagulation(Grade2C).Thosewhoexhibitsignsofthrombusextensionshouldbeanticoagulated.(See'Indications'above.)
Inmostpatients,anticoagulationshouldbestartedimmediately(initialanticoagulation)asadelayintherapyincreasestheriskofpotentiallylife
threateningembolization.Optionsincludesubcutaneouslowmolecularweight(LMW)heparin,subcutaneousfondaparinux,theoralfactorXa
inhibitorsrivaroxabanorapixaban,orunfractionatedheparin(UFH).Adecisionbetweentheseagentsisusuallymadebaseduponclinician
experienceaswellastherisksofbleeding,patientcomorbidities,preferences,cost,andconvenience.(See"Venousthromboembolism:Initiationof
anticoagulation(first10days)"and'Initialanticoagulation(first10days)'above.)
Outpatientanticoagulationratherthaninpatienttherapycanbeconsideredwhenpatientsarehemodynamicallystable,havealowriskofbleeding,
donothaverenalinsufficiency,andhaveapracticalsysteminplaceathomefortheadministrationandsurveillanceofanticoagulanttherapy(table
5).ItisnotappropriateinpatientswithmassiveDVT(eg,iliofemoralDVT,phlegmasiaceruleadolens),concurrentpulmonaryembolism,ahighrisk
ofbleedingonanticoagulanttherapy,comorbidconditions,orotherfactorsthatwarrantinhospitalcare.(See'Outpatienttherapy'above.)
Therapeuticanticoagulationshouldbeensuredduringthetransitionfrominitialtolongterm(maintenance)therapy.Optionsforlongtermagents
areoralanticoagulants(directfactorXainhibitors,[rivaroxaban,apixaban,edoxaban],thrombininhibitors[dabigatran],andvitaminKantagonists
[warfarin]),aswellassubcutaneousagents(LMWheparinandfondaparinux).WhilethefactorXaandthrombininhibitorsarepreferred,adecision
betweentheseagentsisusuallymadebaseduponclinicianexperienceaswellastherisksofbleeding,patientcomorbidities,preferences,cost,and
convenience(table4).Interruptionsshouldbeminimizedduringthefirstthreemonthsofanticoagulationduetothehighriskofrecurrentthrombosis.
(See"Venousthromboembolism:Anticoagulationafterinitialmanagement"and'Longtermanticoagulation(10daysto3months)'above.)

 ForpatientswithacuteDVT,thedurationofanticoagulationshouldbeindividualizedaccordingtothepresenceorabsenceofprovokingevents,risk
factorsforrecurrenceandbleeding,andtheindividualpatient'spreferencesandvalues(algorithm1).Althoughthereisagreementontheminimum
lengthoftimeapatientwithafirstepisodeofDVTshouldbetreated(ie,threemonths),theoptimallengthoftimeisnotknown.Formostpatients
withafirstepisodeofDVT(provokedandunprovoked,proximalanddistal),anticoagulantsshouldbeadministeredforthreemonthsratherthanfor
shorterperiods(eg,fourorsixweeks).Mostexpertsalsoagreethatextendinganticoagulationbeyondthreemonthsisconsideredinselect
populations.(See"Venousthromboembolism:Anticoagulationafterinitialmanagement",sectionon'Durationoftreatment'and"Rationaleand
indicationsforindefiniteanticoagulationinpatientswithvenousthromboembolism".)
SpecialpopulationsofpatientswithacuteDVTrequirespecificconsideration:
Forpatientsinwhomanticoagulationiscontraindicatedorinwhomtheriskofbleedingisestimatedtooutweightheriskofrecurrent
thromboembolism,wesuggesttheinsertionofanIVCfilterratherthannotherapy(Grade2C).WealsosuggestthatanIVCfilterbeplacedfor
patientswithacuteproximalDVTwhohaverecurrentembolismdespiteadequateanticoagulationandforpatientswhohavepoor
cardiopulmonaryreservewhomaynottolerateadditionalembolism.Wepreferretrievablefiltersfortheavoidanceoflongtermcomplicationsof
filterplacement.Additionally,wepreferthatpatientswithDVTreceiveaconventionalcourseofanticoagulationoncethecontraindication
resolves.(See'Patientswithcontraindicationstoanticoagulation'aboveand'Inferiorvenacavafilter'above.)
Forpatientswithactivemalignancyandpregnantwomen,wesuggestthatLMWheparinbeselectedastheinitialandlongtermanticoagulantof
choiceratherthanotheragents(Grade2C).Inpatientswithactivemalignancy,warfarinanddirectoralanticoagulantsarealternativeswhen
LMWheparincannotbeadministered.FactorXaanddirectthrombininhibitorshavenotbeenadequatelytestedinpregnantwomenwithacute
DVTandassuchshouldnotbeadministered.(See'Specialpopulations'aboveand"Treatmentofvenousthromboembolisminpatientswith
malignancy"and"Deepveinthrombosisandpulmonaryembolisminpregnancy:Treatment".)
ForpatientswithmassiveiliofemoralDVTorphlegmasiaceruleadolenswithsymptomsfor<14daysandgoodfunctionalstatus,wesuggest
systemicorcatheterdirectedthrombolytictherapy,and/orclotremoval(eg,catheterextraction,catheterfragmentation,surgicalthrombectomy)
ratherthananticoagulationalone(Grade2C).Themostappropriateinterventiondependsupontheinstitution'sexpertise.(See'Phlegmasia
ceruleadolens'aboveand"Fibrinolytic(thrombolytic)therapyinacutepulmonaryembolismandlowerextremitydeepveinthrombosis",section
on'Lowerextremitydeepveinthrombosis'.)
ForpatientswithaDVTandadiagnosisofheparininducedthrombocytopenia(HIT),allformsofheparinshouldbediscontinuedandimmediate
anticoagulationwithanonheparinanticoagulantstarted.(See"Managementofheparininducedthrombocytopenia".)
ForpatientswithacuteDVTwhoarefullyanticoagulated,hemodynamicallystable,andwhosesymptoms(eg,pain,swelling)areundercontrol,we
suggestearlyambulationinpreferencetobedrest(Grade2C).Wealsosuggestthatelasticgraduatedcompressionstockings(GCS)notbe
routinelyadministeredinpatientsforthepreventionofpostthrombotic(postphlebitic)syndrome(Grade2B).(See'Ambulation'aboveand
'CompressionstockingsforthepreventionofPTS'above.)
PatientsshouldbemonitoredforthecomplicationsofDVTaswellasthoseofanticoagulation.Theseincludefurtherclotextension,recurrence,
embolization,postthrombotic(postphlebitic)syndrome,chronicthromboembolicpulmonaryhypertension,bleeding,thrombocytopenia,and
thrombosisrelatedorbleedingrelateddeath.(See'Monitoringandfollowup'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1.KearonC,AgenoW,CannegieterSC,etal.Categorizationofpatientsashavingprovokedorunprovokedvenousthromboembolism:guidancefrom
theSSCofISTH.JThrombHaemost201614:1480.
2.HustedS,deCaterinaR,AndreottiF,etal.NonvitaminKantagonistoralanticoagulants(NOACs):Nolongernewornovel.ThrombHaemost2014
111:781.
3.BarnesGD,AgenoW,AnsellJ,etal.Recommendationonthenomenclaturefororalanticoagulants:communicationfromtheSSCoftheISTH.J
ThrombHaemost201513:1154.
4.BrowseNL,ThomasML.Sourceofnonlethalpulmonaryemboli.Lancet19741:258.
5.HavigO.Deepveinthrombosisandpulmonaryembolism.Anautopsystudywithmultipleregressionanalysisofpossibleriskfactors.ActaChir
ScandSuppl1977478:1.
6.GalanaudJP,SevestrePietriMA,BossonJL,etal.Comparativestudyonriskfactorsandearlyoutcomeofsymptomaticdistalversusproximal
deepveinthrombosis:resultsfromtheOPTIMEVstudy.ThrombHaemost2009102:493.
7.BARRITTDW,JORDANSC.Anticoagulantdrugsinthetreatmentofpulmonaryembolism.Acontrolledtrial.Lancet19601:1309.
8.CarrierM,LeGalG,WellsPS,RodgerMA.Systematicreview:casefatalityratesofrecurrentvenousthromboembolismandmajorbleedingevents
amongpatientstreatedforvenousthromboembolism.AnnInternMed2010152:578.
9.KearonC,AklEA,ComerotaAJ,etal.AntithrombotictherapyforVTEdisease:AntithromboticTherapyandPreventionofThrombosis,9thed:
AmericanCollegeofChestPhysiciansEvidenceBasedClinicalPracticeGuidelines.Chest2012141:e419S.
10.KearonC.Naturalhistoryofvenousthromboembolism.Circulation2003107:I22.
11.MasudaEM,KistnerRL.Thecaseformanagingcalfveinthrombiwithduplexsurveillanceandselectiveanticoagulation.DisMon201056:601.
12.RighiniM,ParisS,LeGalG,etal.Clinicalrelevanceofdistaldeepveinthrombosis.Reviewofliteraturedata.ThrombHaemost200695:56.
13.SchwarzT,SchmidtB,BeyerJ,SchellongSM.Therapyofisolatedcalfmuscleveinthrombosiswithlowmolecularweightheparin.BloodCoagul
Fibrinolysis200112:597.
14.MacdonaldPS,KahnSR,MillerN,ObrandD.Shorttermnaturalhistoryofisolatedgastrocnemiusandsolealveinthrombosis.JVascSurg2003
37:523.

15.GilletJL,PerrinMR,AllaertFA.Shorttermandmidtermoutcomeofisolatedsymptomaticmuscularcalfveinthrombosis.JVascSurg2007
46:513.
16.LautzTB,AbbasF,WalshSJ,etal.Isolatedgastrocnemiusandsolealveinthrombosis:shouldthesepatientsreceivetherapeuticanticoagulation?
AnnSurg2010251:735.
17.SchwarzT,BuschmannL,BeyerJ,etal.Therapyofisolatedcalfmuscleveinthrombosis:arandomized,controlledstudy.JVascSurg2010
52:1246.
18.SalesCM,HaqF,BustamiR,SunF.Managementofisolatedsolealandgastrocnemiusveinthrombosis.JVascSurg201052:1251.
19.PalaretiG,CosmiB,LessianiG,etal.Evolutionofuntreatedcalfdeepveinthrombosisinhighrisksymptomaticoutpatients:theblind,prospective
CALTHROstudy.ThrombHaemost2010104:1063.
20.DeMartinoRR,WallaertJB,RossiAP,etal.Ametaanalysisofanticoagulationforcalfdeepvenousthrombosis.JVascSurg201256:228.
21.BrateanuA,PatelK,ChaginK,etal.Probabilityofdevelopingproximaldeepveinthrombosisand/orpulmonaryembolismafterdistaldeepvein
thrombosis.ThrombHaemost2016115:608.
22.PalaretiG,CosmiB,LegnaniC,etal.Ddimertoguidethedurationofanticoagulationinpatientswithvenousthromboembolism:amanagement
study.Blood2014124:196.
23.HornerD,HoggK,BodyR,etal.Theanticoagulationofcalfthrombosis(ACT)project:resultsfromtherandomizedcontrolledexternalpilottrial.
Chest2014146:1468.
24.KearonC,AklEA,OrnelasJ,etal.AntithromboticTherapyforVTEDisease:CHESTGuidelineandExpertPanelReport.Chest2016149:315.
25.BoutitieF,PinedeL,SchulmanS,etal.Influenceofprecedinglengthofanticoagulanttreatmentandinitialpresentationofvenous
thromboembolismonriskofrecurrenceafterstoppingtreatment:analysisofindividualparticipants'datafromseventrials.BMJ2011342:d3036.
26.HolbrookA,SchulmanS,WittDM,etal.Evidencebasedmanagementofanticoagulanttherapy:AntithromboticTherapyandPreventionof
Thrombosis,9thed:AmericanCollegeofChestPhysiciansEvidenceBasedClinicalPracticeGuidelines.Chest2012141:e152S.
27.denExterPL,vanEsJ,ErkensPM,etal.Impactofdelayinclinicalpresentationonthediagnosticmanagementandprognosisofpatientswith
suspectedpulmonaryembolism.AmJRespirCritCareMed2013187:1369.
28.SmithSB,GeskeJB,MaguireJM,etal.Earlyanticoagulationisassociatedwithreducedmortalityforacutepulmonaryembolism.Chest2010
137:1382.
29.KoopmanMM,PrandoniP,PiovellaF,etal.Treatmentofvenousthrombosiswithintravenousunfractionatedheparinadministeredinthehospital
ascomparedwithsubcutaneouslowmolecularweightheparinadministeredathome.TheTasmanStudyGroup.NEnglJMed1996334:682.
30.LevineM,GentM,HirshJ,etal.Acomparisonoflowmolecularweightheparinadministeredprimarilyathomewithunfractionatedheparin
administeredinthehospitalforproximaldeepveinthrombosis.NEnglJMed1996334:677.
31.BoccalonH,EliasA,ChalJJ,etal.Clinicaloutcomeandcostofhospitalvshometreatmentofproximaldeepveinthrombosiswithalow
molecularweightheparin:theVascularMidiPyreneesstudy.ArchInternMed2000160:1769.
32.O'ShaughnessyD,MilesJ,WimperisJ.UKpatientswithdeepveinthrombosiscanbesafelytreatedasoutpatients.QJM200093:663.
33.GrauE,TeniasJM,RealE,etal.Hometreatmentofdeepvenousthrombosiswithlowmolecularweightheparin:Longtermincidenceofrecurrent
venousthromboembolism.AmJHematol200167:10.
34.DunnA,BiohD,BeranM,etal.Effectofintravenousheparinadministrationondurationofhospitalization.MayoClinProc200479:159.
35.DunnAS,SchechterC,GotlinA,etal.Outpatienttreatmentofdeepvenousthrombosisindiverseinnercitypatients.AmJMed2001110:458.
36.SegalJB,BolgerDT,JenckesMW,etal.Outpatienttherapywithlowmolecularweightheparinforthetreatmentofvenousthromboembolism:a
reviewofefficacy,safety,andcosts.AmJMed2003115:298.
37.ChongBH,BrightonTA,BakerRI,etal.Oncedailyenoxaparinintheoutpatientsettingversusunfractionatedheparininhospitalforthetreatment
ofsymptomaticdeepveinthrombosis.JThrombThrombolysis200519:173.
38.DaskalopoulosME,DaskalopoulouSS,TzortzisE,etal.Longtermtreatmentofdeepvenousthrombosiswithalowmolecularweightheparin
(tinzaparin):aprospectiverandomizedtrial.EurJVascEndovascSurg200529:638.
39.RamacciottiE,ArajoGR,LastoriaS,etal.Anopenlabel,comparativestudyoftheefficacyandsafetyofoncedailydoseofenoxaparinversus
unfractionatedheparininthetreatmentofproximallowerlimbdeepveinthrombosis.ThrombRes2004114:149.
40.OthienoR,AbuAffanM,OkpoE.Homeversusinpatienttreatmentfordeepveinthrombosis.CochraneDatabaseSystRev2007:CD003076.
41.TrujilloSantosJ,LozanoF,LorenteMA,etal.Aprognosticscoretoidentifylowriskoutpatientswithacutedeepveinthrombosisinthelowerlimbs.
AmJMed2015128:90.e9.
42.KlineJA,JimenezD,CourtneyDM,etal.ComparisonofFourBleedingRiskScorestoIdentifyRivaroxabantreatedPatientsWithVenous
ThromboembolismatLowRiskforMajorBleeding.AcadEmergMed201623:144.
43.DouketisJD.Treatmentofdeepveinthrombosis:whatfactorsdetermineappropriatetreatment?CanFamPhysician200551:217.
44.EINSTEINInvestigators,BauersachsR,BerkowitzSD,etal.Oralrivaroxabanforsymptomaticvenousthromboembolism.NEnglJMed2010
363:2499.
45.AgnelliG,BullerHR,CohenA,etal.Oralapixabanforthetreatmentofacutevenousthromboembolism.NEnglJMed2013369:799.
46.HokusaiVTEInvestigators,BllerHR,DcoususH,etal.Edoxabanversuswarfarinforthetreatmentofsymptomaticvenousthromboembolism.N
EnglJMed2013369:1406.
47.SchulmanS,KearonC,KakkarAK,etal.Dabigatranversuswarfarininthetreatmentofacutevenousthromboembolism.NEnglJMed2009
361:2342.
48.RodgerM,BredesonC,WellsPS,etal.Costeffectivenessoflowmolecularweightheparinandunfractionatedheparinintreatmentofdeepvein
thrombosis.CMAJ1998159:931.
49.O'BrienB,LevineM,WillanA,etal.Economicevaluationofoutpatienttreatmentwithlowmolecularweightheparinforproximalveinthrombosis.
ArchInternMed1999159:2298.

50.BckmanK,CarlssonP,KentsonM,etal.Deepvenousthrombosis:anewtaskforprimaryhealthcare.Arandomisedeconomicstudyofoutpatient
andinpatienttreatment.ScandJPrimHealthCare200422:44.
51.HuseDM,CumminsG,TaylorDC,RussellMW.Outpatienttreatmentofvenousthromboembolismwithlowmolecularweightheparin:aneconomic
evaluation.AmJManagCare20028:S10.
52.SpyropoulosAC,HurleyJS,CieslaGN,deLissovoyG.Managementofacuteproximaldeepveinthrombosis:pharmacoeconomicevaluationof
outpatienttreatmentwithenoxaparinvsinpatienttreatmentwithunfractionatedheparin.Chest2002122:108.
53.TillmanDJ,CharlandSL,WittDM.Effectivenessandeconomicimpactassociatedwithaprogramforoutpatientmanagementofacutedeepvein
thrombosisinagroupmodelhealthmaintenanceorganization.ArchInternMed2000160:2926.
54.vandenBeltAG,BossuytPM,PrinsMH,etal.Replacinginpatientcarebyoutpatientcareinthetreatmentofdeepvenousthrombosisan
economicevaluation.TASMANStudyGroup.ThrombHaemost199879:259.
55.SegalJB,StreiffMB,HofmannLV,etal.Managementofvenousthromboembolism:asystematicreviewforapracticeguideline.AnnInternMed
2007146:211.
56.GouldMK,DembitzerAD,SandersGD,GarberAM.Lowmolecularweightheparinscomparedwithunfractionatedheparinfortreatmentofacute
deepvenousthrombosis.Acosteffectivenessanalysis.AnnInternMed1999130:789.
57.deLissovoyG,YusenRD,SpiroTE,etal.Costforinpatientcareofvenousthrombosis:atrialofenoxaparinvsstandardheparin.ArchInternMed
2000160:3160.
58.WellsPS,ForgieMA,RodgerMA.Treatmentofvenousthromboembolism.JAMA2014311:717.
59.KearonC,AklEA.Durationofanticoagulanttherapyfordeepveinthrombosisandpulmonaryembolism.Blood2014123:1794.
60.SarwarS,NarraS,MunirA.Phlegmasiaceruleadolens.TexHeartInstJ200936:76.
61.HaimoviciH.Theischemicformsofvenousthrombosis.1.Phlegmasiaceruleadolens.2.Venousgangrene.JCardiovascSurg(Torino)1965
5:Suppl:164.
62.LangeronP,GillotC.[Phlegmasiacaeruleadolens.Acutevenousstasisandischemicphlebothrombosis].JMalVasc199217:116.
63.PerkinsJM,MageeTR,GallandRB.Phlegmasiacaeruleadolensandvenousgangrene.BrJSurg199683:19.
64.BrockmanSK,VaskoJS.Phlegmasiaceruleadolens.SurgGynecolObstet1965121:1347.
65.KearonC,KahnSR,AgnelliG,etal.Antithrombotictherapyforvenousthromboembolicdisease:AmericanCollegeofChestPhysiciansEvidence
BasedClinicalPracticeGuidelines(8thEdition).Chest2008133:454S.
66.MeissnerMH,GloviczkiP,ComerotaAJ,etal.Earlythrombusremovalstrategiesforacutedeepvenousthrombosis:clinicalpracticeguidelinesof
theSocietyforVascularSurgeryandtheAmericanVenousForum.JVascSurg201255:1449.
67.TungCS,SolimanPT,WallaceMJ,etal.Successfulcatheterdirectedvenousthrombolysisinphlegmasiaceruleadolens.GynecolOncol2007
107:140.
68.OguzkurtL,TercanF,OzkanU.Manualaspirationthrombectomywithstentplacement:rapidandeffectivetreatmentforphlegmasiaceruleadolens
withimpendingvenousgangrene.CardiovascInterventRadiol200831:205.
69.VedanthamS.Interventionalapproachestoacutevenousthromboembolism.SeminRespirCritCareMed200829:56.
70.CaseyET,MuradMH,ZumaetaGarciaM,etal.Treatmentofacuteiliofemoraldeepveinthrombosis.JVascSurg201255:1463.
71.BashirR,ZackCJ,ZhaoH,etal.Comparativeoutcomesofcatheterdirectedthrombolysisplusanticoagulationvsanticoagulationalonetotreat
lowerextremityproximaldeepveinthrombosis.JAMAInternMed2014174:1494.
72.KearonC,KahnSR,AgnelliG,etal.Antithrombotictherapyforvenousthromboembolicdisease:AmericanCollegeofChestPhysiciansEvidence
BasedClinicalPracticeGuidelines(8thEdition).Chest2008133:454S.
73.SchellongSM,SchwarzT,KroppJ,etal.Bedrestindeepveinthrombosisandtheincidenceofscintigraphicpulmonaryembolism.Thromb
Haemost199982Suppl1:127.
74.PartschH,BlttlerW.Compressionandwalkingversusbedrestinthetreatmentofproximaldeepvenousthrombosiswithlowmolecularweight
heparin.JVascSurg200032:861.
75.AschwandenM,LabsKH,EngelH,etal.Acutedeepveinthrombosis:earlymobilizationdoesnotincreasethefrequencyofpulmonaryembolism.
ThrombHaemost200185:42.
76.PartschH.Therapyofdeepveinthrombosiswithlowmolecularweightheparin,legcompressionandimmediateambulation.Vasa200130:195.
77.AldrichD,HuntDP.Whencanthepatientwithdeepvenousthrombosisbegintoambulate?PhysTher200484:268.
78.AndersonCM,OverendTJ,GodwinJ,etal.Ambulationafterdeepveinthrombosis:asystematicreview.PhysiotherCan200961:133.
79.AissaouiN,MartinsE,MoulyS,etal.Ametaanalysisofbedrestversusearlyambulationinthemanagementofpulmonaryembolism,deepvein
thrombosis,orboth.IntJCardiol2009137:37.
80.KahnSR,ShrierI,KearonC.Physicalactivityinpatientswithdeepvenousthrombosis:asystematicreview.ThrombRes2008122:763.
81.SnowV,QaseemA,BarryP,etal.Managementofvenousthromboembolism:aclinicalpracticeguidelinefromtheAmericanCollegeofPhysicians
andtheAmericanAcademyofFamilyPhysicians.AnnInternMed2007146:204.
82.PrandoniP,LensingAW,PrinsMH,etal.Belowkneeelasticcompressionstockingstopreventthepostthromboticsyndrome:arandomized,
controlledtrial.AnnInternMed2004141:249.
83.BrandjesDP,BllerHR,HeijboerH,etal.Randomisedtrialofeffectofcompressionstockingsinpatientswithsymptomaticproximalvein
thrombosis.Lancet1997349:759.
84.KahnSR,GinsbergJS.Thepostthromboticsyndrome:currentknowledge,controversies,anddirectionsforfutureresearch.BloodRev2002
16:155.
85.GinsbergJS,HirshJ,JulianJ,etal.Preventionandtreatmentofpostphlebiticsyndrome:resultsofa3partstudy.ArchInternMed2001161:2105.
86.PartschH,KaulichM,MayerW.Immediatemobilisationinacuteveinthrombosisreducespostthromboticsyndrome.IntAngiol200423:206.

87.AschwandenM,JeanneretC,KollerMT,etal.Effectofprolongedtreatmentwithcompressionstockingstopreventpostthromboticsequelae:a
randomizedcontrolledtrial.JVascSurg200847:1015.
88.KahnSR,ComerotaAJ,CushmanM,etal.Thepostthromboticsyndrome:evidencebasedprevention,diagnosis,andtreatmentstrategies:a
scientificstatementfromtheAmericanHeartAssociation.Circulation2014130:1636.
89.KahnSR,ShapiroS,WellsPS,etal.Compressionstockingstopreventpostthromboticsyndrome:arandomisedplacebocontrolledtrial.Lancet
2014383:880.
90.JainA,CifuAS.Prevention,Diagnosis,andTreatmentofPostthromboticSyndrome.JAMA2016315:1048.
91.MolGC,vandeReeMA,KlokFA,etal.Oneversustwoyearsofelasticcompressionstockingsforpreventionofpostthromboticsyndrome
(OCTAVIAstudy):randomisedcontrolledtrial.BMJ2016353:i2691.
92.MousaA,HendersonP,DayalR,etal.Endoluminalrecanalizationinapatientwithphlegmasiaceruleadolensusingamultimodalityapproach.
Vascular200513:313.
93.LinSC,MousaA,BernheimJ,etal.Endoluminalrecanalizationinapatientwithphlegmasiaceruleadolensusingamultimodalityapproachacase
report.VascEndovascularSurg200539:273.
94.WhiteRH,BrunsonA,RomanoPS,etal.OutcomesAfterVenaCavaFilterUseinNoncancerPatientsWithAcuteVenousThromboembolism:A
PopulationBasedStudy.Circulation2016133:2018.
95.StreiffMB.Venacavalfilters:acomprehensivereview.Blood200095:3669.
96.BeckerDM,PhilbrickJT,SelbyJB.Inferiorvenacavafilters.Indications,safety,effectiveness.ArchInternMed1992152:1985.
97.GirardP,SternJB,ParentF.Medicalliteratureandvenacavafilters:sofarsoweak.Chest2002122:963.
98.MurielA,JimnezD,AujeskyD,etal.Survivaleffectsofinferiorvenacavafilterinpatientswithacutesymptomaticvenousthromboembolismanda
significantbleedingrisk.JAmCollCardiol201463:1675.
99.SteinPD,MattaF.Venacavafiltersinunstableelderlypatientswithacutepulmonaryembolism.AmJMed2014127:222.
100.DecoususH,LeizoroviczA,ParentF,etal.Aclinicaltrialofvenacavalfiltersinthepreventionofpulmonaryembolisminpatientswithproximal
deepveinthrombosis.PrventionduRisqued'EmboliePulmonaireparInterruptionCaveStudyGroup.NEnglJMed1998338:409.
101.PREPICStudyGroup.Eightyearfollowupofpatientswithpermanentvenacavafiltersinthepreventionofpulmonaryembolism:thePREPIC
(PreventionduRisqued'EmboliePulmonaireparInterruptionCave)randomizedstudy.Circulation2005112:416.
102.MismettiP,LaporteS,PellerinO,etal.Effectofaretrievableinferiorvenacavafilterplusanticoagulationvsanticoagulationaloneonriskof
recurrentpulmonaryembolism:arandomizedclinicaltrial.JAMA2015313:1627.
103.SteinPD,MattaF,KeyesDC,WillyerdGL.Impactofvenacavafiltersoninhospitalcasefatalityratefrompulmonaryembolism.AmJMed2012
125:478.
104.IsogaiT,YasunagaH,MatsuiH,etal.Effectivenessofinferiorvenacavafiltersonmortalityasanadjuvanttoantithrombotictherapy.AmJMed
2015128:312.e23.
105.HajdukB,TomkowskiWZ,MalekG,DavidsonBL.Venacavafilterocclusionandvenousthromboembolismriskinpersistentlyanticoagulated
patients:aprospective,observationalcohortstudy.Chest2010137:877.
106.FoxMA,KahnSR.Postthromboticsyndromeinrelationtovenacavafilterplacement:asystematicreview.JVascIntervRadiol200819:981.
107.HemmilaMR,OsborneNH,HenkePK,etal.ProphylacticInferiorVenaCavaFilterPlacementDoesNotResultinaSurvivalBenefitforTrauma
Patients.AnnSurg2015262:577.
108.JaffMR,McMurtryMS,ArcherSL,etal.Managementofmassiveandsubmassivepulmonaryembolism,iliofemoraldeepveinthrombosis,and
chronicthromboembolicpulmonaryhypertension:ascientificstatementfromtheAmericanHeartAssociation.Circulation2011123:1788.
109.MismettiP,RivronGuillotK,QuenetS,etal.Aprospectivelongtermstudyof220patientswitharetrievablevenacavafilterforsecondary
preventionofvenousthromboembolism.Chest2007131:223.
110.NicholsonW,NicholsonWJ,TolericoP,etal.PrevalenceoffractureandfragmentembolizationofBardretrievablevenacavafiltersandclinical
implicationsincludingcardiacperforationandtamponade.ArchInternMed2010170:1827.
111.DabbaghO,NagamN,ChitimaMatsigaR,etal.Retrievableinferiorvenacavafiltersarenotgettingretrieved:whereisthegap?ThrombRes2010
126:493.
Topic1362Version90.0

GRAPHICS
Lowerextremity(CEAP)veinlist
Superficialveins

Deepveins

Perforatorveins

Telangiectasiasorreticularveins

Inferiorvenacava

Thigh

Greatsaphenousveinabovetheknee

Commoniliacvein

Calf

Greatsaphenousveinbelowtheknee

Internaliliacvein

Smallsaphenousvein

Externaliliacvein

Nonsaphenousveins

Pelvic:gonadal,broadligamentveins,other
Commonfemoralvein
Deepfemoralvein
Femoralvein*
Poplitealvein
Crural:anteriortibial,posteriortibial,peronealveins(allpaired)
Muscular:gastrocnemial,solealveins,other

CEAP:ClinicalEtiologyAnatomyPathophysiologyclassificationoflowerextremitychronicvenousdisorders.
*Formerlyreferredtoasthesuperficialfemoralvein,amisnomersinceitisadeepvein.
Graphic77469Version4.0

Algorithmforthetreatmentoflowerextremitydeepvenousthrombosis(DVT)

ThisalgorithmonlyappliestopatientswithafirstepisodeofDVT.
*PleaserefertotheUpToDatetopicondeepvenousthrombosis:longtermanticoagulation(threetosixmonths).
PatientswithanunprovokeddistalDVTshouldreceiveatleastthreemonthsofanticoagulation.Asmallproportionmaybenefitfromindefiniteanticoagulation.Pleasereferto
theUpToDatetopiconrationaleandindicationsforindefiniteanticoagulationinpatientswithvenousthromboembolism.
PleaserefertotheUpToDatetopiconrationaleandindicationsforindefiniteanticoagulationinpatientswithvenousthromboembolism.
Graphic97117Version2.0

Riskfactorsforbleedingwithanticoagulanttherapyandestimatedriskofmajorbleedinginlow,moderate,and
highriskcategories
Riskfactors*
Age>65years
Age>75years
Previousbleeding
Cancer
Metastaticcancer
Renalfailure
Liverfailure
Thrombocytopenia
Previousstroke
Diabetes
Anemia
Antiplatelettherapy
Pooranticoagulantcontrol
Comorbidityandreducedfunctionalcapacity
Recentsurgery
Frequentfalls
Alcoholabuse

Estimatedabsoluteriskofmajorbleeding(%)
Categorizationofriskofbleeding

Lowrisk (0riskfactors)

Moderaterisk (1riskfactor)

Highrisk (2riskfactors)

Baselinerisk(%)

0.6

1.2

4.8

Increasedrisk(%)

Totalrisk(%)

1.6

3.2

12.8

Baselinerisk(%/years)

0.3

0.6

2.5

Increasedrisk(%/years)

0.5

Totalrisk(%/years)

0.8**

1.6**

6.5

Anticoagulation0to3months

Anticoagulationafterfirst3months

*Theincreaseinbleedingassociatedwithariskfactorwillvarywith(1)severityoftheriskfactor(eg,locationandextentofmetastaticdisease,plateletcount),(2)
temporalrelationships(eg,intervalfromsurgeryorapreviousbleedingepisode),and(3)howeffectivelyapreviouscauseofbleedingwascorrected(eg,upperGI
bleeding).
Importantforparenteralanticoagulation(eg,first10days),butlessimportantforlongtermorextendedanticoagulation.
Althoughthereisevidencethatriskofbleedingincreaseswiththeprevalenceofriskfactors,thiscategorizationschemehasnotbeenvalidated.Furthermore,asingle
riskfactor,whensevere,willresultinahighriskofbleeding(eg,majorsurgerywithinthepasttwodays,severethrombocytopenia).
Comparedwithlowriskpatients,moderateriskpatientsareassumedtohaveatwofoldriskandhighriskpatientsaneightfoldriskofmajorbleeding.

The1.6%correspondstotheaverageofmajorbleedingwithinitialUFHorLMWHtherapyfollowedbyVKAtherapy.Weestimatedbaselineriskbyassuminga2.6
relativeriskofmajorbleedingwithanticoagulation(refertofootnote).
ConsistentwithfrequencyofmajorbleedingobservedbyHulletalinhighriskpatients [1].
Weestimatethatanticoagulationisassociatedwitha2.6foldincreaseinmajorbleedingbasedoncomparisonofextendedanticoagulationwithnoextended
anticoagulation.TherelativeriskofmajorbleedingduringthefirstthreemonthsoftherapymaybegreaterthanduringextendedVKAtherapybecause(1)theintensityof
anticoagulationwithinitialparenteraltherapymaybegreaterthanwithVKAtherapy(2)anticoagulantcontrolwillbelessstableduringthefirstthreemonthsand(3)
predispositionstoanticoagulantinducedbleedingmaybeuncoveredduringthefirstthreemonthsoftherapy.However,studiesofpatientswithacutecoronary
syndromesdonotsuggesta2.6relativeriskofmajorbleedingwithparenteralanticoagulation(eg,UFHorLMWH)comparedwithcontrol.
Ourestimatedbaselineriskofmajorbleedingforlowriskpatients(andadjustedupformoderateandhighriskgroupsasperfootnote).
**ConsistentwithfrequencyofmajorbleedingduringprospectivestudiesofextendedanticoagulationforVTE.
Reference:
1.HullRD,RaskobGE,RosenbloomD,etal.Heparinfor5daysascomparedwith10daysintheinitialtreatmentofproximalvenousthrombosis.NEnglJMed
1990322:1260.
Reproducedfrom:KearonC,AklEA,ComerotaAJ,etal.AntithrombotictherapyforVTEdisease:AntithromboticTherapyandPreventionofThrombosis,9thed:
AmericanCollegeofChestPhysiciansEvidenceBasedClinicalPracticeGuidelines.Chest2012141:e419S.TableusedwiththepermissionofElsevierInc.Allrights
reserved.
Graphic97160Version3.0

Rateofbleedingstratifiedbyriskinpatientswithvenousthromboembolism(VTE)onanticoagulation
Bleedingrisk

First3months

Annualrateafterfirst3months

Lowrisk(noriskfactorspresent)

1.6percent

0.8percent

Intermediaterisk(oneriskfactorpresent)

3.2percent

1.3percent

Highrisk(twoormoreriskfactorspresent)

12.8percent

6.5percent

Datafrom:KearonC,AklEA,ComerotaAJ,etal.AntithrombotictherapyforVTEdisease:AntithromboticTherapyandPreventionofThrombosis,9thed:American
CollegeofChestPhysiciansEvidenceBasedClinicalPracticeGuidelines.Chest2012141:e419S.
Graphic107543Version1.0

Factorsthatinfluenceagentselectionforanticoagulationinpatientswithacutevenousthromboembolism
Preferred
anticoagulant

Factor

Qualifyingremarks

Cancer

LMWH

Moresoif:Justdiagnosed,extensiveVTE,metastaticcancer,verysymptomaticvomitingon
cancerchemotherapy.

Parenteraltherapytobe
avoided

Rivaroxabanapixaban

VKA,dabigatran,andedoxabanrequireinitialparenteraltherapy.

Oncedailyoraltherapy
preferred

RivaroxabanedoxabanVKA

Liverdiseaseandcoagulopathy

LMWH

DOAscontraindicatedifINRraisedbecauseofliverdiseaseVKAdifficulttocontrolandINRmay
notreflectantithromboticeffect.

Renaldiseaseandcreatinine
clearance<30mL/min

VKA

DOAsandLMWHcontraindicatedwithsevererenalimpairment.DosingofDOAswithlevelsof
renalimpairmentdifferwiththeDOAandamongjurisdictions.

Coronaryarterydisease

VKA,rivaroxaban,apixaban,
edoxaban

CoronaryarteryeventsappeartooccurmoreoftenwithdabigatranthanwithVKA.Thishasnot
beenseenwiththeotherDOAs,andtheyhavedemonstratedefficacyforcoronaryarterydisease.
Antiplatelettherapyshouldbeavoidedifpossibleinpatientsonanticoagulantsbecauseof
increasedbleeding.

DyspepsiaorhistoryofGI
bleeding

VKA,apixaban

Dabigatranincreaseddyspepsia.Dabigatran,rivaroxaban,andedoxabanmaybeassociatedwith
moreGIbleedingthanVKA.

Poorcompliance

VKA

INRmonitoringcanhelptodetectproblems.However,somepatientsmaybemorecompliantwith
aDOAbecauseitislesscomplex.

Thrombolytictherapyuse

UFHinfusion

Greaterexperiencewithitsuseinpatientstreatedwiththrombolytictherapy.

Reversalagentneeded

VKA,UFH

Pregnancyorpregnancyrisk

LMWH

Potentialforotheragentstocrosstheplacenta.

Cost,coverage,licensing

Variesamongregionsandwith
individualcircumstances

LMWH:lowmolecularweightheparinVTE:venousthromboembolismVKA:vitaminKdependentantagonistDOAs:directoralanticoagulantsINR:international
normalizedratioGI:gastrointestinalUFH:unfractionatedheparin.
Reproducedfrom:KearonC,AklEA,OrnelasJ,etal.AntithromboticTherapyforVTEDisease:CHESTGuidelineandExpertPanelReport.Chest2016149:315.Table
usedwiththepermissionofElsevierInc.Allrightsreserved.
Graphic107541Version1.0

Minimalrequirementsforearlyhospitaldischargeoroutpatienttherapyofvenousthromboembolicdisease
Theresponsiblephysicianmustensurethatallofthefollowingconditionsapply:
Thepatientisambulatoryandinstablecondition,withnormalvitalsigns
Thereisalowaprioririskofbleedinginthepatient
Severerenalinsufficiencyisnotpresent
Thereisapracticalsysteminplaceforthefollowing:
AdministrationofLMWheparinand/orwarfarinwithappropriatemonitoring,and
SurveillanceandtreatmentofrecurrentVTEandbleedingcomplications

VTE:venousthromboembolismLMWheparin:lowmolecularweightheparin.

AdaptedfromHyers,TM,Agnelli,G,Hull,RD,etal.Antithrombotictherapyforvenousthromboembolicdisease.Chest2001119:176S.(SixthACCPConsensus
ConferenceonAntithromboticTherapy).
Graphic70140Version2.0

Typesofinferiorvenacavafilters

MaximumIVCdiameter
(mm)

Manufacturer

Requiredsheathsize
(O.D.)*

Insertionsites

Material

Permanent(nonretrievable)
TitaniumGreenfield

28

BostonScientific

12Fr

Jugular,femoral

Titanium

OvertheWire
Greenfield

28

BostonScientific

12Fr

Jugular,femoral

316stainless
steel

VenaTechLP

28

B.BraunMedical

9Fr

Jugular,femoral

Phynox

VenaTechLGM

28

B.BraunMedical

12Fr

Jugular/femoralsinglesystem

Phynox

SimonNitinolFilter
(SNF)

28

Bard

9Fr

Jugular,femoral,subclavian,
antecubital

Nitinol(NiTi)

TrapEase

30

Cordis(J&J)

6Fr

Jugular,femoral,antecubital

Elgiloy

GianturcoRoehm
Bird'snest

40

Cook

12Fr

Jugular,femoral

304stainless
steel

Optional(permanentorretrievable)
OptEase

30

Cordis(J&J)

6Fr

Jugular,femoral,antecubital

Elgiloy

Gunthertulip

30

Cook

8.5Fr

Jugular,femoral

Conichrome

CookCelect

30

Cook

7Fr(IJ),8.5Fr(F)

Jugular,femoral,UniSet

Conichrome*

Option

30

ArgonMedical

6.5Fr

Jugular,femoral

Nitinol(NiTi)

ALNfilter

32

ALNInternational

7Fr

Jugular,femoral,basilic

316stainless
steel

Cruxfilter

28

Volcano

9Fr

Jugular,femoral

Nitinol(NiTi)

Denali

28

Bard

8.4Fr

Jugular,femoral

Nitinol(NiTi)

EachofthefiltersdepictedareapprovedforuseintheUnitedStatesaspermanentfilters,butsomeareapprovedasoptional(ie,permanentorretrievable).
IVC:inferiorvenacavaFr:FrenchIJ:internaljugularF:femoral.
*Outerdiameter(O.D.)specifiedwheretheinformationisavailable.
TrademarknamesforthecobaltchromiumnickelmolybdenumironalloyspecifiedbyASTMF1058andISO58327.
Innerdiameter.
Datafrom:
1.http://www.astm.org.
2.http://www.iso.org.
Graphic51423Version6.0

ContributorDisclosures
GregoryYHLip,MD,FRCPE,FESC,FACC Speaker'sBureau:Bayer[Atrialfibrillationandthrombosis(rivaroxaban)]BMS/Pfizer[Atrialfibrillation
andthrombosis(apixaban)]BoehringerIngelheim[Atrialfibrillationandthrombosis(dabigatran)]DaiichiSankyo[Atrialfibrillationandthrombosis
(edoxaban)]Medtronic[Atrialfibrillationandthrombosis]SanofiAventis[Atrialfibrillationandthrombosis].Consultant/AdvisoryBoards:Bayer/Janssen
[Atrialfibrillationandthrombosis(rivaroxaban)]BMS/Pfizer[Atrialfibrillationandthrombosis(apixaban)]BoehringerIngelheim[Atrialfibrillationand
thrombosis(dabigatran)]DaiichiSankyo[Atrialfibrillationandthrombosis(edoxaban)]Merck[Atrialfibrillationandthrombosis]Sanofi[Atrialfibrillation
andthrombosis]Biotronik[Atrialfibrillationandthrombosis]Medtronic[Atrialfibrillationandthrombosis]Portola[Atrialfibrillationand
thrombosis]. RussellDHull,MBBS,MSc Grant/Research/ClinicalTrialSupport:LEOPharma[VTE(Tinzaparin)]Sanofi[VTE(Enoxaparin)]Portola
[VTE(Betrixaban)]Bayer[VTE(Rivaroxaban)]. LawrenceLKLeung,MD Nothingtodisclose JessMandel,MD Nothingtodisclose GeraldineFinlay,
MD Nothingtodisclose
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthroughamultilevel
reviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofall
authorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy