Management of Deep Venous Thrombosis
Since deep vein thrombosis (DVT) and its subsequent pulmonary emboli have such a high morbidity and mortality rate, management is aggressive. Treatment includes anticoagulation (first and foremost) and when indicated, invasive intervention. The risk of recurrent thrombosis and pulmonary emboli are greatest immediately after diagnosis of DVT, so treatment should be immediate.
Whether the risk of thrombosis is congenital or acquired, anticoagulation is indicated for the presence of any deep vein thrombi that are identified. This involves the use of systemic anticoagulation for up to 10 days, which is accomplished via
- Subcutaneous low molecular weight heparin or fondaparinux (once-daily Arixtra)
- Direct oral anticoagulants: rivaroxaban (Xarelto) or apixaban (Eliquis). These are direct clotting cascade factor Xa and thrombin inhibitors. They have similar efficacy to injected heparin and have the convenience of avoiding injections, but they are more expensive and should there be a delay in acquiring them, anticoagulation can begin immediately with subcutaneous heparin until they are available.
After the initial treatment, anticoagulation should be continued long-term. If the agent used for long-term maintenance is different than that used for the immediate initial therapy, a transition is required that assures continued effective anticoagulation. First choice long-term anticoagulants are the factor Xa and thrombin inhibitors unless there is pregnancy, renal insufficiency, or cancer. These fixed-dose agents do not require routine laboratory monitoring for dose changes like warfarin does. Management of DVT also requires close surveillance using duplex ultrasound imaging, as the presence of a DVT is a risk in itself for recurrent DVT and pulmonary emboli. If there is frequent showering of the lung vasculature with emboli from DVT, a filter can be placed in the vena cava to act as a filter.