Phlegmasia cerulea dolens. From PMID: 17229945

Thanks to Dr. van den Burg and Julien Nguyen, PGY2 for a comprehensive introduction to lower extremity DVT management!

Learning points from today:

• When to treat?
  • Assess for contraindications.
  • No bleeding risk score developed specifically for anticoagulation in VTE, but for HASBLED score is being used for anticoagulation in atrial fibrillation. (PMID: 20299623)
  • All proximal DVT should be treated (popliteal, femoral, iliac vein)
  • Symptomatic distal DVT generally treated.
  • Asymptomatic distal DVT may undergo serial U/S surveillance.
• For how long do we treat?
  • 3 months for active episode of VTE.
  • Treating beyond 3 months (i.e., indefinitely) is for “secondary prevention,” typically done if active cancer or 2+ unprovoked VTE.
  • See this great Blood article for a great review of the literature regarding treatment duration. (PMID: 24497538)
• Treatment options
  • Factor Xa inhibitors:
    • Parenteral: Some LMWH (enoxaparin, dalteparin, tinzaparin, nadroparin)
    • Oral: rivaroxaban, apixaban, edoxaban.
  • Direct thrombin inhibitors (No “x” in generic name):
    • Parenteral: bivalirudin, argatroban, desirudin.
    • Oral: dabigatran.
  • Coumadin
• Idarucizumab as a reversal agent for dabigatran is undergoing expedited FDA approval.  (PMID:  26095746, 26095632)
• Consider IR and/or vascular surgery consult for catheter-directed thrombolysis or thrombectomy if evidence of ischemia due to decreased venous outflow (e.g., phlegmasia cerulea dolens, phlegmasia alba dolens).