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Warfarin (Coumadin) is a teratogen; treat with full-dose heparin initially, followed by SC heparin starting at 15,000 U q12h.
Warfarin is safe with breastfeeding.
LMWH, dalteparin, fondaparinux, apixaban are pregnancy Category B.
Dabigatran, Edoxaban are pregnancy Category C.
ADDITIONAL THERAPIES
Edoxaban (recently FDA aprooved) after initial treatment with heparin is as effective as warfarin in preventing recurrences in patients with acute VTE, and has less bleeding complications (6)[B].
SURGERY/OTHER PROCEDURES
- In selected patients with proximal DVT (iliofemoral DVT, <2 weeks of symptoms, good functional status, >1 year of life expectancy), consider catheter-directed thrombolysis/open thrombectomy.
- When anticoagulants have failed or are contraindicated, filtering devices are recommended in the acute setting.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Admission for respiratory distress, proximal VTE, candidate for thrombolysis, active bleeding, renal failure, phlegmasia cerulea dolens, history of HIT
Nursing
Limb elevation and multilayered compression.
Discharge Criteria
Medically stable and properly anticoagulated; overlap of anticoagulation and warfarin monitoring may be done as an outpatient.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Gradual resumption of normal activity, with avoidance of prolonged immobility
- Duration of warfarin treatment after DVT
- 3 months for treatment of a DVT secondary to a reversible risk factor
- Patients with unprovoked DVT can be considered for prolonged secondary prophylaxis
- In patients who have completed 3 months of anticoagulation after an unprovoked VTE, a positive D-dimer 1 month after discontinuation of therapy correlates with the risk of VTE recurrence (7)[A].
Patient Monitoring
- Monitor platelet count while on heparin, LMWH, fondaparinux.
- An anti-Xa activity level may help guide LMWH titration of therapy, but it is not usually needed.
- Investigate significant bleeding (e.g., hematuria or GI hemorrhage) because anticoagulant therapy may unmask a preexisting lesion (e.g., cancer, peptic ulcer disease, or arteriovenous malformation).
PATIENT EDUCATION
- Patients should wear compression stockings post-DVT.
- Dietary habits should be discussed when warfarin is initiated to ensure that intake of vitamin K-rich foods is monitored.
PROGNOSIS
- 20% of untreated proximal (e.g., above the calf) DVTs progress to pulmonary emboli, and 10-20% of those are fatal; with anticoagulant therapy, mortality is decreased 5- to 10-fold.
- DVT confined to the infrapopliteal veins has a small risk of embolization but can propagate into the proximal system.
COMPLICATIONS
PE (fatal in 10-20%), arterial embolism (paradoxical embolization) with arteriovenous (AV) shunting, chronic venous insufficiency, postphlebitic syndrome (pain and swelling in affected limb without new clot formation), treatment-induced hemorrhage, soft tissue ischemia associated with massive clot and high venous pressures; phlegmasia cerulea dolens (rare but a surgical emergency)
REFERENCES
11 Decousus H, Qu ©r © I, Presles E, et al. Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study. Ann Intern Med. 2010;152(4):218-224.22 Kahn S, Shapiro S, Wells P, et al. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet. 2014;383(9920):880-888.33 Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e152S-e184S.44 Geersing GJ, Zuithoff NP, Kearon C, et al. Exclusion of deep vein thrombosis using the Wells rule in clinically important subgroups: individual patient data meta-analysis. BMJ. 2014;348:g1340.55 Tafur AJ, Kalsi H, Wysokinski WE, et al. The association of active cancer with venous thromboembolism location: a population-based study. Mayo Clin Proc. 2011;86(1):25-30.66 B ¼ller HR, D ©cousus H, Grosso MA, et al. Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med. 2013:369(15):1406-1415.77 Palareti G, Cosmi B, Legnani C, et al. D-dimer testing to determine the duration of anticoagulation therapy. N Engl J Med. 2006;355(17):1780-1789.
ADDITIONAL READING
- Agnelli G, B ¼ller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism. N Eng J Med. 2013;369(9):799-808.
- Bauersachs R, Berkowitz SD, Brenner B, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Eng J Med. 2010;363(26):2499-2510.
- Kyrle PA, Rosendaal FR, Eichinger S. Risk assessment for recurrent venous thrombosis. Lancet. 2010;376(9757):2032-2039.
- Lyman GH, Khorana A, Kuderer N, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;31(17):2189-2204.
- Prins MH, Lensing AW, Bauersachs R, et al. Oral rivaroxaban versus standard therapy for the treatment of symptomatic venous thromboembolism: a pooled analysis of the EINSTEIN-DVT and PE randomized studies. Thromb J. 2013;11(1):21.
- Schulman S, Kearon C, Kakkar AK, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med. 2009;361(24):2342-2352.
SEE ALSO
Antithrombin Deficiency; Factor V Leiden; Protein C Deficiency; Protein S Deficiency; Prothrombin 20210 (Mutation); Pulmonary Embolism
CODES
ICD10
- I80.209 Phlbts and thombophlb of unsp deep vessels of unsp low extrm
- I80.299 Phlebitis and thombophlb of deep vessels of unsp low extrm
- I80.10 Phlebitis and thrombophlebitis of unspecified femoral vein
- I80.229 Phlebitis and thrombophlebitis of unspecified popliteal vein
- I80.221 Phlebitis and thrombophlebitis of right popliteal vein
- I80.223 Phlebitis and thrombophlebitis of popliteal vein, bilateral
- I80.222 Phlebitis and thrombophlebitis of left popliteal vein
- I80.201 Phlbts and thombophlb of unsp deep vessels of r low extrem
- I80.202 Phlbts and thombophlb of unsp deep vessels of l low extrem
- I80.291 Phlebitis and thombophlb of deep vessels of r low extrem
- I80.292 Phlebitis and thombophlb of deep vessels of l low extrem
- I80.11 Phlebitis and thrombophlebitis of right femoral vein
- I80.13 Phlebitis and thrombophlebitis of femoral vein, bilateral
- I80.293 Phlebitis and thombophlb of deep vessels of low extrm, bi
- I80.12 Phlebitis and thrombophlebitis of left femoral vein
- I80.203 Phlbts and thombophlb of unsp deep vessels of low extrm, bi
ICD9
- 451.19 Phlebitis and thrombophlebitis of deep veins of lower extremities, other
- 451.11 Phlebitis and thrombophlebitis of femoral vein (deep) (superficial)
SNOMED
- 46253008 Thrombophlebitis of lower extremities (disorder)
- 40198004 thrombophlebitis of deep veins of lower extremity (disorder)
- 1748006 Thrombophlebitis of deep femoral vein (disorder)
- 195411001 Thrombophlebitis of the popliteal vein (disorder)
- 52496006 Thrombophlebitis of femoropopliteal vein (disorder)
CLINICAL PEARLS
- Many cases are asymptomatic and are diagnosed after embolization.
- Of the patients with superficial thrombophlebitis, 25% will have DVT at presentation.
- Heparin and warfarin should overlap for a minimum of 5 days to achieve target INR.
- The current American Society of Clinical Oncology guidelines acknowledge the value of primary prophylaxis in selected patients with active cancer receiving outpatient chemotherapy.