Diagnosis and Management of DVT – Spoon-Feed Version

December 2, 2020

Written by Kevin Stoffer

Spoon Feed
This article reviews recent literature investigating the diagnosis and management of lower extremity DVT.

Why does this matter?
We see patients with LE DVT frequently, and the management of this disease continues to evolve. Here is a summary of the latest information you need to know.

Did I develop a DVT from too much turkey?
In this systematic review, authors siphoned through 2,100 articles produced over the last five years, developing a practice-changing brief of RCTs, meta-analyses, observational studies, and guidelines.

Epidemiology

• An isolated distal (i.e. calf vein) DVT carries an all-cause mortality rate of 4.6 per 100 person years.

• Risk factors for DVT include obesity, pregnancy, malignancy, major surgery or immobilization, CKD, atherosclerosis, diabetes, infection, inflammatory disease, chronic lung disease, heart failure and inherited disorders.

Diagnosis

• Pretest probability or D-dimer do not rule out DVT by themselves; they should be used together.

• Use a Wells score to categorize your patient as high or low risk. The Wells score does not perform well for inpatients.

• If low or moderate risk (i.e. Wells <3), use age adjusted D-dimer to stratify further. Wells <3, high-sensitivity D-dimer negative, rules our DVT. Any positive D-dimer warrants ultrasound.

• If high risk (i.e. Wells ≥3) or in cancer patients, skip the D-dimer and go straight to ultrasound.

• Negative two-point compression ultrasounds need a repeat scan in 5-7 days. Whole-leg US is usually preferred.

• Be aware of other diagnoses such as May-Thurner Syndrome, superficial thrombophlebitis, and post-thrombotic syndrome.

Treatment

• DOACs are non-inferior to warfarin and cause less bleeding.

• The largest barrier to DOACs is cost.

• Use LMWH with pregnancy and malignancy; however, DOACs may be used in non-gastrointestinal malignancy.

• Most patients with good follow-up can be managed as an outpatient.

• Aspirin for secondary prevention has higher rates of recurrence than DOACs.

• Treat isolated calf vein DVT if, “severe symptoms or risk factors for pulmonary embolism or extension to proximal veins (such as hospitalization, history of VTE, and cancer.”

• Catheter-directed thrombolysis does not reduce recurrence of DVT, post-thrombotic syndrome, and may increase bleeding.

Next is a handy table to decide on the right treatment modality, and an algorithm proposed by the authors to put this all together.

Source
Diagnosis and Treatment of Lower Extremity Venous Thromboembolism: A Review. JAMA. 2020 Nov 3;324(17):1765-1776. doi: 10.1001/jama.2020.17272.

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