An Algorithmic Approach to Management of Venous Thromboembolism

Abstract

Venous thromboembolism (VTE) is associated with significant morbidity and mortality. Factors such as the presence of transient risk factors for VTE, risk of bleeding, and location of deep vein thrombosis (DVT) determine the duration of anticoagulation. Extended anticoagulation is offered to patients with unprovoked pulmonary embolism (PE) or proximal DVT and a low risk of bleeding. Anticoagulation for 3 months is advised in patients with provoked DVT or PE, high risk of bleeding, and isolated distal or upper extremity DVT. In patients with unprovoked PE or proximal DVT and a low risk of bleeding, who want to stop anticoagulation after 3 months, further risk stratification is necessary. Clinical scoring system, and thrombophilia testing otherwise not routinely performed, may be considered to measure risk of annual recurrence in such cases. Short-term anticoagulation may be considered in subsegmental PE and superficial vein thrombosis, particularly if patients are at low risk of bleeding and have persistent risk factors for recurrent VTE. In cases of catheter-associated thrombosis, the catheter need not be removed routinely, and the patient may be anticoagulated for 3 months or longer if the catheter is maintained in patients with cancer. Extensive screening for occult cancer in cases of unprovoked VTE is not beneficial. New oral anticoagulants such as apixaban, rivaroxaban, or dabigatran may be preferred to vitamin K antagonists in patients without cancer or renal failure, more so after the development of reversal agents such as idarucizumab and andexanet alfa.

Cancer Screening in Patients with Unprovoked Thromboembolism: How to do it and Who Benefits?

“…The ideal follow-up time after an episode of uVTE is not yet fully established. The risk of diagnosing cancer is highest in the first six months and remains high for at least twelve months, but some studies show that it remains higher than in the general population up to six years after uVTE [3][4][5][6]. For this reason, in our study, cancer diagnosis data were collected up to one year and up to the third year after the uVTE episode.…”

“…Cancer is a well-established independent risk factor for venous thromboembolism (VTE), and an episode of unprovoked VTE (uVTE) may be the first manifestation of a hidden neoplasm [1][2][3]. The incidence of cancer associated with uVTE is about 4.5%-5%, with the risk being particularly high in the first six months after the episode and higher in colorectal, pancreatic, brain and lung tumours [3][4][5][6]. Most studies show a risk reduction after the first 12 months, equalling the general population, but others show increased rates up to six years [4,5,7].…”

“…The incidence of cancer associated with uVTE is about 4.5%-5%, with the risk being particularly high in the first six months after the episode and higher in colorectal, pancreatic, brain and lung tumours [3][4][5][6]. Most studies show a risk reduction after the first 12 months, equalling the general population, but others show increased rates up to six years [4,5,7]. 1 1 2 1 1 Cancer screening after an episode of uVTE may allow an early diagnosis of occult cancer.…”