Clinical Presentation and Short- and Long-term Outcomes in Patients With Isolated Distal Deep Vein Thrombosis vs Proximal Deep Vein Thrombosis in the RIETE Registry

Abstract

IMPORTANCEInsufficient data exist about the clinical presentation, short-term, and long-term outcomes of patients with isolated distal deep vein thrombosis (IDDVT), that is, thrombosis in infrapopliteal veins without proximal extension or pulmonary embolism (PE).OBJECTIVE To determine the clinical characteristics, short-term, and 1-year outcomes in patients with IDDVT and to compare the outcomes in unadjusted and multivariable adjusted analyses with patients who had proximal DVT. DESIGN, SETTING, AND PARTICIPANTS This was a multicenter, international cohort study in participating sites of the Registro Informatizado Enfermedad Tromboembólica (RIETE) registry conducted from March 1, 2001, through February 28, 2021. Patients included in this study had IDDVT. Patients with proximal DVT were identified for comparison. Patients were excluded if they had a history of asymptomatic DVT, upper-extremity DVT, coexisting PE, or COVID-19 infection. MAIN OUTCOMES AND MEASURES Primary outcomes were 90-day and 1-year mortality, 1-year major bleeding, and 1-year venous thromboembolism (VTE) deterioration, which was defined as subsequent development of proximal DVT or PE. RESULTS A total of 33 897 patients were identified with isolated DVT (without concomitant PE); 5938 (17.5%) had IDDVT (mean [SD] age, 61 [17] years; 2975 male patients [50.1%]), and 27 959 (82.5%) had proximal DVT (mean [SD] age, 65 [18] years; 14 315 male patients [51.2%]). Compared with individuals with proximal DVT, those with IDDVT had a lower comorbidity burden but were more likely to have had recent surgery or to have received hormonal therapy. Patients with IDDVT had lower risk of 90-day mortality compared with those with proximal DVT (odds ratio [OR], 0.47; 95% CI, 0.40-0.55). Findings were similar in 1-year unadjusted analyses (hazard ratio [HR], 0.52; 95% CI, 0.46-0.59) and adjusted analyses (HR, 0.72; 95% CI, 0.64-0.82). Patients with IDDVT had a lower 1-year hazard of VTE deterioration (HR, 0.83; 95% CI, 0.69-0.99). In 1-year adjusted analyses of patients without an adverse event within the first 3 months, IDDVT was associated with lower risk of VTE deterioration (adjusted HR, 0.48; 95% CI, 0.24-0.97). By 1-year follow-up, symptoms or signs of postthrombotic syndrome were less common in patients with IDDVT (47.6% vs 60.5%). CONCLUSIONS AND RELEVANCEResults of this cohort study suggest that patients with IDDVT had a less ominous prognosis compared with patients with proximal DVT. Such differences were likely multifactorial, including the differences in demographics, risk factors, comorbidities, particularly for all-cause mortality, and a potential association of thrombus location with VTE deterioration and postthrombotic syndrome. Randomized clinical trials are needed to assess the optimal long-term management of IDDVT.

Anatomic distribution of lower extremity deep venous thrombosis is associated with an increased risk of pulmonary embolism: A 10-year retrospective analysis

“…Commonly, patients with proximal LEDVT had a higher likelihood for development of PE than those with distal LEDVT ( 18 , 23 ). For this, the CHEST guideline emphasizes the importance of thrombus location in treatment choices between serial imaging and anticoagulation therapy ( 37 ).…”

“…As recommended by the 2019 European Society of Cardiology (ESC) guideline, thrombus location can also be used to confirm PE ( 38 ). Except for the different anatomic location, proximal and distal LEDVT differ substantially in many aspects, including age, sex, comorbidity burden and VTE risk factors (e.g., recent surgery) ( 18 , 19 , 33 ). After adjusting for confounding factors, we also found that proximal LEDVT was risk factor for developing PE in multivariate analysis and sensitivity analysis (Model 1).…”

“…Recently, the occurrence of PE seems to be closely related to the anatomic distribution of lower extremity DVT (LEDVT) ( 16 , 17 ). In general, isolated distal LEDVT is presumed to be more benign than proximal LEDVT, presenting a lower risk of PE, VTE recurrence, post-thrombotic syndrome and mortality ( 18 – 20 ). On the other hand, thrombus sidedness, especially bilateral LEDVT, was found to be associated with an increased risk of PE ( 12 , 17 ).…”

Derivation and External Validation of a Risk Prediction Model for Pulmonary Embolism in Patients With Lung Cancer: A Large Retrospective Cohort Study

“… 1 Pulmonary embolism (PE) is a serious disease of the pulmonary circulation caused by the obstruction of the pulmonary arteries or their branches, which was caused by the dislodgement of emboli mostly from the deep veins of the lower extremities. 2 The incidence of PE in patients with LC is reported to be 6 times higher than that in the population without malignancy. Furthermore, patients with LC are more likely to develop PE than patients with other types of solid tumors, and PE has a mortality risk second only to cancer.…”

Anticoagulation in Patients with Isolated Distal Deep Vein Thrombosis: Bringing the Puzzle Together

“…1 Similar to proximal DVT, recurrence risk tends to be higher in patients with cancer-associated or unprovoked IDDVT than in those with transient risk factors. [2][3][4] In high-risk subgroups, long-term recurrence rates may reach those observed in patients with proximal DVT. [2][3][4] Despite this, the management of IDDVT remains uncertain and widely heterogenous across centers worldwide.…”