How I treat isolated distal deep vein thrombosis (IDDVT)

Abstract

Thromboses limited to infrapopliteal leg deep veins (isolated distal deep vein thrombosis [IDDVT]) are frequently diagnosed in subjects with suspected pulmonary embolism or DVT and account for one-fourth to one-half of all diagnosed leg DVTs. Despite their frequency, the natural history of IDDVTs and their real risk of thromboembolic complications are still uncertain because of the scarcity of prospective, blind, nonintervention studies. Therefore it is still debated whether they warrant diagnosis and treatment. Diagnosis is based on ultrasonographic examination, which is more operator dependent and less sensitive in distal than in proximal veins. The available data seem to support the view that most IDDVTs are self-limiting and inconsequential for patients, though in some cases they can be associated with complications and warrant diagnosis and treatment. The available guidelines for treatment of IDDVTs give different indications ranging from serial imaging of the deep veins for 2 weeks to detect and treat only in case of proximal extension, to giving oral anticoagulation in all IDDVT patients for 3 months. I review this issue, focusing on possible and suggested treatments in symptomatic IDDVT patients, and describe our current therapeutic approach to these patients.

Reasons for the persistent incidence of venous thromboembolism

“…Of the increase in leg DVT incidence, most was due to isolated distal leg DVT; proximal leg DVT incidence decreased by 16% per decade while isolated distal leg DVT incidence increased by 45% per decade; the latter observation may reflect improved imaging sensitivity for distal leg DVT over time (e.g., whole leg venous duplex ultrasonography). Moreover, the clinical significance of isolated distal leg DVT is uncertain [24]. Given that PE is an independent predictor of reduced survival compared to DVT alone [25], one might predict that the number of deaths solely due to PE also decreased over this timeframe.…”

Clinical outcomes of isolated distal deep vein thrombosis versus proximal venous thromboembolism in cancer patients: The Cleveland Clinic experience

“…The American College of Chest Physicians guidelines suggest the same approach for both proximal and isolated distal cancer‐associated DVTs with the recommendation to continue anticoagulant treatment for 3 months or longer . However, there remains a gulf between consensus guidelines and routine clinical practice where patients with cancer‐associated IDDVT are still being treated on a case‐by‐case basis …”

Long‐term risk of postthrombotic syndrome after symptomatic distal deep vein thrombosis: The CACTUS‐PTS study

“…As distal DVT is frequent and accounts for up to half of all lower limb DVT, this is an important knowledge gap. Furthermore, whether distal DVT needs to be treated with therapeutic anticoagulation is still debated and anticoagulant treatment is not routinely recommended in international guidelines . Thus, in clinical practice, not all patients with distal DVT are offered therapeutic anticoagulation, which could have an impact on their risk of developing future PTS.…”