Should we diagnose and treat distal deep vein thrombosis?

Robert‐Ebadi, Helia; Righini, Marc

doi:10.1182/asheducation-2017.1.231

Cited by 40 publications

(47 citation statements)

References 56 publications

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“…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.…”

Section: Introductionmentioning

confidence: 99%

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

Galanaud

Righini

Collen

et al. 2020

Journal of Thrombosis and Haemostasis

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Background After a proximal lower limb deep vein thrombosis (DVT; involving popliteal veins or above), up to 40% of patients develop postthrombotic syndrome (PTS) as assessed by the Villalta scale (VS). Poor initial anticoagulant treatment is a known risk factor for PTS. The risk of developing PTS after isolated distal DVT (infra‐popliteal DVT without pulmonary embolism), and the impact of anticoagulant treatment on this risk, are uncertain. Methods Long‐term follow‐up of CACTUS double‐blind trial comparing 6 weeks of s.c. nadroparin (171 IU/kg/d) versus s.c. placebo for a first symptomatic isolated distal DVT. At least 1 year after randomization, patients had a PTS assessment in clinic or by phone using the VS. Results After a median follow‐up of 6 years, PTS was present in 30% (n = 54) of the 178 patients who had a PTS assessment. PTS was moderate or severe in 24% (n = 13) of cases. There was no statistically significant difference in prevalence of PTS in the nadroparin versus placebo groups (29% versus 32%, P = .6), except in patients without evidence of primary chronic venous insufficiency (9% versus 24%, P = .04). Rates of venous thromboembolism recurrence during follow‐up in the nadroparin and placebo groups were, respectively, 8% (n = 7) and 14% (n = 13; P = .2). Conclusion After a first isolated distal DVT, the risk of PTS is substantial but much lower than that reported after proximal DVT. Anticoagulation with nadroparin doesn't provide any clear benefit to prevent PTS, except in patients without preexisting chronic venous insufficiency. Anticoagulation might be associated with a lower risk of venous thromboembolism recurrence.

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Section: Introductionmentioning

confidence: 99%

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

Galanaud

Righini

Collen

et al. 2020

Journal of Thrombosis and Haemostasis

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“…Multivariate analysis showed a statistically significant ( p value = 0.019) reduction in DVT incidence between patients who received only mechanical thromboprophylaxis (10.05%) and patients who received additional chemoprophylaxis (3.42%). However, most DVT observed in our study were distal DVTs, which have limited clinical significance as they are less strongly associated with PE compared to proximal DVT [ 18 , 19 ].…”

Section: Discussionmentioning

confidence: 99%

“…The clinical significance and management of distal DVT is another area of controversy [ 26 ]. Unlike proximal DVT and PE, which have been extensively studied, with anticoagulation being the mainstay of treatment, much less is known about the optimal management of distal DVT [ 19 , 27 ]. While some advocate anticoagulation to prevent proximal extension and PE, others favor a more conservative approach of close monitoring and ultrasound surveillance as distal DVT are less likely to extend to proximal veins and lead to PE [ 18 , 19 , 28 ].…”

Section: Discussionmentioning

confidence: 99%

“…Unlike proximal DVT and PE, which have been extensively studied, with anticoagulation being the mainstay of treatment, much less is known about the optimal management of distal DVT [ 19 , 27 ]. While some advocate anticoagulation to prevent proximal extension and PE, others favor a more conservative approach of close monitoring and ultrasound surveillance as distal DVT are less likely to extend to proximal veins and lead to PE [ 18 , 19 , 28 ]. Currently, the ACCP guidelines suggest serial imaging for low-risk patients with distal DVT and anticoagulation for high-risk or severely symptomatic patients only [ 27 ].…”

Section: Discussionmentioning

confidence: 99%

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Short-duration chemoprophylaxis might reduce incidence of deep vein thrombosis in Asian patients undergoing total knee arthroplasty

Zhang

Htet

Tan

et al. 2020

Knee Surg & Relat Res

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Background Venous thromboembolism (VTE) is a serious complication that may occur after total knee arthroplasty (TKA), leading to the recommendation of routine chemoprophylaxis by international guidelines. This study aims to determine if short-duration chemoprophylaxis after TKA reduces the incidence of VTE in an Asian population. Methods A retrospective study of 316 patients who underwent unilateral primary TKA between 1 January 2011 and 31 December 2013 was conducted. All patients received mechanical prophylaxis. One hundred seventeen patients (37%) received additional chemoprophylaxis, whereas 199 patients (63%) did not. A Doppler ultrasound (DUS) of both lower limbs was conducted for all patients within 6 days after surgery (median = 3 days) to assess for both proximal and distal DVT. Chemoprophylaxis in the form of enoxaparin (low molecular weight heparin; LMWH), aspirin, or heparin was administered until patients had a normal DUS, for a median duration of 4 days. Patients were followed up clinically for a minimum of 6 months to monitor for delayed or recurrent VTE and at least 2 years for patient-reported outcome measures. Results Overall, 24 patients (7.59%) developed deep vein thrombosis (DVT): three proximal and 21 distal DVTs. Twenty-three of the 24 patients were asymptomatic. Twenty of 199 patients (10.05%) with only mechanical prophylaxis developed DVT, whereas four of 117 patients (3.42%) with additional chemoprophylaxis developed DVT. Multivariate analysis showed that chemoprophylaxis use was associated with reduced incidence of DVT (odds ratio = 0.19, p value = 0.011). Other factors associated with increased DVT incidence include female gender (odds ratio = 5.45, p value = 0.034), positive history of cancer (odds ratio = 5.14, p value = 0.044), and increased length of stay in hospital (odds ratio = 1.19, p value < 0.001). Conclusions Our study has shown that despite the low incidence of DVT in Asian patients undergoing TKA, short-duration chemoprophylaxis might be effective in reducing the incidence of DVT. However, most DVTs observed in our study were distal and may be of limited clinical significance. Further studies are needed to investigate the impact of chemoprophylaxis use on the incidence of PE and overall mortality rates among Asian patients.

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“…[16,17] Nevertheless, the bene t of treating patients with isolated calf DVT remains uncertain and controversial. [17][18][19][20][21][22][23] In light of this ongoing controversy, we sought to investigate the prevalence and clinical characteristics of isolated calf DVT on complete duplex ultrasound examination as the initial test in patients with suspected DVT.…”

Section: Introductionmentioning

confidence: 99%

Isolated Calf Deep Venous Thrombosis: Prevalence, Clinical Characteristics and Implications for Ultrasound Evaluation

Heller¹,

Becher²,

Kröger³

et al. 2020

Preprint

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Objectives It remains controversial whether to include calf veins in the initial ultrasound evaluation of suspected deep venous thrombosis (DVT). We sought to investigate the prevalence and clinical characteristics of isolated calf DVT.Materials and Methods We retrospectively analyzed a cohort of 596 patients (median age 69 years, 52.3% women) evaluated with complete duplex ultrasound of the leg veins for suspected acute DVT within one year. Radiology reports were analyzed for the presence and localization of DVT. Electronic chart review was performed to collect clinical information.Results DVT was found in 157 patients (26.3%), of which 74 patients (47.1%) had isolated calf DVT. Isolated calf DVTs were most commonly located in the posterior tibial veins (22 patients, 29.7%), fibular veins (41 patients, 55.4%) and muscle veins (19 patients, 25.7%). There were no differences in age or gender between patients with isolated calf DVT and patients with more proximal DVT. Isolated calf DVT was more commonly associated with leg pain (52.7% vs. 33.7%, p = 0.0234) and less commonly associated with subjective leg swelling (35.1% vs. 55.4%, p = 0.0158) and objectively measured difference in leg circumference (23% vs. 39.8%, p = 0.0268). D-Dimers were significantly lower in patients with isolated lower leg DVT (median 2.3 vs. 6.8 mg/L, p < 0.0001) compared to patients with more proximal DVT.Conclusions Isolated calf DVT is almost as common as more proximal DVT. Our data supports performing complete duplex ultrasound including the calf veins in suspected DVT.

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Should we diagnose and treat distal deep vein thrombosis?

Cited by 40 publications

References 56 publications

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

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

Short-duration chemoprophylaxis might reduce incidence of deep vein thrombosis in Asian patients undergoing total knee arthroplasty

Isolated Calf Deep Venous Thrombosis: Prevalence, Clinical Characteristics and Implications for Ultrasound Evaluation

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