Treatment of distal deep vein thrombosis

Abstract

BackgroundThe treatment of distal (below the knee) deep vein thrombosis (DVT) is not clearly established. Distal DVT can either be treated with anticoagulation, or monitored with close follow-up to detect progression to the proximal veins (above the knee), which requires anticoagulation. Proponents of this monitoring strategy base their decision to withhold anticoagulation on the fact that progression is rare and most people can be spared from potential bleeding and other adverse e ects of anticoagulation. ObjectivesTo assess the e ects of di erent treatment interventions for people with distal (below the knee) deep vein thrombosis (DVT). Search methodsThe Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 12 February 2019. We also undertook reference checking to identify additional studies. Selection criteriaRandomised controlled trials (RCTs) for the treatment of distal DVT. Data collection and analysisTwo review authors independently selected trials and extracted data. We resolved disagreements by discussion. Primary outcomes of interest were recurrence of venous thromboembolism (VTE), DVT and major bleeding and follow up ranged from three months to two years. We performed fixed-e ect model meta-analyses with risk ratio (RRs) and 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE. Main resultsWe identified eight RCTs reporting on 1239 participants. Five trials randomised participants to anticoagulation for up to three months versus no anticoagulation. Three trials compared anticoagulation treatment for di erent time periods. Anticoagulant compared to no intervention or placebo for distal DVT treatmentAnticoagulation with a vitamin K antagonist (VKA) reduced the risk of recurrent VTE during follow-up compared with participants receiving no anticoagulation (RR 0.34, 95% CI 0.15 to 0.77; 5 studies, 496 participants; I 2 = 3%; high-certainty evidence), and reduced the risk of Treatment of distal deep vein thrombosis (Review)

Failure of the Ottawa Score to Predict the Risk of Recurrent Venous Thromboembolism in Cancer Patients: The Prospective PREDICARE Cohort Study

“…13 In addition, while the choice of treating distal DVT is still debated, particularly in low-risk patients, in patients with active cancer continuing to give therapeutic anticoagulation seems advisable. 14,15 The present study, which is the first prospective study specifically designed to validate the Ottawa score, has several strengths. The short period of inclusion (11 months) makes it unlikely that major changes in anticancer treatments could have influenced the study results.…”

“…Splanchnic vein thromboses also represent a different entity and should be analyzed separately (13). In addition, while the choice of treating distal DVT is still debated, particularly in low-risk patients, in patients with active cancer continuing to give therapeutic anticoagulation seems advisable (14,15). The present study, which is the first prospective study specifically designed to validate the Ottawa score, has several strengths.…”

Recommendations from the ICM-VTE: General

“…The Cochrane Library recently collated a systematic review pertaining to management of distal DVT. Kirkilesis et al, evaluated 8 RCT involving both nonsurgical and surgical patients which included 1,239 participants with distal DVT who were randomized to treatment with anticoagulation with vitamin K antagonists or no anticoagulation 752 . There was no difference with respect to development of PE (relative risk [RR] 0.81, 95% confidence interval [CI] 0.18 – 3.59) between the treatment groups.…”

Anticoagulation for Distal Lower‐extremity Deep Venous Thromboses

“…3 This systematic review and meta-analysis includes five randomized controlled trials (n = 503 patients) comparing anticoagulation with no intervention or placebo for the treatment of distal DVTs as well as three randomized controlled trials (n = 736 patients) comparing anticoagulation for 6 weeks versus 12 weeks or more. 4 The trials included adults over 18 years of age with a distal DVT identified on ultrasound or venography. The primary outcomes were recurrence of VTE (defined as DVT recurrence in the calf veins, progression of DVT to proximal veins, and pulmonary embolism [PE]) and major bleeding (defined as a 2 g/dL decrease in hemoglobin, transfusion of ≥2 units of red blood cells, bleeding in a critical site, or bleeding contributing to death).…”

“…This systematic review and meta‐analysis includes five randomized controlled trials ( n = 503 patients) comparing anticoagulation with no intervention or placebo for the treatment of distal DVTs as well as three randomized controlled trials ( n = 736 patients) comparing anticoagulation for 6 weeks versus 12 weeks or more 4 . The trials included adults over 18 years of age with a distal DVT identified on ultrasound or venography.…”