Editing Deep vein thrombosis (section)

== Treatment: ==

* Superficial venous thrombosis
** Treat with anti-inflammatories and LMWH for 45 days
** Needs USS too to exclude DVT
* DVT
** Medical (for choice of anticoagulant, look under 'periop medicine' -> 'thrombosis'
*** Upper limb DVT
**** Therapeutic anticoagulation for at least 3 months
**** USS as baseline prior to ceasing
*** Proximal DVT:
**** Recommendations as per Austin Thrombosis guideline
**** '''First unprovoked proximal DVT - minimum 3 months, but consider longer'''
**** '''Second unprovoked DVT - long term'''
**** '''First provoked proximal DVT - Minimum 3 months'''
**** '''Second or recurrent provoked DVT - minimum 3 months'''
**** '''High-risk features consider >6 months or lifetime'''
**** '''Those with occlusion of CFV should be admitted and considered for thrombus removal'''
**** Beware of females of childbearing potential - avoid pregnancy while on warfarin or DOAC
**** Repeat DUS should be performed prior to cessation of anticoagulation, as a baseline
*** Distal DVT:
**** Asymptomatic - may not require anticoagulation. Follow-up DUS in 2/52 and only treat if there is proximal extension.
**** Symptomatic:
*****
*** SVT:
****
** '''Surgical'''
*** The rationale for treatment is to prevent PTS - see below for pathophysiology
*** Decide whether to operate or not, then pick the most appropriate modality (see flowchart below)
*** Rutherford's actually advocates pursuing thrombus removal for all patients with IFDVT who are at risk of PTS. Also consider thrombus removal for those with thrombotic obliteration of popliteal and proximal tibial veins, as they can get bad below-knee PTS.
*** Removal of thrombus is difficult after two weeks
*** Patients with limb-threatening venous ischaemia due to IFDVT causing venous outflow obstruction should have thrombus removal if possible
*** Indications
**** Lower limb - consider in younger patients with iliofemoral DVT, avoid in patients >60 generally
**** Upper limb - venous gangrene or venous TOS which you are going to fix
*** '''Modalities:'''
**** Thrombolytic therapy
***** Catheter-directed thrombolysis
****** Safer and more effective than systemic infusion, and also prevents wasting the drug
****** Mechanism - activation of fibrin-bound plasminogen and resultant production or plasmin
****** Success rates of 75-90% are achieved, and most have good DVT-free long-term survival
****** Bleeding complications 5-11% (mostly the access site)
****** Serious distant bleeding is uncommon and intracranial bleeding rare
***** Pharmacomechanical thrombolysis
****** Endovascular mechanical thrombectomy
******* Amplatz, Angiohet, Trerotola, Oasis products
******* Combination of mechanical device and plasminogen activator removed 82% of thrombus
******* Faster than CDT alone
****** USS-accelerated Thrombolysis
****** Endovascular Aspiration Thrombectomy
**** Operative Venous Thrombectomy
***** Effective short and long-term outcomes, few complications
***** Superior to anticoagulation alone for ileofemoral DVT in terms of patency, venous pressure, leg oedema and PTS
***** Roughly similar results to catheter-directed thrombolysis for IFDVT
***** Benefits are the ability to achieve proximal patency and maintain distal valve competence
***** Need to be sure to remove all thrombus, correct underlying lesions and maintain therapeutic anticoagulation post-operatively
****


From Rutherford's: