Should my patient with below-knee venous thrombosis receive anticoagulation?

In contrast to proximal lower extremity deep venous thrombosis for which anticoagulation (AC) is standard therapy, whether below-knee deep venous thrombosis (BKDVT) (eg,  involving peroneal, soleus, tibial, or gastrocnemius veins) should routinely receive AC is a matter of debate because of lack of solid supportive evidence. 1-3

The American College of Chest Physicians (ACCP) recommends AC for patients with BKDVT who are severely symptomatic or have risk factors for extension of the thrombus but this recommendation is based on low-quality scientific evidence (grade 2C or “weak”).3 For other patients, surveillance ultrasound is recommended in 2 weeks to exclude clot propagation more proximally, and therefore the need for AC.  Of course, decision regarding AC should be made in the context of the patient’s risk of serious bleeding.

The following facts about BKDVT may help in therapeutic decision making:1

  • Most cases resolve spontaneously without AC
  • The incidence of propagation varies from 3%-32%
  • Embolization is unlikely in the absence of extension into proximal veins

Also remember that clot propagation usually occurs within 2 weeks of initial diagnosis. That’s why surveillance ultrasound is recommended during this period when watchful waiting is preferred.

References 

  1. Fleck D, Albadawi H, Wallace A, etal. Below-knee deep vein thrombosis (DVT): diagnostic and treatment patterns. Cariovasc Diagn Ther 2017;7(Suppl3):S134-39. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5778527/
  2. Olson EJ, Zander AL, Van Gent J-M, et al. Below-knee deep vein thrombosis: An opportunity to prevent pulmonary embolism? J Trauma Acute Care Surg 2014;77:459-63. https://www.ncbi.nlm.nih.gov/pubmed/25159251
  3. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. CHEST 2012;141 (Suppl):e419S-e494S. https://www.ncbi.nlm.nih.gov/pubmed/22315268

 

Should my patient with below-knee venous thrombosis receive anticoagulation?

My bed-bound, debilitated patient is being transferred to a long-term facility (LTF). Should I continue the venous thromboembolism (VTE) prophylaxis she has been receiving in the hospital?

There are no randomized-controlled studies that examine the effectiveness of VTE prophylaxis in debilitated patients following discharge from the hospital, and currently  the literature does not recommend prophylaxis for chronic immobility as a single risk factor for VTE (1). However, given the expected morbidity, potential mortality and hospital readmission associated with VTE,  prophylaxis should be considered in residents of LTFs with the following comorbidities (2):

  • Acute exacerbation of congestive heart failure
  • Acute exacerbation of chronic obstructive pulmonary disease
  • Acute infection (e. g. pneumonia, urosepsis, skin and soft tissue infections, infectious diarrhea)
  • Acute exacerbation of inflammatory/autoimmune diseases
  • Active malignancy
  • Immobility and prior VTE

 

Unless contraindicated, patients should receive prophylactic doses of unfractionated heparin, enoxaparin, or other approved drugs. Mechanical VTE prophylaxis should be used only when the risk of bleeding is considered unacceptably high or when there are drug intolerances or adverse effects.

The need for VTE prophylaxis should be reassessed regularly taking into account patient’s overall health status, mobility, drug tolerance and goals of care.

 

References

  1. Pai M, Douketis JD. Preventing venous thromboembolism in long-term care residents: Cautious advice based on limited data. Cleveland Clin J Med 2010;77: 123-130.  https://www.ncbi.nlm.nih.gov/pubmed/20124270    
  2. Robinson Am. Venous thromboembolism prophylaxis for chronically immobilized long-term care residents. Ann Long-Term Care 2013;10:30. https://www.managedhealthcareconnect.com/article/venous-thromboembolism-prophylaxis-chronically-immobilized-long-term-care-residents
My bed-bound, debilitated patient is being transferred to a long-term facility (LTF). Should I continue the venous thromboembolism (VTE) prophylaxis she has been receiving in the hospital?