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Chapter 260. Treatment of Venous Thromboembolism

Lori-Ann Linkins, MSc, MD; Clive Kearon, MB, MRCPI, FRCPC, PhD

  1. Which patients with venous thromboembolism (VTE) can be treated as outpatients?

  2. What is the treatment for acute VTE deep vein thrombosis and/or pulmonary embolism (PE)?

  3. What is the role of thrombolytic therapy in the treatment of PE?

  4. How are patients with acute VTE and bleeding managed?

  5. How is the duration of treatment of VTE determined?

  6. Should I perform a thrombophilic workup?

  7. What is the risk of bleeding associated with long-term anticoagulant therapy?

The foundation of treatment of venous thromboembolism (VTE) is anticoagulant therapy. The objectives of anticoagulant therapy are: (1) to prevent extension and potentially fatal embolization of the initial thrombus and (2) to prevent recurrent VTE.

Proximal deep vein thrombosis is defined as a deep vein thrombosis (DVT) that involves the popliteal and more proximal veins of the leg. Distal deep vein thrombosis is defined as a DVT that is confined to the calf veins (including the calf trifurcation).

Triage and Hospital Admission

Patients who are hemodynamically stable with a low bleeding risk and normal renal function, and who are likely to be compliant with anticoagulant therapy, can be safely treated as outpatients. Patients with DVT and severe intractable pain or phlegmasia cerulea dolens (blue, painful leg due to complete venous obstruction leading to impaired arterial flow) should be admitted to hospital for initiation of treatment. Patients with pulmonary embolism (PE) and severe symptoms or abnormal vital signs should be admitted to the hospital and those with signs of hemodynamic compromise (eg, low oxygen saturation, low systolic blood pressure, persistent tachycardia) should be considered for thrombolytic therapy (discussed later). Validated prognostic scores are available to help physicians select which patients with PE can be treated as outpatients.

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Case 260-1

A 40-year-old male underwent a craniotomy for glioblastoma multiforme (GBM) on hospital day #1. His preoperative platelet count was 244,000/mm3. Postoperatively, he received mechanical VTE prophylaxis and UFH 5,000 U subcutaneously twice a day. On postoperative day #11 he became acutely short of breath. CT-PA protocol imaging identified multiple bilateral PE and a common femoral DVT.

What treatment should this patient receive? If this patient had thrombocytopenia (or a 50% drop in his platelet count), would you recommend a different treatment?

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Case 260-2

A 58-year-old female with a past medical history of asthma was seen for shortness of breath on three occasions in the outpatient setting. Despite therapy for asthma, her symptoms progressed and on the day of admission she developed chest pain that radiated to her left shoulder. Routine admission testing revealed an abnormal ECG showing deeply inverted T waves in her anterior precordium without reciprocal changes in other leads and slightly abnormal liver function tests. Her vital signs were normal and stable. She had elevated troponin and brain naturetic hormone levels that did not increase on repeated ...

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