In-Hospital Management and Follow-Up Treatment of Venous Thromboembolism: Focus on New and Emerging Treatments

Abstract

Venous thromboembolism (VTE), encompassing pulmonary embolism (PE) and deep venous thrombosis (DVT), is a major cause of morbidity and mortality of particular relevance for intensivists and hospitalists. Acute VTE is usually managed with parenteral unfractionated heparin or low-molecular-weight heparin, followed by an oral vitamin K antagonist. Data are lacking for optimal treatment of less common occurrences, such as upper extremity DVT, and for approaches such as thrombolysis for PE associated with early signs of hemodynamic compromise or inferior vena cava filters when anticoagulation is contraindicated. Direct oral anticoagulants (DOACs) including apixaban, dabigatran, edoxaban, and rivaroxaban are now added to the armamentarium of agents available for acute management of VTE and/or reducing the risk of recurrence. This review outlines an algorithmic approach to acute VTE treatment: from aggressive therapies when anticoagulation may be inadequate, to alternative choices when anticoagulation is contraindicated, to anticoagulant options in the majority of patients in whom anticoagulation is appropriate. Evidence-based guidelines and the most recent DOAC clinical trial data are discussed in the context of the standard of care. Situations and treatment approaches for which data are unavailable or insufficient are identified. VTE therapy in care transitions is discussed, as are choices for secondary prevention.

Comparison of Treatment Result Between Anticoagulation Alone and Catheter-Directed Thrombolysis Plus Anticoagulation in Acute Lower Extremity Deep Vein Thrombosis

“…The development of new oral anticoagulants (NOACs) offers hope for more therapeutic anticoagulation options in DVT. The safety and efficacy profiles of these new agents, as compared with conventional anticoagulation therapy, are of paramount importance [20,21]. NOACs have a more predictable anticoagulant effect and were recently demonstrated to be as safe as warfarin, although they were administered in fixed doses without routine laboratory monitoring.…”

Interventional Therapy for Upper Extremity Deep Vein Thrombosis

“…22 A standard course of anticoagulation is 3 months for a first provoked LEDVT or at least 6 to 12 months for an unprovoked LEDVT, and this course is typical for UEDVT, although there are no separate guidelines. 21,23 The use of prophylactic anticoagulation is not routinely recommended to prevent UEDVT in patients with central catheters. 6,22,23 However, a randomized phase III trial of 420 patients found a significant reduction in catheter-related DVT, without a significant increase in adverse events, in cancer patients treated with low-dose LMWH or low-dose warfarin as prophylaxis.…”

“…21,23 The use of prophylactic anticoagulation is not routinely recommended to prevent UEDVT in patients with central catheters. 6,22,23 However, a randomized phase III trial of 420 patients found a significant reduction in catheter-related DVT, without a significant increase in adverse events, in cancer patients treated with low-dose LMWH or low-dose warfarin as prophylaxis. 24 The differences in the rates of catheter-associated DVT among the control (14.8%), warfarin (6%), and LMWH groups (10%) were statistically significant.…”

A comparative CFD study of four inferior vena cava filters

“…Venous thromboembolism (DVT and/or PE) has an incidence of 1.4 to 2.2 per 1000 persons‐year among US citizens aged over 45 years, and mortality rate is approximately 25% in the first 30 days. () To prevent PE, DVT patients are usually treated with anticoagulant drugs . However, in patients who have contraindications or are unresponsive to anticoagulation therapy the placement of a filter into the inferior vena cava (IVC) is indicated.…”

“…However, in patients who have contraindications or are unresponsive to anticoagulation therapy the placement of a filter into the inferior vena cava (IVC) is indicated. () These filters are devices specifically designed to capture blood clots that are transported by the blood flow within the vein. They are made of titanium or metal alloys, and they are available in a good variety of models.…”