A healthy 35-year-old male, with no medication history, presents with two days of atraumatic, gradual-onset, gradually-worsening left calf cramping and swelling. The symptoms started the day he returned from a weeklong trip to California. He has tried regular ice, elevation, and round-the-clock Motrin for two days without improvement.
On exam, you find a well-appearing man with normal vitals whose left calf is slightly more swollen than the right and mildly tender to palpation. The extremity has no overlying skin changes, signs of trauma, or neurovascular compromise. The DVT ultrasound reveals a thrombus extending from the peroneal veins to the popliteal vein, with the most proximal portion just above the popliteal fossa. What do you do?
Your management decisions hinge on the answers to these questions:
How did this happen: provoked (ie malignancy, travel) vs. unprovoked
Where the clot is: proximal (popliteal vein and above) vs. distal (calf veins), superficial (saphenous veins) vs. deep (most other veins)
What your patient’s creatinine clearance is: order a chemistry and use it to choose/dose an anticoagulant
Now that you’ve answered these questions, classify your DVT in order to choose a treatment course:
Distal DVT: you don’t have to do anything, but consider the following when you’re considering serial ultrasounds to monitor for extension, antiplatelet therapy or initiating DOAC therapy.
Whether having a distal, untreated DVT would significantly affect your patient’s life in the years to come (ie risk for chronic venous stasis, lower extremity pain, etc)
The risk vs. benefit analysis in anticoagulating this particular patient
The thrombus’ risk of proximal propagation -- i.e. its proximity to the proximal venous system and its size (> 5 cm is concerning)
Whether your patient is known to be hypercoagulable (i.e. hematologic disorder, malignancy)
Proximal DVT without history of cancer, first encounter: DOAC for 3 months
Proximal DVT with history of cancer, first encounter: Lovenox for 3 months
Superficial thrombophlebitis: warm compresses, compression stockings, ibuprofen, repeat ultrasound in 3-5 days to monitor for extension
Recurrent DVT despite anticoagulation: admit for heparinization, vascular and hematology consults, and discussion about a long-term plan (i.e. IVC filter)
What is your patient’s disposition?
The ambulatory, non-pregnant, otherwise healthy patient with stable hemodynamics, normal renal function, a low bleeding risk, and access to timely follow-up can be discharged. Don’t forget to counsel this patient about the many risks of anticoagulation (ie to seek immediate care if they experience physical trauma, especially head strike).
If your patient fails any of those conditions or has an extensive clot, consider admission.
After this patient was found to have stable hemodynamics, normal renal function, a low bleeding risk, and access to timely follow-up, he was counseled about the risks of anticoagulation and given his first dose of Xarelto (15 mg) in the ED. He was then discharged home with primary care/hematology followup as well as Xarelto 15 mg BID for 21 days, with further care to be dictated by the outpatient providers.
Take-Away #1:
Ask yourself: why this happened (provoked vs unprovoked), where the clot is (proximal vs distal and superficial vs deep), and what your patient’s renal function is (to help choose/dose an anticoagulant).
Take-Away #2:
Most distal DVTs, especially in patients without risk factors or severe symptoms, do not require treatment, but every patient has an individual risk vs benefit analysis which should be considered on a case-by-case basis. First-time proximal DVTs typically require either a DOAC or Lovenox for 3 months. A recurrent DVT despite anticoagulation requires admission for heparinization, and vascular/hematology consults to formulate a better long-term plan (ie an IVC filter).
Take-Away #3:
The ambulatory, non-pregnant, otherwise healthy patient with stable hemodynamics, normal renal function, a low bleeding risk, and access to timely follow-up can be discharged. (Don’t forget to counsel this patient about the risks of anticoagulation.) If your patient fails any of those conditions or has an extensive clot, consider admission.
Sonika Raj MD, MS is a current third year resident at Stony Brook Emergency Medicine.
References:
Edited by Bassam Zahid, MD