Diagnosis and management of iliofemoral deep vein thrombosis: clinical practice guideline

• Published in: Canadian Medical Association journal (CMAJ) Vol. 187; no. 17; pp. 1288 - 1296
• Main Authors: Liu, David, Peterson, Erica, Dooner, James, Baerlocher, Mark, Zypchen, Leslie, Gagnon, Joel, Delorme, Michael, Sing, Chad Kim, Wong, Jason, Guzman, Randolph, Greenfield, Gavin, Moodley, Otto, Yenson, Paul
• Format: Journal Article
• Language: English
• Published: Canada Joule Inc 17-11-2015; CMA Impact, Inc; 8872147 Canada Inc
• Subjects: Algorithms; Anticoagulants - therapeutic use; Canadians; Care and treatment; Clinical medicine; Diagnosis; Disease management; Femoral Vein; Guidelines; Humans; Ilium - blood supply; Medical diagnosis; Postthrombotic Syndrome - diagnosis; Postthrombotic Syndrome - therapy; Practice Guidelines as Topic; Thrombolytic Therapy; Thrombosis; Treatment Outcome; Ultrasonography; Vena Cava Filters; Venous thrombosis; Venous Thrombosis - diagnosis; Venous Thrombosis - diagnostic imaging; Venous Thrombosis - therapy; United States; Canada
• ISSN: 0820-3946; 1488-2329
• DOI: 10.1503/cmaj.141614

Novel oral anticoagulants (rivaroxaban, dabigatran and apixaban) have also been shown to be effective for the treatment of acute DVT (see Appendix 2). Studies comparing these agents with warfarin for management of acute venous thromboembolism have shown that all three are non-inferior to warfarin for prevention of recurrent venous thromboembolism (dabigatran, hazard ratio [HR] 1.09, 95% CI 0.76-1.57; rivaroxaban, HR 0.89, 95% CI 0.66-1.19; apixaban, HR 0.84, 95% CI 0.60-1.18).31-35 Both rivaroxaban and apixaban were associated with significantly reduced rates of major bleeding relative to conventional therapy (rivaroxaban, HR 0.54, 95% CI 0.37-0.79; apixaban, HR 0.31, 95% CI 0.17- 0.55), whereas the major bleeding profile of dabigatran was similar to that of warfarin (HR 0.73, 95% CI 0.48-1.11). Novel oral anticoagulants offer several advantages over warfarin, including no requirement for laboratory monitoring, use of fixed doses, lack of interactions with food and limited interactions with other medications. Drawbacks to their use include the lack of a reversal agent, renal excretion and higher cost.32,34,35 Rivaroxaban and apixaban are currently approved in Canada for treatment of acute venous thromboembolism. Initial RCTs of compression therapy for the prevention of post-thrombotic syndrome in patients with proximal DVT (including iliofemoral DVT) yielded conflicting results, but were hindered by lack of a placebo control, small numbers of patients, single-centre recruitment and open-label design.59-62 The recent SOX trial, a multicentre placebo-controlled RCT of external compression stockings for the prevention of post-thrombotic syndrome, randomly assigned patients with a first episode of symptomatic proximal DVT to wear active external compression stockings or placebo stockings (without therapeutic compression) daily for two years.63 There was no difference between the groups in cumulative incidence of postthrombotic syndrome (14.2% with active external compression stockings v. 12.7% with placebo stockings, p = 0.58), post-thrombotic syndrome severity or recurrent venous thromboembolism. These results bring into question whether the use of external compression stockings should be recommended for all patients with acute symptomatic DVT for the prevention of post-thrombotic syndrome. Drawbacks of external compression therapy include discomfort, difficulty applying stockings and the cost of original and replacement stockings. The only major contraindication to their use is symptomatic peripheral arterial disease.60 Relative to femoropopliteal or distal DVT, iliofemoral DVT carries a higher risk of phlegmasia cerulea dolens, recurrent venous thromboembolism and post-thrombotic syndrome. Anticoagulant therapy remains the cornerstone of management, mainly to prevent recurrent venot hromboembolism. However, selected patients with iliofemoral DVT may benefit from alternative clot-management strategies, such as inferior vena cava filters, compression therapy, and clot removal or reduction strategies. Clot removal or reduction strategies are life- and limb-salvaging for patients with phlegmasia cerulea dolens, but they also reduce the risk of postthrombotic syndrome in patients without phlegmasia cerulea dolens, particularly if candidate patients undergo early triage for intervention.