Management of Recurrent Venous Thromboembolism on Anticoagulation

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  Figure 1. Proposed algorithm for suspected therapeutic-dose DOAC failure. * Workup to include the following: 4-limb Doppler US, CTA PE (based on symptoms or if not completed previously), CT A/P (extensive LLE proximal VTE), + ad hoc vascular imaging for unusual sites. Consider d-dimer in cases of non-diagnostic imaging. ** Transient provoking factors include surgery, hospitalization or immobility, indwelling lines/catheters, and COVID-19. Chronic provoking factors include malignancy, autoimmune disease, chronic infections, myeloproliferative disorders, and chronic infections. Consider hypercoagulable workup (FVL, PGM, protein C/S antigen and activity, antithrombin 3 and APLS labs, PNH and JAK2 if clinically relevant). *** Re-evaluation to include clinical evaluation and weighing risks/benefits; consider repeat imaging and assess the tolerance of current anticoagulant as well as bleeding risks for shared decision making with the patient. Patient preference for parenteral vs. oral anticoagulation in the long term considered here as well. **** Change to a different oral anticoagulant, choosing alternate DOAC or VKA, if the patient’s preference is for oral anticoagulation.