Anticoagulation for venous thromboembolism

Acute venous thromboembolism (VTE) is treated with parenteral administration of heparin or derivatives, in conjunction with oral vitamin K antagonists (VKAs) to reach and maintain INR values between 2.0 and 3.0 for at least 3 months; the duration of a further period of treatment for secondary prevention of recurrences is still matter of debate. If bleeding occurs during treatment the decision will be based on: a) type of bleeding (major or minor), and b) thrombotic risk if anticoagulation is withheld (characteristics of patients and time elapsed from the index VTE). In case of major bleeding anticoagulation should be stopped and reversed. A first but insufficient measure is i.v. vitamin K administration. Fresh frozen plasma is widely used; however, large volumes are needed (at least 15 mL/kg body weight) with risk for fluid overload. Prothrombin complex concentrate infusion, with 3 or (better) the 4 pro-coagulant factors, is a more efficient (fast and safe) measure. In patients at high thrombotic risk (first month or other conditions) and absolute contraindication for anticoagulation a caval filter is recommended, to avoid as much as possible life-threatening pulmonary embolism.