Controversies in the management of proximal deep vein thrombosis

Controversies in the management of proximal deep vein thrombosisFuture studies should focus on patient selection for interventional therapy, best practices for stent surveillance, and long term anticoagulation D eep vein thrombosis (DVT) is a common condition affecting one in 1000 patients in the Western world. 1 Patients normally present acutely with symptoms of a hot, painful, swollen leg.Fortunately, many DVTs remain restricted to the calf veins, with low risk of acute pulmonary embolism.Patients usually respond quickly to anticoagulation and compression, often with full recovery and no long term sequelae.However, in one-third of patients, the DVT is located more proximal, involving the femoral and/or iliac veins. 2 In patients with a large proximal DVT, symptoms may improve initially, but up to half of patients will report chronic symptoms.3 These chronic symptoms, termed post-thrombotic syndrome (PTS) include leg swelling, difficulty wearing tight shoes or leg coverings, and difficulty walking due to aching and heaviness.In severe cases, this leads to skin changes and venous leg ulceration can occur.[2][3][4] As proximal DVT can occur in relatively young and otherwise healthy people, the long term impact of PTS is significant, with reduction in quality of life 5 and significant health care costs.6,7 The acute management of DVT In patients with proximal DVT, initial management remains anticoagulation.3 Anticoagulation should be directed by local policy and guidelines and should be started without delay.Direct oral anticoagulants have become the standard of care worldwide in the past decade.8 There is no role for inferior vena cava filters in patients able to receive anticoagulation.