Approach to the management of Venous thromboembolism

Step 1 :Confirm PTE or DVT diagnosis

Step 2: Look for contraindications for full dose anticoagulation. If contraindications exist then insert IVC filter.

Step 3 : If no contraindication then look for impending venous gangrene (in case of DVT) or cardiopulmonary collapse (cardiogenic shock/ RV dysfunction in case of PTE). If yes then start thrombolysis

Thrombolysis for DVT:

Indications : Impending venous gangrene, symptom duration < 14 days and low risk of bleeding

Mode : a)Catheter directed thrombolysis (CDT) : Fluroscopy guided placement of multiside holed catheter (pigtail) into the thrombus segment and infusing alteplase for 1-3 days at a rate of 0.5 mg to 3 mg/hour (50 mg diluted in 50 ml of NS). CDT is superior to systemic anticoagulation alone because of reduced post thrombotic syndrome and reduced bleeding complications

b)Pharmacomechanical Catheter directed thrombolysis (PCDT)

PCDT uses either the “Power Pulse” or “isolated thrombolysis” techniques. Power Pulse employs the AngioJet rheolytic thrombectomy system (Bayer, Warrendale, PA) to deliver and disperse the thrombolytic agent by a powerful pulse-spray injection. After bathing the clot in the thrombolytic agent, the AngioJet catheter aspirates the softened thrombus fragments. Isolated thrombolysis uses the Trellis peripheral infusion system (Covidien, Mansfield, MA) to deliver the thrombolytic agent directly into the clot. The agent is then circulated within the clot by an oscillating wire.

Advantage of PCDT over CDT : Reduced dose and infusion duration of alteplase thereby reducing bleeding complications and better efficacy

Thrombolysis for PTE :

For PTE there is insufficient evidence to recommend thrombolysis via a pulmonary artery catheter rather than systemic thrombolysis

Systemic thrombolysis dose: Alteplase 100 mg (10 mg as iv bolus over 10 min f/b 90 mg in 100 ml of NS infused over 2 hours)

Step 4

If there is no evidence of impending gangrene or cardiopulmonary collapse then initiate systemic anticoagulation

Phases of anticoagulation treatment:

Initial phase0 to 10 days:

IV or SC unfractionated heparin/LMWH/Fondaparinux/Rivaroxaban/Apixaban

Long term phase- 10 days to 3 months

Vitamin K antagonist – warfarin/acitrom (target INR: 2-3.5)

Rivaroxaban/Apixaban/Edoxaban/Dabigatran/LMWH

Extended phase-3 months to indefinite 

Indictions for extended therapy- 1.unprovoked/recurrent VTE    2. Malignancy related VTE

Drugs :

Vitamin K antagonist – warfarin/acitrom (target INR: 2-3.5)

Rivaroxaban/Apixaban/Edoxaban/Dabigatran/LMWH

Newer agents : Rivaroxaban(15 mg bd)/Apixaban(10 mg bd)/Edoxaban/Dabigatran(110 or 150 mg bd)

Pros- No need for INR monitoring, non-inferior or slightly efficacious then warfarin/acitrom, lesser major bleeding rates

cons- costlier, lesser availability especially in developing countries and no specific reversal agents

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