# Treatment

Treatment

Deep vein thrombosis The management of  DVT has in the past been focused upon reducing the risk of  pulmonary embolus. Patients who are confirmed to have a DVT on duplex imaging should be rapidly anticoagulated with a ‘treatment dose’ of  subcutaneous LMWH. Patients with significant renal impairment should be commenced on intravenous unfractionated heparin. Patients who have a sensitivity towards heparinoids, such as those with heparin-induced thrombocytopenia, should commence on another anticoagulant, such as fondaparinux (an indirect factor Xa inhibitor) or bivalirudin (a direct thrombin inhib itor). This will achieve rapid anticoagulation and reduce the risk of  embolisation. Typically , patients will then commence on oral anticoagulation for at least 3 months (or longer depending upon the persistence of  risk factors or in recurrent cases). Oral anticoagulation using new or ‘novel’ anticoagulants (NOACs), which directly inhibit either factor Xa (rivaroxaban and apixaban) or thrombin (dabigatran), is recommended as they are equally e ff ective as vitamin K antagonists (warfarin) in preventing recurrent symptomatic VTE but are associated with less major bleeding complications. Patients who cannot be safely anticoagulated (usually because of  bleeding risks) should be considered for a tempo rary inferior vena cava filter, until either they are safe to be Leo Buerger , 1879–1943, Professor of Urologic Surgery , The New Y ork Polyclinic Medical School, New Y ork, NY , USA, described thromboangiitis obliterans in 1908. the filter may be retrie ved. Endovascular surgery aiming to restore patency , including thrombus removal, lysis and stenting tec hniques, are increasingly /uni00A0 used in patients with acute DVT aiming to reduce the risk of  chronic post-thr ombotic syndrome. Research suggests this may be beneficial in selected patients, for example those with iliofemoral thrombosis. Pulmonary embolus Most pulmonary emboli can be treated by anticoagulation and observation, but severe right heart strain and shortness of  breath indicate the need for thrombolysis or radiologically guided catheter embolectomy . Superficial vein thrombosis This condition was previously known as thrombophlebitis. An abnormal endothelium is a much more common precip - itating factor than in most DVTs. Common causes include external trauma (especially to varicose veins), venepunctures and infusions of  hyperosmolar solutions and drugs. The presence of  an intravenous cannula f or longer than 24–48 hours often leads to local thrombosis. Some systemic diseases such as thromboangiitis obliterans (Buerger’s disease) and malignancy , especially of the pancreas, can lead to a flitting thrombophlebitis (thrombophlebitis migrans), a ff ecting di ff er - ent veins at di ff erent times. Finally , coagulation disorders such as polycythaemia, thrombocytosis and sickle cell disease are often associated, as is a concomitant DVT . The surface vein feels solid and is tender on palpation. The overlying skin may be attached to the v ein and in the early stages may be erythematous before gradually turning brown. A linear segment of vein of  variable length can be easily palpated once the inflammation has died down. A full blood count, coagulation screen and duplex scan of the deep veins should usually be obtained. Any sugges - tion of  an associated malignancy should be investig ated using Summary box 62.3 Venous thromboembolism - /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF - 

May be unprovoked, in which case an association with an
inherited thrombophilia should be considered
Is much more commonly seen as a complication of illness or
surgery
Is associated with both quality-of-life impairment and a risk of
mortality
All healthcare professionals should actively assess the
risk and consider preventative measures where this risk is
increased
Management should involve measures to reduce the risk
of extension and/or embolisation, typically with systemic
anticoagulation
Early thrombus removal is increasingly being used aiming to
prevent chronic post-thrombotic syndrome, and rarely for limb
salvage

inal CT scan. Most patients are treated with NSAIDs and topical heparinoid preparations and the condition resolves spontaneously . Proximity to a deep venous junction or long a ff ected length are indications for short-term anticoagulation and interv al duplex assessment. Rarely , infected thrombi require incision or excision. Ligation to prevent propagation into the deep veins is almost never required. Associated DVT or thrombophilia is treated with anticoagulation.