Venous Thrombosis Clinical Practice Guidelines (ESVS, 2021)

European Society for Vascular Surgery

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

February 26, 2021

Guidelines on the management of venous thrombosis were published in February 2021 by the European Society for Vascular Surgery (ESVS) in the European Journal of Vascular & Endovascular Surgery.[1] Class I recommendations are outlined below.

When deep vein thrombosis (DVT) is suspected, clinically assess the pretest probability as part of the diagnostic workup. Use a validated diagnostic pathway.

In the setting of suspected DVT, use ultrasonography as the first modality.

Outpatient management is recommended for most DVT cases.

For DVT treated by early thrombus removal, with or without stenting, anticoagulation therapy should be at least as long as anticoagulation therapy alone would be and at the discretion of the treating physician.

Unprovoked DVT

For unprovoked DVT, the ESVS recommends clinical examination and sex-specific occult malignancy screening (vs routine extensive screening). Reassess the patient’s bleeding risk before continuing anticoagulation longer than 3 months.

For the principal treatment phase, for patients with unprovoked proximal DVT, use of a direct oral anticoagulant (DOA) is recommended over that of low molecular weight heparin (LMWH) followed by a vitamin K antagonist (VKA). In addition, of these patients who have a low or moderate bleeding risk, extend anticoagulation past 3 months and periodically reassess the bleeding risk.

For patients with a second or subsequent unprovoked DVT, extend anticoagulation therapy longer than 3 months.

Provoked DVT

For patients with a provoked proximal DVT and a major transient risk factor, use 3 months of anticoagulation treatment rather than a shorter duration. A DOA is recommended over a VKA for the principal treatment phase.

Proximal DVT

During the initial or principal treatment phase for proximal DVT, in the setting of existing contraindications to anticoagulation, insert a temporary inferior vena cava (IVF) filter.

Apply early compression within 24 hours in those with proximal DVT at 30-40 mmHg with either multilayer bandaging or compression hosiery to reduce pain, edema, and residual venous obstruction.

For patients with proximal DVT who have limited symptoms and signs (based on the Villalta score), limit the use of below knee stockings to 6 or 12 months.

Lower-Extremity DVT

For symptomatic calf DVT that requires anticoagulant treatment, 3 months of therapy is recommended over shorter durations. For those with symptomatic calf DVT not receiving anticoagulation, clinically reassess and repeat whole-leg sonography after 1 week.

For calf DVT, DOAs are recommended over LMWH followed by VKAs.

In the setting of suspected lower limb superficial vein thrombosis, obtain a whole-leg sonogram to determine the extent of the thrombus and rule out asymptomatic DVT.

For patients with lower limb superficial vein thrombosis that:

  • Is ≤ 3 cm from the junction with the deep veins, use therapeutic anticoagulation.

  • Is ≥ 3 cm away from the junction with the deep veins and extends ≥ 5 cm in length, treat with fondaparinux 2.5 mg once daily.

  • Extends ≥ 5 cm in sonographic length and extends ≥ 3 cm from the junction with the deep veins, treat with 45 days of anticoagulation.

Upper-Extremity DVT

For patients with suspected upper-extremity DVT, use ultrasonography as the initial diagnostic modality.

For primary upper-extremity DVT, treat with 3 months of anticoagulation.

Special Populations

Management of pediatric DVT should be guided by clinicians with specific expertise in pediatric thrombosis and hemostasis.

ESVS recommends that DVT during pregnancy be managed with therapeutic doses of LMWH for at least 3 months and for at least 6 weeks postpartum.

In the setting of cancer-associated DVT, use an LMWH for initial and principal phase anticoagulation. For those with active cancer-associated DVT, switch from an LMWH to an OA after 3-6 months of therapy for extended treatment.

In the setting of DVT and high-risk thrombophilia (eg, antiphospholipid syndrome, homozygous factor V Leiden mutation, or deficiencies of protein C or S, or antithrombin), treat with full-dose extended anticoagulation, and reassess periodically. Long-term follow-up by a thrombophilia expert is recommended.

For those with DVT and chronic kidney disease treated with an LMWH, fondaparinux, or a DOA, reassess renal function periodically.

For underweight or overweight patients with DVT that requires anticoagulation, adjust the dose of unfractionated heparin (UH), LMWHs, and fondaparinux.

For more information, please go to Venous Thromboembolism (VTE), Deep Venous Thrombosis (DVT), Pulmonary Embolism (PE), and Inferior Vena Cava Filters,

For more Clinical Practice Guidelines, please go to Guidelines.


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