Outcomes of Isolated Distal Thrombosis Managed with Serial Compression Ultrasonography

Abstract

Background

Isolated distal deep vein thrombosis (IDDVT) is a common subtype of deep vein thrombosis. Consensus guidelines provide conflicting recommendations for IDDVT management; some recommend anticoagulant treatment, while others suggest serial compression ultrasonography (CUS) monitoring for patients at “high risk” of proximal extension. The purpose of this study was to describe outcomes of serial CUS-monitored IDDVT and identify risk factors for thrombus extension into proximal veins or anticoagulant treatment initiation. 

Methods

A retrospective descriptive study was conducted using electronic data from University of Utah Health. Adult subjects with objectively confirmed IDDVT managed using serial CUS surveillance were included. Subjects were followed for 30-days for occurrence of a composite outcome of proximal clot extension or anticoagulant treatment initiation. Descriptive statistics were used to summarize characteristics of the study population. Characteristics were compared across outcome groups using inferential statistics.

Results

A total of 178 subjects were included, with 53 subjects (29.5%) experiencing the composite outcome. A prior history of VTE was significantly higher in those who experienced the composite outcome, or its separate components, than in those who did not.

Conclusions

Our results indicated that 7 out of 10 patients with IDDVT managed with serial CUS did not experience clot propagation or require anticoagulant treatment within 30 days of diagnosis. In lieu of evidence suggesting a clear benefit of anticoagulant treatment, serial CUS monitoring may be an appropriate management strategy for IDDVT. A history of VTE may be a useful surrogate marker for potentially unfavorable IDDVT outcomes.

References:

1. Righini, M., Paris, S., Le Gal, G., Laroche, J., Perrier, A., & Bounameaux, H. (2006). Clinical relevance of distal deep vein thrombosis. Review of literature data. Thrombosis and Haemostasis, 95(1), 56–64. doi: 10.1160/TH05-08-0588.
2. Palareti, G., & Sartori, M. (2016). Treatment of Isolated Below the Knee Deep Vein Thrombosis. Current Atherosclerosis Reports, 18(7). doi: 10.1007/s11883-016-0594-1.
3. Porfidia, A., Carnicelli, A., Bonadia, N., Pola, R., & Landolfi, R. (2016). Controversies in venous thromboembolism: the unique case of isolated distal deep vein thrombosis. Internal and Emergency Medicine, 11(6), 775–779. doi: 10.1007/s11739-016-1453-3.
4. Kearon, C., Akl, E., Ornelas, J., Blaivas, A., Jimenez, D., Bounameaux, H., … Moores, L. (2016). Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest, 149(2), 315–352. doi: 10.1016/j.chest.2015.11.026.
5. Utter, G., Dhillon, T., Salcedo, E., Shouldice, D., Reynolds, C., Humphries, M., White, R. (2016). Therapeutic anticoagulation for isolated calf deep vein thrombosis. JAMA Surgery, 151(9). doi: 10.1001/jamasurg.2016.1770.
6. Kirkilesis, G., Kakkos, SK., Bicknell, C., Salim, S., Kakavia, K. (2020). Treatment of distal deep vein thrombosis. Cochrane Database of Systematic Reviews, issue 4. doi: 10.1002/14651858.CD013422.pub2.
7. Ferrara, F., Meli, F., Amato, C., Cospite, V., Raimondi, F., Novo, G. (2006). Optimal duration of treatment in surgical patients with calf venous thrombosis involving one or more veins. Angiology, 57, 418-23.
8. Horner, D., Hogg, K., Body, R., Nash, M., Baglin, T., Mackway-Jones, K. (2014). The Anticoagulation of Calf Thrombosis (ACT) Project. Chest, 146(6), 1468-77. doi: 10.1378/chest.14-0235.
9. Lagerstedt, C., Olsson, CG., Fagher, BO., Oqvist, BW., Albrechtsson, U. (1985). Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis. Lancet, 2(8454), 515-8.
10. Nielsen, HK., Husted, SE., Krusell, LR., Fasting, H., Charles, P., Hansen, HH., et al. (1994). Anticoagulant therapy in deep venous thrombosis. A randomized controlled study. Thrombosis Research, 73, 215-26.
11. Pinede, L., Ninet, J., Duhaut, P., Chabaud, S., Demolombe-Rague, S., Durieu, I., et al. (2001). Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis. Circulation, 103(20), 2453-60. doi: 10.1161/01.CIR.103.20.2453.
12. Righini, M., Galanaud, J.-P., Guenneguez, H., Brisot, D., Diard, A., Faisse, P., … Quere, I. (2016). Anticoagulant therapy for symptomatic calf deep vein thrombosis (CACTUS): a randomised, double-blind, placebo-controlled trial. The Lancet Haematology, 3(12), e556–e562. doi: 10.1016/s2352-3026(16)30131-4.
13. Schulman, S., Rhedin, A., Lindmarker, P., Carlsson, A., Lafrars, G., Nicol, P., et al. (1995). A comparison of six week with six months of oral anticoagulation therapy after a first episode of venous thromboembolism. New England Journal of Medicine, 332(25), 1661-5.
14. Schwarz, T., Buschmann, L., Beyer, J., Halbritter, K., Rastan, A., Schellong, S. (2010). Therapy of isolated calf muscle vein thrombosis: a randomized, controlled study. Journal of Vascular Surgery, 52(5), 1246-50. doi: 10.1016/j.jvs.2010.05.094.
15. Nicolaides AN, Fareed J, Kakkar AK, et al. Prevention and treatment of venous thromboembolism– international consensus statement. (2013). International Angiology, 32(2), 111-260.
16. Ortel, TL., Neumann, G., Ageno, W., Beyth, R., Clark, NP., Cuker, A., et al. (2020). American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Advances, 4(19), 4693-4738. doi: 10.1182/bloodadvances.2020001830.
17. Tian, Z., Sun, S., Eguale, T., Rochefort, C. (2017). Automated Extraction of VTE Events From Narrative Radiology Reports in Electronic Health Records. A Validation Study. Medical Care, 55(10), e73-e80.