Table 4.
Algorithmic approach to tailor individualised approach in treating acute DVT
| 1. Anticoagulation Only: For low-risk patients (small, distal DVTs) or those at high risk of bleeding. |
| ○ Anticoagulation Agents: Use DOACs (Direct Oral Anticoagulants) or LMWH. |
| ○ Duration: Short-term (3–6 months) vs. long-term anticoagulation based on recurrence risk. |
| 2. Catheter-Directed Thrombolysis (CDT): For patients with large proximal DVTs (e.g., iliofemoral) with low bleeding risk and symptoms <14 days. |
| ○ Thrombolytic Therapy: tPA or urokinase delivered directly via catheter. |
| ○ Benefits: Reduce post-thrombotic syndrome (PTS), increase venous patency. |
| ○ Logistics: Requires availability of interventional radiology suite and skilled personnel. |
| 3. Pharmacomechanical Thrombectomy (PMT): For patients with extensive thrombus burden or those in whom CDT alone is insufficient. |
| ○ Devices: Use devices such as AngioJet, Aspirex, or ClotTriever to assist in clot removal. |
| ○ Combination: Often combined with CDT for better efficacy. |
| ○ Considerations: Requires availability of specialized mechanical devices and operator expertise. |
| 4. Venous Stenting: Consider in cases of residual venous obstruction (RVO) after CDT or PMT, especially in iliac vein compression (May-Thurner syndrome). |
| ○ Indications: Obstruction >50%, development of superficial collaterals, symptomatic relief. |
| ○ Procedure: Stent deployment with intravascular ultrasound (IVUS) guidance for precision. |
| ○ Long-Term: Requires follow-up for patency, PTS, and complications like stent occlusion. |
| Step 5: Multidisciplinary Review |
| • Team Discussion: Involve vascular surgeons, interventional radiologists, and hematologists for consensus on complex cases. |
| • Patient Preference: Include patient in decision-making, considering their preferences, quality of life, and long-term prognosis. |
| Step 6: Post-Procedure Follow-Up and Adjustment |
| • Early Follow-Up: Within 1 month for imaging (venous duplex or IVUS) to confirm venous patency. |
| • Long-Term Monitoring: Regular follow-ups every 3–6 months for recurrence of symptoms, assessment for PTS, and anticoagulation management. |