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1/10
How should we manage pts with a below knee DVT?
A short tweetorial trying to address this commonly encountered conundrum...
How should we manage pts with a below knee DVT?
A short tweetorial trying to address this commonly encountered conundrum...
2/10
You see a fit and well 48 F with painful swelling of her R calf. No risk factors for VTE. She has pitting oedema below the knee, R calf 2cm > L. Wells= 1
D-dimer 820 US: non-compressive thrombus in post tib & perineal veins consistent with R calf DVT.
Do you?
You see a fit and well 48 F with painful swelling of her R calf. No risk factors for VTE. She has pitting oedema below the knee, R calf 2cm > L. Wells= 1
D-dimer 820 US: non-compressive thrombus in post tib & perineal veins consistent with R calf DVT. Do you?
3/10
So do we know the best approach? Simply put, no. The largest RCT is the CACTUS trial which compared 6wk LMWH v placebo. Importantly they excluded high risk groups (cancer, prev VTE, pregnancy) https://bit.ly/38MUjhR
So do we know the best approach? Simply put, no. The largest RCT is the CACTUS trial which compared 6wk LMWH v placebo. Importantly they excluded high risk groups (cancer, prev VTE, pregnancy) https://bit.ly/38MUjhR
4/10
Sadly for us the study was underpowered, and failed to reach statistical significance. See below a nice table (courtesy of @srrezaie) summarising the key results.
Sadly for us the study was underpowered, and failed to reach statistical significance. See below a nice table (courtesy of @srrezaie) summarising the key results.
5/10
Of interest from
was the low primary outcome event rate in the placebo group (5.4%), and that 3 of the 7 patients who did go on to develop a proximal DVT had this detected at the scheduled day 3-7 US 
Of interest from
was the low primary outcome event rate in the placebo group (5.4%), and that 3 of the 7 patients who did go on to develop a proximal DVT had this detected at the scheduled day 3-7 US
6/10
A recent Cochrane review (April 2020) reported benefit of anticoagulatoon based on
VTE recurrence & low risk of bleeding, but the 4 other trials included in the meta analysis were tiny so cautious interpretation of this is recommended https://bit.ly/3eiIS2F
A recent Cochrane review (April 2020) reported benefit of anticoagulatoon based on
VTE recurrence & low risk of bleeding, but the 4 other trials included in the meta analysis were tiny so cautious interpretation of this is recommended https://bit.ly/3eiIS2F
7/10
So surely NICE give us clear advice on what do?
There is no specific mention (or recognition) of treatment strategies for below knee DVTs
So surely NICE give us clear advice on what do?
There is no specific mention (or recognition) of treatment strategies for below knee DVTs
8/10
BUT...
For suspected DVTs they only recommend doing PROXIMAL vein US, & if -ve, repeating in 6-8 days (if D-dimer also high). As you can’t treat what you don’t see, they in practice seem to advise repeat US and only Rx a below knee DVT if it progresses proximally
BUT...
For suspected DVTs they only recommend doing PROXIMAL vein US, & if -ve, repeating in 6-8 days (if D-dimer also high). As you can’t treat what you don’t see, they in practice seem to advise repeat US and only Rx a below knee DVT if it progresses proximally
9/10
My personal take home:
for most, 3/12 anticoag is a safe option, & may reduce the risk of more significant VTE
if high risk for progression (prev VTE, cancer, pregnancy) = anticoagulate
if high risk of bleeding or pt preference; serial US a reasonable option
My personal take home:
for most, 3/12 anticoag is a safe option, & may reduce the risk of more significant VTE if high risk for progression (prev VTE, cancer, pregnancy) = anticoagulate if high risk of bleeding or pt preference; serial US a reasonable option
10/10
For more expert reviews/opinion read:
@srrezaie : https://rebelem.com/cactus-trial-anticoagulation-symptomatic-calf-deep-vein-thrombosis/
@WeAreCanadiEM : https://canadiem.org/isolated-distal-dvt-diagnostic-and-management/
& pls feel free to share thoughts/suggestions and correct any errors I’ve made!
For more expert reviews/opinion read:
@srrezaie : https://rebelem.com/cactus-trial-anticoagulation-symptomatic-calf-deep-vein-thrombosis/
@WeAreCanadiEM : https://canadiem.org/isolated-distal-dvt-diagnostic-and-management/
& pls feel free to share thoughts/suggestions and correct any errors I’ve made!
