Reader Responses: How would you manage residual vein thrombosis in this patient with a history of DVT?

Here’s how readers responded to a You Make the Call question about management of residual vein thrombosis in a patient with a history of DVT.


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Check the patient’s platelet count and levels of von Willebrand factor (VWF) antigen, factor VIII, D-dimer, and ADAMTS13 level. You need to remove the IVC filter. In my opinion, if VWF/VWF antigen and FVIII levels are high, it would be a serious condition.

Jae Chang, MD
Orange, CA

I suggest removing the IVC filter because its presence is a very strong risk factor for DVT extension. I doubt whether it was necessary to place the IVC filter at all. Are there any randomized controlled trials showing a benefit for IVC?

Bernhard Lämmle, MD
Mainz, Germany

We generally do not take residual thrombosis on doppler into account for clinical decision making. This is an unusual case, as there has been no anticoagulation so far. Now that bleeding is not an issue, I would consider at least three months of anticoagulation before removing the IVC filter.

Chirag A. Shah, MD
Ahmedabad, India

I would manage this patient with full dose direct oral anticoagulation (DOAC), for example apixaban 10 mg two times daily for a week, then 5 mg two times daily. Once he is past the induction, I would remove the filter if possible and keep him on 5 mg apixaban or an equivalent DOAC for six months, then 2.5 mg twice daily indefinitely. The chronic nature of this process argues against clot lysis unless he has acute exacerbation of symptoms.

Richard Lind, MD
Asheville, NC

The risk is low for rebleeding at this point, three months after transurethral resection of the prostate and arterial embolization. The IVC filter should be removed and the patient should be started on an effective anticoagulant for the next six months.

Francis Ssali, MD
Kampala, Ugand