Management of venous thromboembolism

Summary

The therapy of deep venous thrombosis consists of several elements and depends on the localization, the age and the extent of the thrombus. In addition, the patient’s age and the life expectancy may influence the modality of treatment. The present overview discusses various types of initial therapy and long-term treatment of venous thromboembolism and also reviews future perspectives of pharmacological treatment. The initial treatment regimens comprise thrombolysis, thrombectomy, inferior vena cava filters and the anticoagulation with either unfractionated heparin or low molecular weight heparins. Thrombolysis is only effective in the initial phase of acute thromboembolic disorders, and the potential benefits must be balanced against the risk of hemorrhage. In the case of totally occlusive venous thrombosis, a successful outcome is more likely if the thrombolytic agent is infused into the thrombus via catheter directed thrombolysis. Thrombectomy should be considered in patients with acute iliofemoral venous thrombosis of less than seven days duration and a life expectancy of more than ten years. A filter device should be inserted in the inferior vena cava in patients with venous thrombosis above the knee when anticoagulation is contraindicated or when adequate anticoagulation fails to prevent recurrent embolism. The intravenous administration of unfractionated heparin has been the modality of choice for initial treatment of venous thromboembolism during several decades, however, this type of therapy requires an aPTT-adjusted dosing due to a broad interindividual variation of laboratory results. Numerous clinical trials have provided firm evidence that low molecular weight heparins given subcutaneously are significantly superior to intravenous, unfractionated heparin with regard to thrombus regression and reductions of severe hemorrhages, mortality and recurrent thromboembolism. Thus, these preparations may become the treatment of choice in the near future. Pulmonary embolism may be treated with low molecular weight heparins as well.

Long-term treatment of venous thromboembolism is usually performed with oral anticoagulants. The recommended therapeutic range is an INR of 2.0 to 3.0, however the optimal duration of oral anticoagulant therapy for patients with acute proximal deep venous thrombosis is uncertain.

Various thrômbin-inhibitors have been tested for initial treatment of thrombosis, however further investigations of their efficacy, safety and cost-effectiveness will have to provide firm evidence on their superiority when compared to unfractionated or low molecular weight heparins.

Keywords

Venous thrombosis - pulmonary embolism - treatment - heparin - low molecular weight heparins - oral anticoagulation - thrombolysis - thrombectomy

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