Clinical Presentation

Typical signs and symptoms of DVT include:

• Swelling, pain, warmth, and redness, usually in one leg (may be unilateral or bilateral)
• Dilated superficial veins over affected area
• Positive Homan’s sign (pain with dorsiflexion of the foot)
• Risk factors for DVT include:
  • Older age (>60 years)
  • Obesity
  • Recent surgery or trauma
  • Prolonged immobility
  • Active cancer
  • Estrogen therapy or pregnancy
  • Previous DVT/PE or clotting disorder
  • Indwelling central venous catheter

Special Populations

Several patient populations require special consideration when managing DVT:

• Pregnancy – VTE risk increases 4- to 5-fold during pregnancy. Low molecular weight heparins (LMWHs) are preferred over warfarin due to lower risks of teratogenicity and bleeding. Monitoring anti-Xa levels is recommended.
• Cancer – Cancer patients have a 4- to 7-fold higher risk of VTE, especially during chemotherapy. Extended anticoagulation is usually warranted. LMWHs are preferred over warfarin in the initial treatment phase.
• Renal dysfunction – For CrCl <30 mL/min, unfractionated heparin or LMWH doses may need to be reduced. Direct oral anticoagulants should be avoided or dose reduced depending on the agent.
• Obesity – Weight-based dosing is preferred for LMWHs. Anti-Xa monitoring can help guide proper dosing. Data for direct oral anticoagulants in morbid obesity is limited.
• Elderly – Older patients are at increased risk of bleeding on anticoagulants. Close monitoring is warranted. Drug interactions must also be carefully evaluated.

Complications

• Post-thrombotic syndrome – Venous insufficiency and edema resulting from venous damage. Compression stockings help prevent. Anticoagulation reduces risk.
• Pulmonary embolism – Potentially fatal complication if large clot breaks off and travels to lungs. Proximal DVTs have higher PE risk. IVCFs may be placed prophylactically.
• Recurrent DVT – Anticoagulation therapy does not eliminate risk of recurrence, especially when irreversible risk factors are present. Extended treatment duration may be warranted.