Evidence-Based Novel Management Options of Acute Deep Vein Thrombosis (DVT) and Prevention of DVT Recurrence in Primary Care Medicine Anno 2018 - 2020

Complete compression ultrasonography (CCUS) rules in and out acute deep vein thrombosis (DVT) and picks up alternative diagnoses (AD) including Baker's cyst, muscle hematomas, old DVT, and superficial vein thrombosis.CCUS from the ileofemoral region to the popliteal and calf veins has become the objective test in routine daily practice to diagnose acute DVT and to classify distal, proximal and inguinal Leg Extremity Thrombosis (LET class I, II and III DVT) extension.Acute DVT patients are recommended to wear medical elastic stockings (MECS) for symptomatic relief of swollen legs for a few weeks.Objective testing with colour duplex ultrasonography (DUS) at time points 1, 3 and 6 months post-DVT for residual vein thrombosis is of critically importance to assess the risk for DVT recurrence and post-thrombotic syndrome (PTS) evolution.Prospective studies clearly indicate that MECS only relieves subjective symptoms of PTS but do not reduce DVT recurrence and do not improve the objective signs of PTS after long-term and lifelong follow-up.Rapid and complete recanalization on DUS within 1 to 3 months post-DVT is associated with no reflux and low risk on DVT and PTS on the basis of which MECS and anticoagulation with vitamin K antagonist or Direct Oral anti-Xa or IIa Coagulant (DOAC) inhibitor can be withhold at 3 months post-DVT.Delayed recanalisation with residual vein thrombosis (RVT) on DUS at 3 months post-DVT is assocated with reflux due to valve destruction and a high risk of DVT recurrence and PTS indicating the need to extend anticoagulation for 6 momths to 1 year in the absence of PTS and for 2 years in the presence of PTS.Direct Anticoagulants: DOACs preferentially apixaban twice daily have become the first line treatment option of acute DVT and PE for effective reduction of venous thromboembolism (VTE).Apixaban BID is superior to rivaroxaban OD for 3 to 6 months acute DVT/PE treatment in terms of significantly less major bleeds (MB) clinical relevant non-major (CRNM) bleeds.Low dose apixaban BID daily is the treatment of choice for extended anticoagulation in post-DVT patients at high risk of DVT recurrence.Patients with acute DVT in the ileofemoral veins are at highest risk of DVT recurrence.Catheter Directed Thrombolysis (CDT) on top of anticoagulation for the invasive treatment of acute iliofemoral deep-vein thrombosis compared with standard anticoagulant therapy (vitamine K antagnist or DOAC) alone is noninferior and absolutely not superior in terms of post-thrombotic syndrome sequelae after 1 year.A prospective safety-efficacy DVT-PTS Bridging the Gap management study is proposed in patients with a first distal, proximal and iliofemoral thrombosis to reduce the overall DVT recurrence rate from about 30% to less than 5% patient/years to prevent PTS significantly during long-term follow-up.