Deep venous thrombosis


Clinical Spectrum of Venous thromboembolism

Only 40% of ambulatory ED patients with PE have concomitant DVT[1][2]

Leg Vein Anatomy

Significant risk of PE:

  • Common femoral vein
  • (Superficial) femoral vein
    • (Superficial) femoral vein is part of the deep system, not the superficial system as the name suggests!
  • Popliteal veins

Clinical Features

  • Leg swelling with circumference >3cm more than unaffected side
  • Tenderness over calf muscle
  • Homan's sign - pain during dorsiflexion of foot (SN 60-96% and SP 20-72%)[3]

Differential Diagnosis

Calf pain

Unilateral leg swelling


  • Clinical exam
  • Risk stratification for further testing indicated using, e.g. Modified Wells Score

Modified Wells Score

Can be applied for patients whose clinical presentation is concerning for a DVT in order to risk stratify.

  • Active cancer (<6 mo) (1pt)
  • Paralysis, paresis, or immobility of extremity (1pt)
  • Bedridden >3 days because of symptoms within 4 weeks (1pt)
  • TTP along deep venous system (1pt)
  • Entire leg swollen (1pt)
  • Unilateral calf swelling >3cm below tibial tuberosity (1pt)
  • Unilateral pitting edema (1pt)
  • Collateral superficial veins, not varicose (1pt)
  • Previously documented DVT (1pt)
  • Alternative diagnosis as likely or more likely than DVT (-2pts)


  • A score of 0 or lower → minimal risk - DVT prevalence of 5%. D-dimer testing is safe in this group - negative d-dimer decreases the probability of disease to <1% allowing an ultrasound to be deferred.
  • A score of 1-2 → moderate risk - DVT prevalence of 17%. D-dimer testing still effective and a negative test decreases post-test probability disease to <1%
  • A score of 3 or higher → high risk - DVT prevalence of 17-53% → patients should receive an ultrasound[4]

Upper extremity DVT

Requires ultrasound for diagnosis. Cannot be ruled out with d-dimer.[5]

  • Generally involves axillary or subclavian veins
  • Primary upper extremity DVT typically presents in young healthy individuals
  • Secondary upper extremity DVT often due to indwelling catheters
  • Obtain a chest x-ray to rule out bony abnormalities that may be causing venous obstruction


The distinction between distal and proximal relates to veins below and above the knee respectively.[6] Patients with superficial venous thromboses such as the long saphenous and short saphenous are at risk of developing a DVT, especially in patients who have a history of prior DVT although management with anticoagulation is controversial.[7]

Proximal DVT

Proximal veins are the external iliac, common femoral, greater saphenous, profound femoral, (superficial) femoral vein, popliteal vein

  • If NO phlegmasia cerulea dolens:
  • If phlegmasia cerulea dolens:
    • Consider thrombolytics +/- thrombectomy
    • Anticoagulate with heparin/coumadin x 3 months
  • If anticoagulation contraindicated:

Distal DVT

Distal veins are the anterior tibial, posterior tibial, peroneal, gastrocnemius, soleus.

  • Symptomatic
  • Asymptomatic with extension of thrombus toward proximal veins
  • Asymptomatic without extension
    • Discharge with compressive U/S q2 weeks
  • 2020 review from JAMA[8] recommend treat calf DVT if "severe symptoms or risk factors for pulmonary embolism or extension to proximal veins (such as hospitalization, history of VTE, and cancer)."

VTE in Pregnancy[9]

  • Therapeutic LMWH or unfractionated heparin anticoagulation dose in:
    • Antepartum outpatient with multiple prior VTEs or any VTE with high-risk thrombophilia until 6 weeks postpartum
    • Postpartum inpatient with prior unprovoked, estrogen-provoked VTE, or low-risk thrombophilia for duration of admission
  • Lower prophylactic anticoagulation dose in:
    • Antepartum outpatient with prior unprovoked, estrogen-provoked VTE, or low-risk thrombophilia until6 weeks postpartum
    • Patients admitted > 72 hrs, not at high risk for bleeding or imminent delivery
    • Resume 12 hours after C-section and removal of epidural / spinal needle in indicated patients
  • Halt anticoagulation if imminent delivery, C-section, epidural / spinal needle

Recurrent DVT on Therapeutic Anticoagulation

  • Admit patients for vascular surgery and hematologist consult
  • Consider Greenfield IVC filter placement
  • Typically start heparin for additional anticoagulation

Upper extremity DVT

  • If secondary to catheter, do not necessarily have to remove [10]
  • Anticoagulation as per lower extremity DVTs.
  • Patient should be admitted

Anticoagulation Options

Medication Warfarin (Coumadin) Rivaroxaban (Xarelto) Apixaban (Eliquis)
Standard Dosing
  • Enoxaparin 1mg/kg q12h x 4-5 days
  • Warfarin
    • Starting dose of 5mg/day
    • Give 7d supply with first dose in ED
  • 15mg PO BID x 21 days
    • Then 20mg PO daily (duration depending on risk factors)
  • 10mg PO BID x 7 days
    • Then 5mg PO BID daily (duration depending on risk factors)
Renal Dosing
  • Unfractionated Heparin 80 units/kg bolus
    • Then 18 units/kg/hour
    • Check PTT after 6hr; adjust infusion to maintain PTT at 1.5-2.5x control
  • Warfarin as above
  • Check creatinine on all patients prior to initiation
  • CrCl <30 avoid use
  • No dosage adjustments necessary for renal impairment
    • However, CrCl <25 mL/minute were excluded from clinical trials

Contraindications to anticoagulation

  • Active hemorrhage
  • Platelets <50
  • History of intracerebral hemorrhage



Consider if all of the following are present:

  • Ambulatory
  • Hemodynamically stable
  • Low risk of bleeding in patient
  • Absence of renal failure
  • Able to administer anticoagulation with appropriate monitoring
  • Able to arrange for 2-3 day follow-up


For any of the following:

  • Ileofemoral DVT that is a candidate for thrombectomy (should have the following):[11]
    • Acute iliofemoral DVT (symptom duration <21 days)
    • Low risk of bleeding
    • Good functional status and reasonable life expectancy
  • Phlegmasia cerulea dolens
  • High risk of bleeding on anticoagulation
  • Significant comorbidities
  • Symptoms of concurrent PE
  • Recent (within 2 weeks) stroke or transient ischemic attack
  • Severe renal dysfunction (GFR < 30)
  • History of heparin sensitivity or Heparin-Induced Thrombocytopenia
  • Weight > 150kg
  • Upper extremity DVT

See Also


  1. Righini M, Le GG, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008; 371(9621):1343-1352.
  2. Daniel KR, Jackson RE, Kline JA. Utility of the lower extremity venous ultrasound in the diagnosis and exclusion of pulmonary embolism in outpatients. Ann Emerg Med. 2000; 35(6):547-554.
  3. Anand SS, et al. Does this patient have deep vein thrombosis? JAMA. 1998; 279(14):1094-9.
  4. Del Rios M et al. Focus on: Emergency Ultrasound For Deep Vein Thrombosis. ACEP News. March 2009.
  5. Kucher N. Clinical practice Deep-vein thrombosis of the upper extremities. N Engl J Med. 2011;364:861–869.
  6. Gualtiero P. How I treat isolated distal deep vein thrombosis (IDDVT). Blood 2014 123:1802-1809; doi:
  7. Litzendorf ME. Satiani B. Superficial Venous thrombosis:disease progression and evolving treatment approaches. Vasc Health Risk Manag. 2011(7). 569-575
  8. Diagnosis and Treatment of Lower Extremity Venous Thromboembolism: A Review. JAMA. 2020 Nov 3;324(17):1765-1776. doi:
  9. DʼAlton ME et al. National Partnership for Maternal Safety: Consensus bundle on venous thromboembolism. Obstet Gynecol 2016 Oct; 128:688.
  10. Kovacs MJ et al. A pilot study of central venous catheter survival in cancer patients using low-molecular-weight heparin (dalteparin) and warfarin without catheter removal for the treatment of upper extremity deep vein thrombosis (the catheter study) JTH. 2007;5:1650–1653.
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