Management of venous thromboembolism.
OBJECTIVE
To describe the drugs used to treat venous thromboembolism (VTE) and to review particular aspects of the management (elastic stockings, thrombolysis, thrombectomy, vena cava filter).


METHODS
Our review of the literature is focused on consensus documents and recent large randomized trials.


RESULTS
Subcutaneous low molecular weight heparins (LMWH) have been shown to be both safe and effective for the initial treatment of VTE and have largely replaced unfractionated heparin, unless there is a contraindication to LMWH such as severe renal insufficiency. Low molecular weight heparins or unfractionated heparin are usually administered for five to seven days. Treatment is gradually switched from heparin to oral vitamin K antagonists (VKA) which are usually started the same day as heparin. The duration of oral anticoagulation must be tailored to the individual patient according to the presence of reversible or continuing risk factors. In patients with active cancer, long-term treatment of VTE with LMWH has been shown to be more effective than oral anticoagulation and is recommended for the first three to six months of long-term anticoagulant therapy as an alternative approach to VKA. Elastic stockings are recommended because they have been shown to prevent postthrombotic syndrome. Thrombolysis is, usually, not justified for the treatment of deep venous thrombosis, but is used in cases of massive pulmonary embolism with arterial hypotension and/or shock. Vena cava filter placement is mainly indicated in patients with a proximal deep venous thrombosis and an absolute contraindication to anticoagulation.


CONCLUSIONS
The initial management of patients with acute VTE has largely been simplified due to the use of LMWH. Early conversion to VKA is recommended for the great majority of patients. New agents, such as anti-Xa or oral thrombin inhibitors, are promising alternatives to heparins or VKA.
de Moerloose
Philippe
P
Service d'Angiologie et d'Hémostase, Hôpitaux Universitaires de Genève, 1211 Geneva 14, Switzerland. philippe.demoerloose@hcuge.ch
Samama
Charles Marc
CM
Motte
Serge
S
D000818:Animals; D000925:Anticoagulants / Q000627:therapeutic use; D001458:Bandages; D017128:Embolectomy; D006801:Humans; D017131:Thrombectomy; D013923:Thromboembolism / Q000517:prevention & control / Q000628:therapy*; D015912:Thrombolytic Therapy; D016306:Vena Cava Filters
D000925:Anticoagulants