Residual Vein Thrombosis Research Articles

PO-15 Cancer-related venous thrombosis: residual vein thrombosis improves screening for occult cancer

PO-15 Cancer-related venous thrombosis: residual vein thrombosis improves screening for occult cancer

Residual Vein Thrombosis Improves Screening for Occult Cancer: Results On 537 Patients with Idiopathic Deep Vein Thrombosis.

Abstract 3999Poster Board III-935 BackgroundClinical advantage of extensive screening for occult cancer in patients with idiopathic Deep Vein Thrombosis (DVT) is unknown. We have demonstrated that the Residual Vein Thrombosis (RVT)-based screening for occult cancer improves early detection as well as cancer-related mortality (Siragusa S et al. Blood 2007;110(699):OC). Here we report on final analysis of 537 patients over a period of 8 years. Objective of the studyWe conducted a prospective study evaluating whether a RVT-based screening for cancer is sensitive and influences cancer-related mortality. Study designProspective with two cohorts of DVT patients: the first cohort was monitored for clinical overt cancer only (Group A), while the second (Group B) received complete screening for occult neoplasm and subsequent surveillance. Materials and methodsConsecutive patients with a first episode of DVT who presented RVT after 3 month of anticoagulation and without signs and/or symptoms for overt cancer. Screening for occult cancer was based on: ultrasound and/or CT scan of the abdomen and pelvis, gastroscopy, colonoscopy or sigmoidoscopy, hemoccult, sputum cytology and tumor markers. These tests were extended with mammography and Pap smear for women and ultrasound of the prostate and total specific prostatic antigen (PSA) for men. All investigations had to be completed within four-weeks from the assessment of RVT. All patients were followed-up for at least 2 years. Incidence and cancer-related mortality was compared between the two groups by survival curves (Kaplan-Mayer) and related Breslow test for statistics. ResultsOver a period of 8 years, 537 patients were included in the analysis: first cohort included 346 patients (Group A), second cohort 191 (Group B). Clinical characteristics between groups were homogenous. During the follow-up, 8.3% of patients developed overt cancer in group A; in group B, 7.8% of patients had diagnosed cancer at the moment of extensive screening while 2 new cases (0.7%) occurred during the follow-up (Table). The sensitivity of this approach was 92.1% (95% confidence intervals 75.2-104.2). Cancer-related mortality was 7.5% in group A and 3.6% in group B (p< 0.001). ConclusionsThe RVT-based screening for occult cancer is highly effective for improving early detection as well as cancer-related mortality in a cohort of 537 patient with DVT of the lower limbs.TableCancer eventsCharacteristicGroup A (n= 346)Group B (N= 191)Cancer, No (%) at screening time- -15 (7.8)Cancer, No (%) during clinical surveillance29 (8.3)2 (1.0)Density incidence (cases x 1000 p/y)42.339.6Median time of diagnosing cancer, months (range)7.2 (1.3-21.5)3.2 (0-13.2)Cancer-related mortality, No (%)26 (7.5)6 (3.6)Cancer-related mortality, median time (range)19 (3.9-28.2)18 (3.2-6.4) Disclosures:Off Label Use: Hydroxyurea use in myelofibrosis.

How should we determine length of anticoagulation after proximal deep vein thrombosis of the lower limbs?

The current approach for deciding the duration of vitamin K antagonist (VKA) treatment after an episode of venous thrombo-embolism (VTE) is mainly based on the characteristic of the index event (3 months or longer in case of unknown/persistent risk factors, 3 months or less in case of removable causes). However, the length of anticoagulation should be tailored on the patient's risk for recurrent thrombosis as well as for bleeding, but such 'time for decision' is often unclear and the optimal duration of VKA remains debatable. The presence of persistent residual vein thrombosis and increased D-dimer levels after stopping therapy are predictors for recurrent deep vein thrombosis (DVT). Management strategies based on these parameters have been demonstrated to optimize the decision for VKA duration, as they establish the patient's intrinsic risk for recurrent events. This annotation discusses current practice and upcoming approaches regarding the length of VKA treatment after a first episode of DVT.

Residual Vein Thrombosis to Establish Duration of Anticoagulation After a First Episode of Deep Vein Thrombosis: The Duration of Anticoagulation Based on Compression UltraSonography (DACUS) Study

Residual Vein Thrombosis to Establish Duration of Anticoagulation After a First Episode of Deep Vein Thrombosis: The Duration of Anticoagulation Based on Compression UltraSonography (DACUS) Study

Safety of Electroconvulsive Therapy in Psychiatric Patients Shortly After the Occurrence of Pulmonary Embolism

We encountered 2 patients with a psychiatric disorder (depression in one and catatonia in one) accompanied by motor inhibition that was complicated by pulmonary embolism (PE). In both cases, the psychiatric disorder was safely resolved with electroconvulsive therapy (ECT) during anticoagulant therapy. The 2 cases direct our attention to at least 3 important points regarding safe administration of ECT shortly after the occurrence of PE, that is, careful evaluation of cardiac function and residual deep vein thrombosis before the start of an ECT course, adjustment of anticoagulants, and prevention of recurrent deep vein thrombosis and PE by methods in addition to anticoagulant therapy (fluid infusion, use of support hose, and timely ECT).

Residual Vein Thrombosis for Assessing the Optimal Management of Deep Vein Thrombosis in Cancer Patients: An Interim Analysis of the Cancer DACUS Study.

Type and duration of anticoagulation is still matter of debate in cancer patients with acute Deep Vein Thrombosis (DVT) of the lower limbs. Residual Vein Thrombosis (RVT) has been proven to be effective for assessing the optimal duration of oral anticoagulants in non cancer patients (Siragusa S et al Blood2008:112:511-5). In the present study we evaluate the role of a RVT-based management of anticoagulation with Low-Molecular Weight Heparin in cancer patients with acute DVT. Materials and Methods. Cancer patients with a first episode of DVT were treated with LMWH at therapeutic dosage for 1 month followed by dose reduction of 25% in the next 5 months. At this time, they were managed according to RVT findings: those with RVT were randomized to continue anticoagulants for 6 additional months (Group A1) or to stop (Group A2), while patients without RVT stopped LMWH (Group B). Outcomes were recurrent venous thromboembolism and/or major bleeding. Results. Over a period of 18 months, 134 patients were evaluated across 12 centers in Italy; clinical characteristics and duration of follow-up are reported in the Table 1. RVT was detected in 92 (68.6%) patients; recurrent events occurred in 23.4% of those who discontinued and 15.5% of those who continued LMWH (Table 2 and Figure 1). The adjusted Hazard Ratio (HR) for age and sex (Group A2 vs A1) was 1.58 (95% confidence interval [CI], 0.85–2.93; P = .145). Of the 42 (31.3%) patients without RVT, one had a recurrence (2.3%) (Table 2 and Figure 1). The adjusted HR (B vs A1) was 4.54 (CI 2.3–6.66; P =.028). One major bleeding event occurred in each group of patients who stopped (Group A2 and B) and 2 in those who continued anticoagulation (Table 2). Overall, 31 (23.1%) patients died due to cancer progression after a median follow-up of 13.2 months after randomization. Conclusions. The Cancer DACUS is the first study evaluating an individual marker for assessing duration of anticoagulation in active cancer population. This interim analysis shows that absence of RVT identifies a group of patients at low risk for recurrent thrombosis who can safely stop LMWH after 6 months. Figure 1. Kaplan-Meyer curve for recurrent events among groups Figure 1. Kaplan-Meyer curve for recurrent events among groups Table 1. Baseline patients characteristics Group A 1 (n.45) Group A 2 (n.47) Group B (n.42) P value* *P value refers to chi-squared test unless specified. ^Time from randomization (6 months after the index Deep Vein Thrombosis) #Active cancer at the time of diagnosis Female sex (%) 22 (48.8) 23 (48.9) 20 (47.6) 0.999 Age, mean + SD (y) 58.2 ± 12.2 63.7 ± 11.1 57.8 ± 11.6 0.124 Total duration of follow-up, (y)^ 31.5 32.8 29.9 0.146 Mean follow-up, (y)^ 1.2 ± 0.56 1.1 ± 0.53 1.1 ± 0.60 0.156 #Type of cancer: Gastrointestinal, n (%) 16 (35.5) 18 (38.3) 16 (38) 0.32 Genitourinary, n (%) 9 (20) 7 8 (17) 7 (16.6) 0.23 Breast, n (%) (15.5) 8 6 (12.7) 6 (14.2) 0.45 Lung, n (%) (17.7) 5 10 (21.2) 10 (23.8) 0.32 Haematologic, n (%) (11.1) 5 (10.6) 6 (14.2) 0.67 Table 2. Study Outcomes Outcomes Group A 1 (n.45) Group A 2 (n.47) Group B (n.42) P value* * P value refers to chi-squared test unless specified. ** P value refers to Fisher exact test 0.021 0.030 A1 vs B** Recurrences, n/total (%) 7/45 (15.5) 11/47(23.4) 1/42 (2.3) 0.010 A2 vs B** 0.733 A1 vs A2** Recurrences, n/100 person-year (%) 7/34.75 (20.1) 11/40.33 (27.3) 1/38.92 (2.5) 0.008 Type of recurrent VTE DVT 5 8 1 DVT + PE 2 2 0 Isolated PE 0 1 0 Subtype Controlateral 1 2 1 Major bleeding, n/total (%) 2/45 (4.4) 1/47(2.1) 1/42(2.3) 0.054** Major bleeding n/100 person-yr(%) 2/40.17 (4.9) 1/46.83 (2.1) 1/36.75 (2.7) 0.390

Residual vein thrombosis to establish duration of anticoagulation after a first episode of deep vein thrombosis: the Duration of Anticoagulation based on Compression UltraSonography (DACUS) study

AbstractResidual vein thrombosis (RVT) indicates a prothrombotic state and is useful for evaluating the optimal duration of oral anticoagulant treatment (OAT). Patients with a first episode of deep vein thrombosis, treated with OAT for 3 months, were managed according to RVT findings. Those with RVT were randomized to either stop or continue anticoagulants for 9 additional months, whereas in those without RVT, OAT was stopped. Outcomes were recurrent venous thromboembolism and/or major bleeding. Residual thrombosis was detected in 180 (69.8%) of 258 patients; recurrent events occurred in 27.2% of those who discontinued (25/92; 15.2% person-years) and 19.3% of those who continued OAT (17/88; 10.1% person-years). The relative adjusted hazard ratio (HR) was 1.58 (95% confidence interval [CI], 0.85-2.93; P = .145). Of the 78 (30.2%) patients without RVT, only 1 (1.3%; 0.63% person-years) had a recurrence. The adjusted HR of patients with RVT versus those without was 24.9 (95% CI, 3.4-183.6; P = .002). One major bleeding event (1.1%; 0.53% person-years) occurred in patients who stopped and 2 occurred (2.3%; 1.1% person-years) in those who continued OAT. Absence of RVT identifies a group of patients at very low risk for recurrent thrombosis who can safely stop OAT. This trial was registered at http://www.ClinicalTrials.gov as no. NCT00438230.

Thrombophilia as a predictor of persistent residual vein thrombosis

To compare the probability of leg vein recanalization between carriers and non-carriers of thrombophilia after an episode of deep vein thrombosis (DVT) of the lower extremities, we reviewed the clinical records of 472 patients with proximal DVT who were diagnosed with thrombophilia, and had long-term ultrasound scanning. One hundred and thirty-seven patients (29.0%) were carriers of thrombophilia. After adjusting for age, sex, DVT localization and modality of presentation, the hazard ratio of vein recanalization in thrombophilic compared with non-thrombophilic patients was 0.49 (95% CI, 0.38 to 0.63). These findings suggest that thrombophilia is an independent predictor of persistent residual vein thrombosis.

Management Based on Residual Vein Thrombosis to Optimise the Duration of Oral Anticoagulants After Deep Vein Thrombosis

Management Based on Residual Vein Thrombosis to Optimise the Duration of Oral Anticoagulants After Deep Vein Thrombosis

Absence of Residual Vein Thrombosis after an Episode of Idiopathic Deep Vein Thrombosis: Short-Term Anticoagulation Is Safe. The “Extended Dacus Study”.

Background. The optimal duration of Oral Anticoagulant Therapy (OAT) for Deep Vein Thrombosis (DVT) can be tailored by Residual Vein Thrombosis (RVT) (Siragusa S et al. Blood 2003; 102(11):OC183), a marker able to assess the individual risk for recurrent thrombosis. However, in patients with idiopathic DVT the safety of early interruption of OAT, because of absence of RVT, is still debated.Objective of the study. In the present study, we evaluated the safety of withholding OAT, in patients with idiopathic DVT and without RVT, three months after the index thrombotic episode.Study design. Prospective controlled study with two groups: patients without RVT stopped OAT after 3 months while those with RVT continued for additional 3 months.Materials and Methods. Consecutive patients with a first episode of idiopathic DVT of the lower limbs; patients with cancer or known thrombophilia were excluded. At the third months of OAT, RVT was assessed as previously described; briefly, RVT was considered absent when a clot occupying less than 40% of the vein lumen was detected by compression ultrasonography. Events, classified as recurrent DVT and/or Pulmonary Embolism (PE) and/or major and minor bleeding were evaluated; all patients were followed-up for at least 12 months after OAT discontinuation.Results. During the period 1999–2006, 518 patients were included in the study. In 206 (39.7%) RVT was considered absent (RVT negative group) and they stopped OAT; the remaining 312 patients continued anticoagulants for additional 3 months (RVT positive group). Total duration of follow-up (FU) was 184.7 years for RVT negative group (with a mean FU of 3.0 ± 0.83 years) and 191.3 years for RVT positive group (with a mean FU of 3.1 ± 0.89 years). The rate and type of events during FU is reported in table and figure.Conclusions. This investigation shows that in patients without RVT, three months of OAT are safe even after an episode of idiopathic DVT. This hold for at least 30% of the entire DVT population and has an important clinical impact; in fact, it is possible to select a group of patients with a very low risk for recurrences over a period of 3 years. This approach carries also a negligible risk for bleeding.Events between RVT Negative and Positive GroupsOutcomesRVT Neg. group (206)RVT Pos. group (312)"p" valueRecurrences, n/total (%)*2/206 (0.9)63/312 (20.2)<0.0005Recurrences, n/100 person-year (%)*2/184.7 (1.1)63/191.3 (32.9)<0.0005Type of recurrent VTEDVT143DVT + PE06Isolated PE03Controlateral111Major bleeding, n/total (%)**0/2063/312 (0.9)Major bleeding, n/100 person-Yr (%)**0/184.73/191.3 (1.5)*After OAT discontinuation, **During OAT [Display omitted]

Cancer-Related Venous Thrombosis: Residual Vein Thrombosis Improves Screening for Occult Cancer.

Background. Clinical advantages of extensive screening for occult cancer in patients with idiopathic Deep Vein Thrombosis (DVT) is still debated since this approach improves early detection of cancer but not cancer-related mortality. Recently, we have demonstrated that patients with Residual Vein Thrombosis (RVT), 3 months after DVT, have a high risk for cancer in the subsequent 2 years (Siragusa S et al. Blood 2005; 106(11):OC262). At the present it is unknown whether RVT assessment may be used to select patients, with idiopathic DVT, who require screening for occult cancer.Objective of the study. We conducted a prospective study evaluating whether a RVT-based screening for cancer is sensitive and influences cancer-related mortality.Study design. Prospective with two cohorts of DVT patients: the first cohort was monitored for clinical overt cancer only (Group A), while the second (Group B) received complete screening for occult neoplasm and subsequent surveillance.Materials and methods. Consecutive patients with a first episode of DVT who presented RVT after 3 month of anticoagulation and without signs and/or symptoms for overt cancer. Screening for occult cancer was based on: ultrasound and/or CT scan of the abdomen and pelvis, gastroscopy, colonoscopy or sigmoidoscopy, hemoccult, sputum cytology and tumor markers. These tests were extended with mammography and Pap smear for women and ultrasound of the prostate and total specific prostatic antigen (PSA) for men. All investigations had to be completed within four-weeks from the assessment of RVT. All patients were followed-up for at least 2 years. Incidence and cancer-related mortality was compared between the two groups by survival curves (Kaplan-Mayer) and related Breslow test for statistics.Results. Over a period of 6 years, 345 patients were included in the analysis: first cohort included 213 patients (Group A), second cohort 132 (Group B). Clinical characteristics between groups were homogenous. During the follow-up, 8.4% of patients developed overt cancer in group A; in group B, 8.3% of patients had diagnosed cancer at the moment of extensive screening while one new case (0.7%) occurred during the follow-up (Table). The sensitivity of this approach was 91.6% (95% confidence intervals 74.7–108.5). Cancer-related mortality was 6.5% in group A and 3.0% in group B (p< 0.001) (Figure).Conclusions. Our study demonstrates that RVT-based screening for occult cancer improves early detection as well as cancer-related mortality.Cancer events during surveillanceCharacteristicGroup A (n= 213)Group B (N= 132)Cancer, No (%) at screening time*- -**10 (8.3)Cancer, No (%) during clinical surveillance**18 (8.4)1 (0.7)Density incidence (cases x 1000 p/y)41.940.3Mean time cancer diagnosis (months ±SD)6.9 (1.3)3.6 (0.7)Cancer-related mortality, No (%)14 (6.5)4 (3.0)Cancer-related mortality, mean time (months ±SD)19 (3.4)18 (2.8)*4+0.5 months. **At least 24 months [Display omitted]

PO-55 The persistence of residual vein thrombosis, after an episode of deep vein thrombosis, and the risk of new overt cancer

PO-55 The persistence of residual vein thrombosis, after an episode of deep vein thrombosis, and the risk of new overt cancer

Temporary inferior vena cava filter for deep vein thrombosis and acute pulmonary thromboembolism: effectiveness and indication

Although the temporary inferior vena cava filter (IVC-F) is being used increasingly for protection against pulmonary thromboembolism (PTE), indications for its use are not established. Our strategy for the prevention of PTE is: (1) contraindication or failure of anticoagulation: permanent IVC-F; (2) for patients with residual proximal deep vein thrombosis (a) who have permanent risk factor: permanent IVC-F; (b) who have transient risk factor: temporary IVC-F; (3) others: no IVC-F. Temporary IVC-F was also implanted in deep vein thrombosis (DVT) patients without PTE who were preoperation or had floating thrombus. We investigated the outcome of patients given a temporary IVC-F versus those given a permanent IVC-F to clarify the efficacy and our strategy for implantation of a temporary IVC-F. Subjects were 12 men and 38 women with acute PTE and/or floating DVT admitted to our hospital between April 1999 and April 2002. Patient age was 25-91 years (mean 63 years). Eighteen patients were given a permanent IVC-F (group A) and 32 patients were given a temporary IVC-F (group B) as primary treatment, according to our criteria. There were no major complications in either group. Mortality after implantation of the IVC-F was 35% (6/17) in group A and 16% (4/25) in group B, with no significant difference (P = 0.14). Pulmonary thromboembolism recurred in 18% (3/17) of group A patients but in no group B patients (P = 0.10). All recurrences resulted in death. The 14 patients in group B who were not given a permanent IVC-F after removal of the temporary IVC-F survived. The temporary IVC-F can be used safely in patients with venous thromboembolism and is efficacious in preventing recurrence of PTE. Prognosis after removal of the temporary IVC-F is excellent.

Persistance of residual vein thrombosis after an episode of deep vein thrombosis of the lower limbs and the risk of new cancer and cardiovascular disease

8531 Background: In patients with a first episode of idiopathic or provoked Deep Vein Thrombosis (DVT), the presence of Residual Vein Thrombosis (RVT), detected by UltraSonography (US) at the 3rd month from the index DVT, is an independent risk factor for developing recurrent Venous Thromboembolism (VTE) in the subsequent 2 years. Its absence can safely permit to stop Oral Anticoagulants (OA). At the present, it is unknown whether RVT may also identify patients at increased risk for developing cancer and/or cardiovascular disease (CD). In patients with previous DVT of the lower limbs, we conducted a prospective study for evaluating the correlation between RVT findings and the risk of new cancer and/or CD. Methods: Three hundred-forty-five patients, with a previous episode of idiopathic or provoked DVT, were evaluated; presence/absence of RVT was detected at the 3rd month of OA and patients managed consequently. In the present study, the incidence of VTE recurrence, cancer and new CD was evaluated in the subsequent 3 years after the index DVT. The Kaplan-Meyer curve and the Breslow test has been used for the statistical comparison among groups. Results: The results among the 3 groups are listed in the Table. Patients without RVT had a significant reduction in recurrent VTE and new cancer in comparison to patients with RVT; they also showed a not significant trend in the reduction of CD; these data are applicable in patients with idiopathic or provoked index DVT. In patients with RVT, the advantage of prolonging anticoagulation over 12 months (Group A1) is lost at the end of the treatment. Conclusions: US-detected RVT, at 3rd month from the index DVT, is an independent risk factor for recurrent VTE and cancer; this risk remains over a period of 3 years, independently whether index DVT was idiopathic or provoked. In these patients, the advantage of indefinite anticoagulation should be assessed in properly designed study. [Table: see text] No significant financial relationships to disclose.

The Persistance of Residual Vein Thrombosis, after an Episode of Deep Vein Thrombosis, and the Risk of New Overt Cancer and Cardiovascular Disease.

Background. We have recently demonstrated that the presence of Residual Vein Thrombosis (RVT), UltraSonography (US)-detected at the 3rd month after an episode of Deep Vein Thrombosis (DVT) of the lower limbs, is an independent risk factor for developing recurrent Venous Thromboembolism (VTE). The management of DVT patients by detection of RVT may, therefore, represent a simple and reproducible method for establishing the individual risk of recurrence and for tailoring the optimal duration of Oral Anticoagulants (OA) (Siragusa S et al. Blood 2003; 102(11):OC183a). At the present, it is unknown whether RVT may also identify patients at increased risk for cancer and/or cardiovascular disease (CD).Objective of the study. In patients with DVT of the lower limbs, we conducted a prospective study for evaluating the correlation between RVT and the risk of new overt cancer and/or CD.Materials and methods. Consecutive patients, with an episode of idiopathic or provoked DVT, were evaluated after 3 months from the index DVT; presence/absence of RVT was detected and patients managed consequently (table). The incidence of VTE recurrence, overt cancer and new CD was evaluated over a period of 3 years after the index DVT. Survival curves (Kaplan-Mayer) and related Breslow test have been used for statistics.Results. Three-hundred fourty-five patients were included in the analysis. The results are listed in the table and figures. The incidence of recurrent VTE and new overt cancer was statistically lower in patients without RVT than in those with RVT; no significant differences were found in the incidence of new CD. These data are applicable in patients with idiopathic or provoked index DVT. In patients with RVT, the advantage of prolonging anticoagulation for 12 months was lost at the end of the treatment.Conclusions. This is the first study evaluating the relationship between US-detected RVT and the risk of developing cancer and CD; RVT presence, at 3rd month from the index DVT, is an independent risk factor for recurrent VTE and indicates patients at risk for new overt cancer. This risk remains over a period of 3 years, independently whether index DVT was idiopathic or provoked. In these patients, the advantage of indefinite anticoagulation should be assessed in properly designed study.Incidence of events over a period of 3 years accordingly to RVT findingsGroupNumber of patientsPresence of RVT at the 3rd months of OA from the index DVTDuration of OA from the index DVTIncidence of recurrent VTEIncidence of new cancerIncidence of new CDGroup *A1142yes12 months11 (7.7%)8 (5.6%)7 (4.9%)Group *A291yes3 months16 (17.5%)9 (9.9%)7 (7.7%)Group B112no3 months1 (0.9%)3 (2.6%)4 (3.5%)*Part of these patients were originally randomized to receive 3 or 12 months of OA [Display omitted] [Display omitted]

Extended Anticoagulation Therapy for the Primary and Secondary Prevention of Venous Thromboembolism

Extending the period of anticoagulation is an active area of investigation in both primary and secondary prevention of venous thromboembolic disease. In orthopaedic surgery, particularly in patients undergoing hip surgery, there is a growing interest in using extended anticoagulation beyond that traditionally given in the postoperative period using low-molecular weight heparin, oral anticoagulants, or newer agents such as fondaparinux sodium. Most studies show a benefit to extending anticoagulation without a considerable increase in major bleeding. There have been several large clinical trials addressing the question of extending oral anticoagulation in secondary prevention of venous thromboembolism (VTE). Just how long anticoagulation should be given in the treatment of venous thromboembolic disease remains an open question, depending on the nature of the initial VTE, associated patient risk factors and the risks of major bleeding. Future directions include the use of newer agents for anticoagulation as well as methods of better defining who will benefit most from extended anticoagulation based on an identification of risk factors with the aid of markers such as D-dimer or residual vein thrombosis.

Oral anticoagulant therapy in venous thromboembolism.

The main objective of treatment of venous thromboembolism (VTE) is the prevention of the extension, embolization, and recurrence of thrombosis. The long-term aim is to prevent late recurrences and the post-thrombotic syndrome. Heparin and oral anticoagulants (OACs) have been the cornerstones of VTE treatment in the last 30 years. Low molecular weight heparins (LMWHs) have been introduced more recently in the treatment of the acute phase of VTE, and they have allowed the home treatment of deep vein thrombosis (DVT) in selected cases. The optimal duration of OAC therapy after VTE is still controversial. Several studies have been conducted, and several are ongoing with the aim to stratify patients into risk categories for recurrence. Patients at high risk are candidates for long-term oral anticoagulation as the benefits of extended oral anticoagulation would outweigh the risk of bleeding. Patients are currently stratified into risk categories on the basis of clinical characteristics of the VTE event: (1) first or recurrent event; (2) idiopathic or due to a transient risk factor such as surgery, trauma, hormonal therapy, or immobilization; (3) presence of active cancer; (4) location (proximal DVT and/or pulmonary embolism, PE, or distal DVT); and (5) presence of known hereditary or acquired thrombophilia. Patients with distal VTE or VTE due to a transient risk factor are at a low risk of recurrence and short-term anticoagulation is indicated (3 months). Patients with an idiopathic event or with known thrombophilic defects such as FV Leiden or the G20210A prothrombin mutation are candidates for a longer course of therapy (6 months). Patients with cancer, antiphospholipid antibodies syndrome, recurrent idiopathic event, antithrombin deficiency, protein C or protein S deficiency, homozygosity for FV Leiden, and double heterozygosity are candidates for extended long-term anticoagulation. More recently, studies have indicated that other factors such as D-dimer levels after the discontinuation of OAC therapy or the residual vein thrombosis could be additional predictive factors for recurrences. In patients with VTE and cancer, oral anticoagulation poses a higher risk of bleeding, and such patients are more prone to recurrences. Alternative treatment with LMWH could be safer and more effective in these patients.