Therapy For Deep Vein Thrombosis Research Articles

A Blue Leg: An Interventional Approach to a Limb-Threatening Deep Vein Thrombosis

A Blue Leg: An Interventional Approach to a Limb-Threatening Deep Vein Thrombosis

Compression therapy for deep vein thrombosis - why, yes!

Compression therapy for deep vein thrombosis – why, yes!Eva FreisingerEva FreisingerSearch for more papers by this authorPublished Online:August 28, 2017https://doi.org/10.1024/0301-1526/a000641PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMoreFiguresReferencesRelatedDetails Volume 46Issue 5August 2017ISSN: 0301-1526eISSN: 1664-2872 Published onlineAugust 28, 2017 InformationVasa (2017), 46, pp. 406-406 https://doi.org/10.1024/0301-1526/a000641.© 2017Hogrefe AGPDF download

Gastrointestinal Bleeding During Anticoagulant Therapy for Deep Vein Thrombosis after Simultaneous Pancreas and Kidney Transplantation

A 46-year-old Japanese woman on dialysis for type 1 diabetes and chronic renal failure underwent simultaneous pancreas and kidney transplantation from a brain-dead donor. On postoperative day 3, ilio-femoral deep vein thrombosis on the side of pancreatic transplantation was diagnosed from swelling of the right leg, an increased D-dimer level, and imaging findings. Anticoagulant therapy was initiated to prevent proximal propagation of the thrombosis and pulmonary thromboembolism. However, gastrointestinal bleeding occurred, which was thought to be due to mucosal bleeding from the duodenal graft. Her anticoagulant therapy was adjusted and hemostasis was conducted, controlling the gastrointestinal bleeding without surgical intervention. Blood flow was maintained to both grafts and graft function was good. When gastrointestinal bleeding occurs during anticoagulant therapy for deep vein thrombosis after combined pancreas and kidney transplantation, bleeding can be controlled by adjusting anticoagulant therapy and other appropriate measures.

Evaluation of Inpatient Thrombophilia Pathway

Introduction:Venous thromboembolism (VTE) ranges from asymptomatic deep vein thrombosis (DVT) to fatal pulmonary emboli (PE). VTE is the third most common cardiovascular illness and cause of mortality after acute coronary syndrome and stroke. Medical societies such as American Society of Hematology (ASH), British Society for Haematology, and Society for Vascular Medicine have all created selection criteria, consistent with each other, for when to order a hereditary thrombophilia workup. Guidelines indicate that thrombophilia testing should not be offered to patients who are continuing anticoagulation treatment, or to those who have had "provoked" VTE. Examples include patients who have had a transient risk factor within the past 3 months including surgery, trauma, prolonged immobility, pregnancy or puerperium, and patients on hormonal therapy. The aims of our study is to identify the prevalence of hypercoagulable testing in our hospital, evaluate how our organization follows certain criteria for patients presenting with DVT or PE, and to calculate the economic impact of ordering these workups unnecessarily.MethodsWe conducted a retrospective chart review from July 2014 to June 2015 that identified individuals that were admitted to the hospital with a diagnosed DVT or PE detected by lower extremity doppler ultrasound or computed tomography of the lungs. Inclusion criteria included newly diagnosed patients with DVT or PE. Frequencies were calculated for sex, work-up, ethnicity, smoking, estrogen therapy, malignancy, and history of VTE. Further analysis was run using work-up as predictor variable and cross tabulated with sex, ethnicity, smoking, estrogen therapy, malignancy and history of VTE. Independent t-test were conducted between work-up and age and BMI levels.ResultsWe identified 241 patients admitted to the hospital for DVT or PE. Within this population, 57 individuals (23.7%) had the hypercoagulability pathway. A majority of the patients within this subpopulation were female (57.9%). Sensitivity analysis for the 57 individuals who underwent work-up also included 38.6% with a smoking history, 3.5% on estrogen therapy, 86% without history of malignancy, 40.4% with history of previous DVT or PE, and 89.5% of the patients being Caucasian. The average age and BMI was 55 and 32.9 respectively. No significant relationship was found between the work-up and sex (p= 0.11), ethnicity (p=.65), smoking (p=0.46), estrogen therapy (p= 0.8), without malignancy (p=.051), and history of DVT or PE (p=0.12). There was a significant relationship between age and work-up (p=0.002), with younger patients more likely to have the work-up.ConclusionOur study indicated that younger patients presenting with VTE were likely to under go work-up for thrombophilic disorders. Patients without malignancy and those who did not smoke were also more likely to undergo a work-up. In addition to this, women not on estrogen therapy were less likely to receive a work-up. Even though our results allude to inappropriate thrombophilia testing, we lack statistical significance due to our population size and patient diversity.These tests are expensive, with costs approaching $3,000 for a full thrombophilia panel. This totals around $100,000 to $160,000 of cost savings for the 53 individuals that had the work-up within the one year span. This cost analysis does not include the expense accrued by the patient for prolonged anticoagulation plus the ongoing lab costs of INR monitoring. Research should be further investigated in a larger and more diverse population for better understanding for the role of thrombophilia evaluation in the inpatient setting. DisclosuresNo relevant conflicts of interest to declare.

Endovaskuläre Rekanalisation von Beckenvenenverschlüssen

Deep vein thrombosis (DVT) is associated with a high cost burden for health care systems because of secondary cost intensive complications like pulmonary embolism and especially the post thrombotic syndrome (PTS). The current standard therapy of anticoagulation for DVT therapy has not changed through the years leaving patients especially with iliofemoral vein thrombus on a high-risk situation for developing PTS. Current study situation for endovascular treatment of iliofemoral DVT treatment gives a rationale for active thrombus removal using catheter directed therapy (CDT) or pharmacomechanical thrombectomy (PMT) which improves valvular vein function and luminal patency reducing the potential complication of PTS. For patients with chronich obstruction of the iliac vein system dedicated venous stents and recanalization techniques are today available.

Quantitation of Venous Clot Lysis With D-Dimer Assay During Catheter-Directed Thrombolysis for Lower Extremity Deep Venous Thrombosis

This study evaluated whether D-dimer (DD) concentration analysis is a useful approach for noninvasive monitoring of clot lysis during catheter-directed thrombolysis (CDT) for deep vein thrombosis (DVT). DD levels have been found to be elevated during fibrinolytic therapy for DVT. Therefore, measuring the level of DD is a potential alternative method to assess the effect of fibrinolytic therapy. From January 2013 to March 2014, 32 patients with symptomatic acute DVT involving the iliac or femoral veins were treated using CDT. Urokinase was the thrombolytic agent. Demographics, procedural details, DD concentration, and thrombus score were recorded before and after the thrombolytic therapy. The peak DD concentration was 35.35 ± 11.18 μg/mL during CDT therapy, and the time-integrated DD concentration was 157.95 ± 69.46 μg·d/mL. The peak DD concentrations were higher in patients with substantial lysis compared with those in patients with minimal or no lysis (40 ± 0 versus 30.7 ± 14.57 μg/mL; P = 0.016). The time-integrated DD concentrations were also higher in patients with substantial lysis compared with those in patients with minimal or no lysis (194.14 ± 37.57 units versus 121.75 ± 75.93 units, P = 0.002). There was a moderate correlation (r = 0.57) between the peak DD level and the lysed clot volume. There was also a correlation between the time-integrated DD and clot lysis (r = 0.65). DD concentration analysis offers an alternative approach to noninvasive monitoring of venous clot lysis during CDT for DVT.

Simvastatin ameliorates deep vein thrombosis in rabbits by regulating the fibrinolytic system.

The study aimed to observe the therapeutic effect of simvastatin in a deep vein thrombosis (DVT) animal model and conduct a preliminary study into its mechanism. A total of 72 New Zealand white rabbits were randomly divided into control group (n = 18), low molecular weight heparin (LMWH) group (n = 18), simvastatin group (n = 18), and simvastatin + LMWH group (n = 18). A posterior vena cava thrombus model was established and interventions were administered according to the group procedures. Blood plasma was sampled before and 3, 7, and 14 days after the intervention when the vena cava (including thrombus) specimen was collected. Specimens were weighed, histopathologically examined, and monitored for changes in venous wall inflammation. Concentrations of P-selectin, plasminogen activator inhibitor (PAI-1), and the urokinase plasminogen activator (u-PA) activity were measured with enzyme-linked immunosorbent assay. P-selectin expression in the venous wall was measured with immunohistochemistry, and quantitative PCR detected the changes of local PAI-1/u-PA expression. Simvastatin and LMWH reduced the weight of the thrombus and promoted thrombus dissolution. Simvastatin significantly inhibited the systemic and local expression of P-selectin, whereas LMWH was inhibitory only at the late stage of the acute phase. Plasma active concentration and local gene expression of PAI-1 was inhibited by simvastatin, whereas for u-PA; it was promoted at the early stage of the acute phase, but inhibited in the late stage. Simvastatin inhibited the expression of inflammatory mediators, reduced the DVT inflammatory response, alleviated inflammatory injury and reduced thrombus formation. Simvastatin may provide a beneficial adjuvant therapy for DVT.

Cinderella indications for compression therapy

Not available

D-Dimer Levels and Vitamin K Antagonist Therapy in Deep Vein Thrombosis of the Legs

D-dimer levels are closely related to the clinical status of deep vein thrombosis (DVT). This study aimed to investigate the factors which were associated with the normalization of D-dimer level by vitamin K antagonist (VKA) therapy, the maintenance of normal D-dimer levels for 6months during VKA therapy, and the recurrent elevations of D-dimer above normal level after VKA withdrawal, in DVT of the legs. The 469 consecutive patients with first-episode leg swelling were examined. All blood tests were measured from the initially sampled blood before the administration of medications. Of the 469 patients, 288 (61.4%) showed positive D-dimer test. Radiologic examinations, including Doppler ultrasound and computed tomography venography, of the 288 patients revealed positive DVT of the legs in 135 (46.9%) patients and of these, 122 with total follow-up durations of >6months were enrolled in this study. Linear regression analysis of 100 patients who experienced D-dimer normalization revealed initial D-dimer levels were positively correlated with D-dimer normalization time during VKA therapy (P=0.010). Logistic regression analysis showed initial D-dimer level was negatively associated with the normalization of D-dimer levels by VKA therapy (P=0.045), and being a woman (P=0.005) and having lower protein C (P=0.002) level had negative impacts on the maintenance of normal D-dimer levels for 6months during VKA therapy. Finally, after VKA withdrawal, the recurrent elevations of D-dimer above normal level were more likely to occur in women than in men (P=0.004). From these observations, it is suggested that higher initial D-dimer level, lower protein C level, and female gender may be the adverse risk factors for the treatment of DVT of the legs using VKA.

Evaluation of the deep vein recanalisation and function after low molecular weight heparin (calcium nadroparine) therapy of deep vein thrombosis. Preliminary report

Introduction. The standard treatment for acute episode of deep vein thrombosis (DVT) included at least five days administration of unfractionated heparin followed by oral anticoagulants (OAs) in the subsequent months. In the early 2000s the use of low-molecular-weight heparins (LMWH) was recommended and validated as the equivalent for the standard therapy of acute episode of DVT. The aim of this study was to evaluate the patency of thrombotic venous segments and indirectly the function of valves after therapy with calcium nadroparine in the 10 days ambulatory treatment and three-month secondary prophylaxis of acute DVT. Material and methods. The study group consisted of 50 patients (10 females and 40 males), aged 33 to 92 years (mean age 62.3 years) with first episode of acute, symptomatic deep vein thrombosis of the lower extremities, below the inguinal ligament, who were followed-up during their 10 days ambulatory treatment and three-month secondary prophylaxis with calcium nadroparine. Each patient had clinical examinations and ultrasound of the veins of the lower extremities, using the colour-coded power Doppler ultrasound (CDU) performed by the same experienced physician, using TOSHIBA device (linear probe 6–12 MHz), on day 1 and 10 of the treatment period and after 1 and 3 months of secondary prophylaxis phase. All patients underwent the following laboratory tests: before treatment the coagulation profile, blood group and complete blood count; the control platelet count was performed after 7 to 10 days of LMWH treatment, and then every 10 days. Results. The thrombosis was revealed in the femoro-popliteal segment in 35 (70%) subjects and below the knee in the remaining 15 (30%) patients. There was no case of DVT recurrence, thromboembolic event or death in patients who received LMWH therapy during the 3-month follow-up period. No adverse effects of the treatment were observed. CDU revealed the complete venous recanalisation in 40 (80%) patients and partial recanalisation with residual thrombi and/or wall thickening in the remaining 10 (20%) subjects. After the 3-month treatment period deep vein reflux was not observed in 30 (60%) patients, whereas the remaining 20 (40%) were diagnosed with only an insignificant reflux (lasting 1–2 seconds). Conclusions. The calcium nadroparine therapy is an efficient, safe and well tolerated method of ambulatory treatment and secondary prophylaxis of the acute, symptomatic deep vein thrombosis of the lower extremities. Further, longer and prospective, multi-centre studies are required for better evaluation of the early and late results of DVT treatment with LMWH. They would allow investigating their effect on venous recanalisation, its function and prevention of post-thrombotic syndrome.

Warfarin-induced venous limb gangrene following heparin-induced thrombocytopenia during anticoagulation therapy for deep vein thrombosis and pulmonary thromboembolism

Warfarin-induced venous limb gangrene following heparin-induced thrombocytopenia during anticoagulation therapy for deep vein thrombosis and pulmonary thromboembolism

Management of Deep Vein Thrombosis in Emergency Departments;Time to Change the Viewpoint.

Clot formation within a deep vein is called deep vein thrombosis (DVT). It occurs in about 100 persons per 100,000 population each year in the United States and leads to about 600,000 pulmonary thromboembolism (PTE) cases and also causes 60,000 deaths annually. For many years, unfractionated heparin (UFH) and warfarin have been used for treatment of DVT and prevention of PTE. This approach needs hospitalization and necessitates close monitoring by partial thromboplastin time (PTT) measurement. By development of low molecular weight heparin (LMWH) the need for laboratory monitoring was resolved. In addition, some investigators also claimed that it is accompanied with less bleeding risk and better outcome. Accordingly, outpatient management of DVT became possible and nowadays American College of Chest Physicians (ACCP) advocates outpatient therapy for DVT. This method has been shown to be safe and effective in presence of home adequacy criteria. Home adequacy is defined by ACCP as “well-maintained living conditions, strong support from family or friends, phone access, and ability to quickly return to the hospital if there is deterioration”. Yet, many physicians in Iran prefer to hospitalize all DVT patients because of their belief in the impossibility of outpatient treatment.

Huge Ancient Hematoma in the Calf.

Huge Ancient Hematoma in the Calf.

Xalia, a Non-Interventional Study Comparing Rivaroxaban with Standard Anticoagulation for Initial and Long-Term Therapy in Deep Vein Thrombosis

BackgroundRivaroxaban is approved for the treatment and secondary prevention of acute deep vein thrombosis (DVT) and pulmonary embolism (PE). The aim of the XALIA study was to provide information on the safety and effectiveness of rivaroxaban in routine patient care in a heterogeneous non-selected venous thromboembolism (VTE) population.MethodsXALIA is a multicenter, prospective, non-interventional study and included patients aged ≥18 years with objectively confirmed, acute DVT treated with oral rivaroxaban (the initial approved VTE treatment indication) or standard anticoagulation therapy for ≥3 months. After approval of rivaroxaban for the PE indication, patients with DVT and concomitant PE were also included. Type, dose, and duration of drug therapy were at the physician's discretion. Patients were followed up until 30 days after the end of treatment or study conclusion. The primary statistical analysis includes a descriptive analysis of the primary outcomes of major bleeding and recurrent VTE, which were centrally adjudicated under assessor-blinded conditions; hazard ratios (HRs) with 95% confidence intervals (CIs) from a Cox regression model adjusted for active cancer only are shown.ResultsThis study enrolled 5142 patients across 21 countries, in Europe, Israel, and Canada, between June 2012 and March 2015. Six patients did not receive anticoagulant therapy and 368 patients were treated for >2-14 days with heparin/fondaparinux or 1-14 days with a vitamin K antagonist (VKA) before starting rivaroxaban (as described in the XALIA protocol paper, the latter were defined as 'early switchers' and included in a separate sensitivity analysis [Ageno et al. Thromb J 2014;12:16]).Thus, the primary analysis comprised 2619 patients in the rivaroxaban group (rivaroxaban only or </= 2 days of parenteral treatment) and 2149 in the standard-therapy group (of whom most received low molecular weight heparin plus a VKA). The mean patient ages were 57.3 and 63.0 years, 55% and 52% were male, 5.6% and 19.1% had active cancer at baseline, 3.9% and 10.1% had creatinine clearance (CrCl) <50 mL/min, and 8.4% and 11.9% also had PE in the rivaroxaban and standard-therapy groups, respectively. Patient demographics and baseline clinical characteristics are shown (Table 1).The major bleeding rate was 1.23%/year (n=19) for patients in the rivaroxaban group and 3.32%/year (n=47) for patients in the standard-therapy group. After adjustment for active cancer at baseline, the HR was 0.41 (95% CI 0.24-0.71). The recurrent VTE rate was 2.21%/year (n=34) for patients in the rivaroxaban group and 3.64%/year (n=51) for patients in the standard-therapy group. The HR adjusted for active cancer at baseline was 0.64 (95% CI 0.41-1.00).In the early switcher group, the mean patient age was 59.3 years, 57% were male, 8.2% had active cancer at baseline, 6.5% had CrCl <50 mL/min, and 20.9% had DVT plus PE (Table 1). The event rate in the early switcher group for major bleeding was 1.97%/year and the event rate for recurrent VTE was 2.76%/year.ConclusionsXALIA is the first large non-interventional study comparing the safety and effectiveness of a direct oral anticoagulant, specifically rivaroxaban, in VTE treatment with conventional anticoagulation therapy. The outcomes are consistent with the findings of the EINSTEIN phase III studies, with low rates of major bleeding and symptomatic recurrent VTE (EINSTEIN Investigators. N Engl J Med 2010;363:2499). However, the unadjusted data show that treatment allocation may have been influenced by patient characteristics such as age and co-morbidities, which could affect outcomes. Owing to the differences in patient baseline characteristics, ongoing propensity-score analyses will be presented.Table 1Patient Demographics and Baseline Clinical CharacteristicsCharacteristicRivaroxaban(n=2619)Standard therapy(n=2149)Early switchers(n=368)Mean age, years57.363.059.3Male (%)555257Active cancer (%)5.619.18.2CrCl <50 mL/min (%)3.910.16.5Concomitant PE (%)8.411.920.9 DisclosuresTurpie:Bayer HealthCare: Consultancy, Honoraria; Janssen Research & Development: Consultancy, Honoraria; Astellas: Consultancy, Honoraria; Portola: Consultancy, Honoraria; Takeda: Consultancy, Honoraria. Mantovani:Bayer HealthCare: Consultancy, Honoraria, Speakers Bureau; Boehringer Ingelheim: Research Funding; Pfizer: Research Funding; Bristol-Myers Squibb: Research Funding; Daiichi Sankyo: Research Funding. Haas:Bayer HealthCare: Honoraria; Bristol-Myers Squibb: Honoraria; Boehringer Ingelheim: Honoraria; Daiichi Sankyo: Honoraria; Pfizer: Honoraria; Sanofi: Honoraria; Aspen: Honoraria. Kreutz:Daiichi Sankyo: Honoraria; Bristol-Myers Squibb: Honoraria; Berlin-Chemie: Honoraria; Bayer HealthCare: Consultancy, Honoraria. Monje:Bayer HealthCare: Employment. Schneider:Bayer HealthCare: Employment. van Eickels:Bayer HealthCare: Employment. Gebel:Bayer HealthCare: Employment. Ageno:Boehringer Ingelheim: Research Funding; Bristol-Myers Squibb: Honoraria; Pfizer: Honoraria; GlaxoSmithKline: Research Funding; Bayer HealthCare: Honoraria, Research Funding; Daiichi Sankyo: Honoraria; Alexion Pharmaceuticals: Research Funding.

Endovascular Therapy Is Effective for Leriche Syndrome with Deep Vein Thrombosis.

A 65-year-old man presented to our hospital due to intermittent claudication and swelling in his left leg. He had Leriche syndrome and deep vein thrombosis. We performed endovascular therapy (EVT) for Leriche syndrome, and a temporary filter was inserted in the inferior vena cava. He received anticoagulation therapy for deep vein thrombosis. The stenotic lesion in the terminal aorta was stented with an excellent postprocedural angiographic result and dramatic clinical improvement after EVT. This case suggests that EVT can be a treatment for Leriche syndrome.

若年発症の深部静脈血栓症に対して局所的血栓溶解療法が奏功した先天性アンチトロンビンIII(AT III) 欠損症の1症例

若年発症の深部静脈血栓症に対して局所的血栓溶解療法が奏功した先天性アンチトロンビンIII(AT III) 欠損症の1症例

Deep vein thrombosis and lung embolisms in patients with stroke: prevention and therapy

Prevention and therapy of deep vein thrombosis and pulmonary embolisms in patients with acute stroke (ischemia and hemorrhage) represent a special challenge in the clinical routine. This article gives an overview on the epidemiology, risk factors and causes of deep vein thrombosis and pulmonary embolism in patients with acute stroke. The focus lies on the efficacy and safety of prophylactic treatment with compression stockings, compression devices and anticoagulants. Special therapeutic options in the event of symptomatic deep vein thrombosis and pulmonary embolisms in patients with intracerebral hemorrhage and increased risk of recurrent bleeding are presented.

MONITORING OF ANTICOAGULANT THERAPY IN PATIENTS WITH DEEP VEIN THROMBOSIS

Aim. To evaluate the prevalence of accomplished goal in laboratory clotting parameters for the anticoagulant therapy in deep vein thrombosis (DVT).Material and methods. The study is performed as one-stage, descriptive, analytic, pharmacoepidemiologic investigation. The material for the study were 200 case histories of DVT from Volgograd hospitals. The analyzed were: structure of anticoagulant prescription, coagulogrammes with APTT, prothrombin complex and INR.Results. Direct acting anticoagulants were prescribed in 91% cases. High-molecular heparin was used in 84,5% prescriptions, low-molecular heparins — in 6,5%. Monitoring of APTT was done only in 36% patients. The target values of APTT (1,5–2,5 times higher than upper limit) was reached only in 6% cases. Of the indirect anticoagulants warfarin was used in 75,5%. Although laboratory control of warfarin was done in 97% cases, only in 28% of patients INR at discharge was in the range 2,0–3,0.Conclusion. The data witnesses a variety of drawbacks in anticoagulant therapy of DVT patients. High dosages of HMW heparin and warfarin, not enough rigourous control and dosage titration led to the absence of the desired therapeutic diapasone of hypocoagulation.

Catheter-Directed Interventions for Acute Iliocaval Deep Vein Thrombosis

Acute deep vein thrombosis (DVT) is associated with significant morbidity in the form of acute limb-threatening compromise from phlegmasia cerulea dolens, development of the postthrombotic syndrome (PTS), and even death secondary to pulmonary embolism. Initial therapy for DVT is anticoagulation, which inhibits thrombus propagation but lacks the thrombolytic properties to facilitate active thrombus removal. The existing thrombus burden can cause increased venous hypertension from occlusion as well as damage to venous valves by initiating an inflammatory response, which can ultimately result in PTS in up to half of patients on anticoagulation. The manifestations of PTS include leg pain, swelling, lifestyle-limiting venous claudication, skin hyperpigmentation, venous varicosities, and, in rare cases, venous stasis ulcers. Furthermore, patients with iliocaval DVT and large, free-floating thrombus are at an increased risk for pulmonary embolism despite adequate anticoagulation. Early attempts at thrombus removal with surgical thrombectomy or systemic thrombolysis or both demonstrated reductions in the incidence of PTS but were of limited utility owing to their invasiveness and increased risk of bleeding complications. New minimally invasive endovascular therapies, such as pharmacomechanical catheter-directed thrombolysis, have been proposed, which focus on rapid thrombus removal while decreasing the rate of bleeding complications associated with systemic therapy. This article provides an overview of the current pharmacomechanical catheter-directed thrombolysis protocol utilized at the Mount Sinai Hospital for acute iliocaval DVT.

Duration of anticoagulant therapy for deep vein thrombosis and pulmonary embolism

AbstractIt takes about 3 months to complete “active treatment” of venous thromboembolism (VTE), with further treatment serving to prevent new episodes of thrombosis (“pure secondary prevention”). Consequently, VTE should generally be treated for either 3 months or indefinitely (exceptions will be described in the text). The decision to stop anticoagulants at 3 months or to treat indefinitely is dominated by the long-term risk of recurrence, and secondarily influenced by the risk of bleeding and by patient preference. VTE provoked by a reversible risk factor, or a first unprovoked isolated distal (calf) deep vein thrombosis (DVT), has a low risk of recurrence and is usually treated for 3 months. VTE associated with active cancer, or a second unprovoked VTE, has a high risk of recurrence and is usually treated indefinitely. The decision to stop anticoagulants at 3 months or to treat indefinitely is more finely balanced after a first unprovoked proximal DVT or pulmonary embolism (PE). Indefinite anticoagulation is often chosen if there is a low risk of bleeding, whereas anticoagulation is usually stopped at 3 months if there is a high risk of bleeding. The decision to continue anticoagulation indefinitely after a first unprovoked proximal DVT or PE is strengthened if the patient is male, the index event was PE rather than DVT, and/or d-dimer testing is positive 1 month after stopping anticoagulant therapy.