Deep venous thrombosis: Difference between revisions

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==Diagnosis==
==Background==
{{Venous thromboembolism types}}


{{Venous system anatomy leg}}


CLINICAL FEATURE
==Clinical Features==
[[File:Deep vein thrombosis of the right leg.jpg|thumbnail|DVT of right leg]]
[[File:DVT.jpeg|thumbnail|Large [[DVT]] of left leg]]
*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%)<ref>Anand SS, et al. Does this patient have deep vein thrombosis? JAMA. 1998; 279(14):1094-9.</ref>


- active cancer 1
==Differential Diagnosis==
*[[Acute arterial ischemia|Arterial thrombosis]]
*Arteritis
*[[Arthritis]]
*[[Buerger disease]]
*[[Cellulitis]]
*[[Compartment syndrome]]
*[[Complex regional pain syndrome]]
*[[Fractures (main)|Fracture]]
*[[Gout and Pseudogout|Gout]]
*[[Lymphangitis]]
*Myositis
*[[Necrotizing fasciitis]]
*Nerve entrapment
*[[Neuropathy]]
*[[Osteomyelitis]]
*[[Paget-Schroetter syndrome]]
*Sciatica
*[[Septic Arthritis (General)|Septic Joint]]
*Tendonitis


- paralysis paresis or cast 1
{{Calf pain DDX}}
{{Unilateral leg swelling DDX}}


- bedridden >4 days or major surg within 4 wks 1
==Evaluation==
[[File:DVT-clinical-algorithm.jpg|thumbnail|ACEP DVT Evaluation Algorithm]]
[[File:DVT in the Femoral Vein.png|thumb|DVT of the femoral vein on [[DVT ultrasound]]]]
[[File:Deep vein thrombosis distally to the great saphenous vein, labeled.jpg|thumb|DVT of the common femoral vein on [[DVT ultrasound]].]]
[[ File:Iliac vein deep vein thrombosis.jpg|thumb|Iliac vein vein thrombosis, which constitutes a DVT in the pelvis.]]
===Lower Extremity===
*Clinical exam
*Risk stratification for further testing indicated using (e.g., see Modified Wells Score below)
**Consider [[D-dimer]]
**Consider [[DVT ultrasound]]


- tender along deep venous sys 1
{{Modified Wells Score}}


- entire leg swollen 1
===Upper Extremity===
''Requires [[DVT ultrasound|ultrasound]] for diagnosis.  Cannot be ruled out with d-dimer.<ref>Kucher N. Clinical practice Deep-vein thrombosis of the upper extremities. N Engl J Med. 2011;364:861–869.</ref>''
*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


- calf swelling >3cm measured 10cm below tibial tuberosity 1
==Management==
''The distinction between distal and proximal relates to veins below and above the knee respectively.<ref>Gualtiero P. How I treat isolated distal deep vein thrombosis (IDDVT). Blood 2014 123:1802-1809; doi: https://doi.org/10.1182/blood-2013-10-512616</ref> Patients with '''superficial venous thromboses such as the long saphenous and short saphenous are at risk of developing a DV'''T, especially in patients who have a history of prior [[DVT]] although management with anticoagulation is controversial.<ref>Litzendorf ME. Satiani B. Superficial Venous thrombosis:disease progression and evolving treatment approaches. Vasc Health Risk Manag. 2011(7). 569-575</ref>''
===Proximal DVT===
''Proximal veins are the '''external iliac''', '''common femoral''', '''greater saphenous''', '''profound (deep) femoral''', '''(superficial) femoral vein''', '''popliteal vein'''''
*If NO phlegmasia cerulea dolens:
**Anticoagulate with [[apixaban]], [[rivaroxaban]], or [[heparin]]/[[coumadin]] x 3 months
*If phlegmasia cerulea dolens:
**Consider thrombolytics +/- thrombectomy
**Anticoagulate with [[apixaban]], [[rivaroxaban]], or [[heparin]]/[[coumadin]] x 3 months
*If anticoagulation contraindicated:
**[[IVC filter]]


- pitting edema greater in affected leg 1
====Mechanical Thrombectomy====
Consider pharmaco-mechanical (IR) management of proximal DVTs with the following charateristics:
*Objectively diagnosed (i.e., CT or US)
*Acute (≤14 days)
*Symptomatic (at least one):
**rVCSS Pain Score ≥2
**New edema of calf or thigh (CEAP ≥3)
**Limited mobility or bed bound due to pain / swelling
**Impairment of the tissue perfusion (phlegmasia)


- collateral sprf veins 1
===Distal DVT===
''Distal veins are the '''anterior tibial''', '''posterior tibial''', '''peroneal''', '''gastrocnemius, soleus.'''''
*Symptomatic
**Anticoagulate with [[apixaban]], [[rivaroxaban]], or [[heparin]]/[[coumadin]] x 3 months
*Asymptomatic with extension of thrombus toward proximal veins
**Anticoagulate with [[apixaban]], [[rivaroxaban]], or [[heparin]]/[[coumadin]] x 3 months
*Asymptomatic without extension
**Discharge with compressive U/S q2 weeks
*2020 review from JAMA<ref>Diagnosis and Treatment of Lower Extremity Venous Thromboembolism: A Review.  JAMA. 2020 Nov 3;324(17):1765-1776. doi: https://doi.org/10.1001/jama.2020.17272</ref> 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)."


- alternative dx as likely or greater than that of dvt (-)2
===VTE in Pregnancy<ref>DʼAlton ME et al. National Partnership for Maternal Safety: Consensus bundle on venous thromboembolism. Obstet Gynecol 2016 Oct; 128:688.</ref>===
*Therapeutic [[Enoxaparin|LMWH]] or [[Unfractionated_heparin|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 until''6 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


0- low
===Upper extremity DVT===
*If secondary to catheter, do not necessarily have to remove <ref> 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. </ref>
*Anticoagulation as per lower extremity DVTs.
*Consider admission for catheter directed thrombolysis or mechanical thrombectomy, especially with any of the following characteristics<ref>Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016;149:315-52.</ref>
**Severe symptoms
**Thrombus extending from subclavian to axillary vein
**Other features that suggest success for thrombolysis and decrease risk:
***Symptoms <14 days
***Life expectancy >1 yr
***Low risk for bleeding


1-2 intermediate
==Anticoagulation Options==
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Medication'''
| align="center" style="background:#f0f0f0;"|'''[[Warfarin]] (Coumadin)'''
| align="center" style="background:#f0f0f0;"|'''[[Rivaroxaban]] (Xarelto)'''
| align="center" style="background:#f0f0f0;"|'''[[Apixaban]] (Eliquis)'''
| align="center" style="background:#f0f0f0;"|'''[[Dabigatran]] (Pradaxa)'''
|-
| 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)
||
*[[Enoxaparin]] 1mg/kg q12h x 4-5 days
*Pradaxa 150mg BID <ref> https://pubmed.ncbi.nlm.nih.gov/19966341/ </ref>
|-
| 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
||
*CrCl<50 avoid use
|}


>2 high
===Contraindications to anticoagulation===
*Active hemorrhage
*Platelets <50
*History of [[intracerebral hemorrhage]]


==Disposition==
===Discharge===
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


low prob & neg d dimer= alt dx
===Admit===
For any of the following:
*Ileofemoral DVT that is a candidate for thrombectomy (should have the following):<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646749/</ref>
**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, if indicated for thrombolysis vs outpatient for anticoagulation alone if low risk


if pos dvt get utz
==See Also==
*[[Anticoagulants]]
*[[Pulmonary embolism]]
*[[DVT ultrasound]]
*[[Paget-Schroetter syndrome]]


if int or high prob get utz first- if neg repeat in 2days to 1wk
==External Links==
*[http://www.mdcalc.com/wells-criteria-for-dvt/ MDCalc - Wells' Criteria for DVT]
*[https://rebelem.com/tag/deep-vein-thrombosis/ REBEL EM - Should I Stay or Should I Go: Outpatient Treatment of Venous Thromboembolism]
*[https://coreem.net/core/deep-venous-thrombosis-dvt/ CORE EM - Deep Venous Thrombosis (DVT)]


== ==
==References==
<references/>


 
[[Category:Cardiology]]
==DDx==
[[Category:Vascular]]
 
 
Arterial embolism
 
Septic joint
 
Osteomyelitis
 
Compartment syndrome
 
Nec fasc
 
Gout
 
Neuropathy
 
Nerve entrapment
 
Sciatica
 
Fx
 
Reflex sympathetic dystrophy
 
Lymphangitis
 
Buerger's disease
 
Arthritis
 
Tendonitis
 
Myositis
 
Arteritis
 
 
==Outpt Rx (Harbor Protocol)==
 
 
Outpatient treatment of DVT from the Emergency Department
 
The goal of this protocol is to decrease unnecessary hospital admissions for selected patients who can be treated for deep venous thrombosis on an outpatient basis with low molecular weight heparin (LMWH) and coumadin.
 
 
I. Patient Selection
 
All patients diagnosed with DVT should be considered for potential outpatient management with the following exclusion criteria:
 
Absolute contraindications to outpatient management:
 
 
1. Presence of massive DVT (phlegmasia cerulea dolens)
 
2. Presence of concurrent symptoms of pulmonary embolism (PE)
 
3. High-risk of anticoagulation-related bleeding
 
4. Presence of acute co-morbid conditions and other factors that would necessitate hospitalization.
 
5. Recent (within 2 weeks) stroke or transient ischemic attack
 
6. Hypertensive emergencies
 
7. Severe renal dysfunction (creatinine clearance < 30mL/min)
 
8. History of heparin sensitivity or heparin-induced thrombocytopenia
 
9. Weight > 150kg
 
 
Relative contraindications to outpatient management:
 
1. A history of medical noncompliance
 
2. A history of substance abuse
 
3. An inability to pay for LMWH
 
4. Inability to care for self (or no family, friend or nurse to provide care in outpatient setting)
 
5. Language barrier
 
6. Lack of access to a clinic or telephone
 
 
II. Emergency Department Treatment and follow-up
 
Physicians will:
 
1. Explain the diagnosis and treatment to the patient, including
 
    a. The need to take medication exactly as prescribed
 
    b. The risks of anticoagulation including foods to avoid while taking Coumadin
 
    c. The need to keep follow-up appointments
 
    d. The need to return to the ED immediately for signs or symptoms of PE or worsening leg or arm symptoms
 
    e. Print information for all patients, and ask if the patient has any questions
 
    i. English: http://home.mdconsult.com/das/patient/body/0/43/13766.html
 
          ii. Spanish: http://home.mdconsult.com/das/patient/body/0/43/13767.html
 
2. Write the order for:
 
    a. Lovenox 0.5 mg/kg subcutaneously X 1 by RN
 
    b. Lovenox 0.5 mg/kg subcutaneously X 1 by patient and observed
 
    c. Coumadin 5 mg po x 1
 
3. Arrange for 2-3 day follow-up in an anticoagulation clinic to check INR
 
    a. See Anticoagulation clinic referral in the follow-up binder for patients who are followed at Harbor-UCLA Medical Center.
 
    b. Give appointment at Z: LB for patients without appointments in HIS.
 
4. Confirm or arrange for follow-up with a PMD to continue management.
 
5. Provide referral to home health nurse if the patient is unable to self-inject. This form should be dropped in the box across from scheduled admissions. These referrals are only picked up Monday through Friday!
 
6. Give a prescription for Lovenox 1mg/kg subcutaneously every 12 hours for 5 days (9 doses) and Coumadin 5mg orally daily (give 7 days worth only).
 
7. Provide a Treatment Authorization Request (TAR) to justify prescription for MediCal patients. Please read the instructions for filling out the TAR carefully and make your name and number
 
CLEAR
 
 
Nursing will:
 
1. Provide verbal instruction on how to administer the LMWH injection.
 
2. Demonstrate how to administer Lovenox by giving the initial 0.5mg/kg dose of lovenox.
 
3. Have patients demonstrate self injection giving the second 0.5mg/kg for a total initial dose of 1mg/kg.
 
4. Documenting the ability to self-inject in the chart, or inform the physician that the patient is unable to self-inject.
 
5. Administer the first dose of oral Coumadin
 
6. Provide the usual discharge instructions
 
 
Pharmacy will:
 
1. Provide Lovenox at the Harbor-UCLA Medical Center discounted rate to patients without insurance. Patients with MediCal should get prescriptions at outside pharmacies.
 
2. Lovenox can be prescribed by all licensed emergency physicians.
 
 
 
 
 
 
 
 
[[Category:Heme/Onc]]

Latest revision as of 19:37, 5 February 2025

Background

Clinical Spectrum of Venous thromboembolism

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

Leg Vein Anatomy

Blausen 0609 LegVeins.png

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

DVT of right leg
Large DVT of left leg
  • 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

Differential Diagnosis of Pedal Edema

Evaluation

ACEP DVT Evaluation Algorithm
DVT of the femoral vein on DVT ultrasound
DVT of the common femoral vein on DVT ultrasound.
Iliac vein vein thrombosis, which constitutes a DVT in the pelvis.

Lower Extremity

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

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)

Scoring:

  • 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

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

Management

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 (deep) femoral, (superficial) femoral vein, popliteal vein

Mechanical Thrombectomy

Consider pharmaco-mechanical (IR) management of proximal DVTs with the following charateristics:

  • Objectively diagnosed (i.e., CT or US)
  • Acute (≤14 days)
  • Symptomatic (at least one):
    • rVCSS Pain Score ≥2
    • New edema of calf or thigh (CEAP ≥3)
    • Limited mobility or bed bound due to pain / swelling
    • Impairment of the tissue perfusion (phlegmasia)

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.
  • Consider admission for catheter directed thrombolysis or mechanical thrombectomy, especially with any of the following characteristics[11]
    • Severe symptoms
    • Thrombus extending from subclavian to axillary vein
    • Other features that suggest success for thrombolysis and decrease risk:
      • Symptoms <14 days
      • Life expectancy >1 yr
      • Low risk for bleeding

Anticoagulation Options

Medication Warfarin (Coumadin) Rivaroxaban (Xarelto) Apixaban (Eliquis) Dabigatran (Pradaxa)
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
  • CrCl<50 avoid use

Contraindications to anticoagulation

Disposition

Discharge

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

Admit

For any of the following:

  • Ileofemoral DVT that is a candidate for thrombectomy (should have the following):[13]
    • 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, if indicated for thrombolysis vs outpatient for anticoagulation alone if low risk

See Also

External Links

References

  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. https://www.acep.org/clinical---practice-management/focus-on--emergency-ultrasound-for-deep-vein-thrombosis/
  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: https://doi.org/10.1182/blood-2013-10-512616
  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: https://doi.org/10.1001/jama.2020.17272
  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.
  11. ↑ Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016;149:315-52.
  12. ↑ https://pubmed.ncbi.nlm.nih.gov/19966341/
  13. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646749/
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