Diagnosis and treatment of deep vein thrombosis of the lower and upper limbs. 2024 recommendations of the venous thromboembolism group of the Spanish Society of Internal Medicine

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Recomendaciones del grupo de enfermedad tromboembólica de la Sociedad Española de Medicina Interna 2024" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1653 "Ancho" => 3008 "Tamanyo" => 846819 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Diagnostic algorithm for deep venous thrombosis of the lower extremities." ] ] ] "textoCompleto" => "IntroductionVenous thromboembolic disease (VTD) is a complex and multifactorial disease which can affect virtually any venous vascular territory and encompasses a multitude of different clinical scenarios. This document addresses the diagnosis and treatment of acute deep vein thrombosis (DVT) of the lower and upper limbs. Its scope does not include pulmonary embolism (PE), other venous territories, or those associated with venous catheters or cancer, which will be the subject of another position paper by the Spanish Society of Internal Medicine (SEMI).DVT is a common disease, with a rate of 1/10,000 cases per year in individuals under 40 years of age and 5–6/1,000 in those over 80 years of age. It entails a high morbidity and mortality and has a recurrence rate between 5% and 10% per year and a mortality rate of 4.6% in the first month (and 10% in those who develop PE), a rate that is higher in DVT associated with cancer.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> In the long term, between 20% and 45% of patients will develop post-thrombotic syndrome (PTS), which will be severe in 5%, causing considerable detriment to quality of life with occupational and financial repercussions.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>To avoid these complications, it is necessary to reach a diagnosis and start the correct treatment as early as possible. The management of DVT often requires the intervention of different levels of care (emergency, primary care, hospital), different specialists (internists, vascular surgeons, hematologists, etc.), and different clinical scenarios. This requires proper coordination in order to standardize criteria and optimize management with a patient-centered perspective. The SEMI Thromboembolic Disease Group has created this document with the aim of proposing recommendations through diagnostic and treatment algorithms to facilitate decision making by the professionals involved in caring for DVT in the extremities.Materials and methodsIn order to prepare this consensus document, a team was formed to review and summarize the available evidence in order to draw conclusions and make recommendations. This process entailed a comprehensive review of the literature on the PubMed, Cochrane, and Scopus (Web of Science) databases that focused on identifying evidence related to the subject of the consensus document. The recommendations of the most recent international guidelines on thrombosis<a class="elsevierStyleCrossRefs" href="#bib0015">3–8</a> were considered in the preparation of this document, selecting randomized clinical trials and systematic and narrative reviews published in recent years, especially those on special situations in which the evidence is less robust.<a class="elsevierStyleCrossRefs" href="#bib0045">9–14</a>This document consists of three parts: the first includes diagnostic recommendations, the second addresses treatment recommendations, and the third focuses on particular considerations regarding specific venous territories (isolated distal DVT, iliofemoral DVT, and primary upper extremity DVT) as well as special populations (pregnancy and the postpartum period, advanced kidney failure, extreme weights, and situations of high bleeding risk). In addition to the recommendations, DVT management algorithms as well as guidelines for action are included.The group which created the recommendations wrote the manuscript, which underwent successive revisions by the same group. Finally, the document has been evaluated by a committee of experts, members of the Venous Thromboembolic Disease Group of the Spanish Society of Internal Medicine (SEMI, for its initials in Spanish), and an external reviewer until its final approval.Results and recommendationsDiagnosisThere are different ways of classifying DVT of the lower extremities (LE). This document uses a classification based on the venous territory affected, given its implications for treatment and morbidity and mortality. Accordingly, proximal DVT is defined as when the iliofemoral or popliteal territory is involved and distal DVT is defined as when only the infrapopliteal veins (tibioperoneal trunk, soleus-gastrocnemius veins and their tributaries, and perforating veins) are involved (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The clinical presentation of DVT in the LE (unilateral pain and edema) is not very specific and its differential diagnosis is broad (Table 1, Annex I). In order to optimize the indication for performing complementary examinations, pretest predictive models have been developed that include clinical variables and D-dimer (DD) determinations. DD has a high sensitivity for diagnosing acute DVT and allows for ruling it out when the result is normal. However, its specificity is low, since it can be elevated in multiple clinical situations (advanced age, cancer, inflammation, trauma, pregnancy, etc.) and it is not useful in patients with medium or high clinical probability. To reach a diagnosis of DVT, the pretest clinical probability should be evaluated (which can be done using the validated Wells scale), identifying the predisposing and/or precipitating risk factors (RF) involved in VTD (Table 2, Annex I). Analytical tests (including DD) and a compression ultrasound should be performed, which will allow for obtaining a confirmatory diagnosis in most cases (MR angiography or CT venography are also diagnostic techniques, although they are not the first choice due to their higher cost and lower availability).Compression ultrasound (CUS) is the diagnostic technique of choice. Its main diagnostic criterion is a lack of compression of the venous segment examined. When available, it is recommended to perform a color Doppler ultrasound (CDUS) of the entire affected extremity and at least a two-point (femoral and iliac) ultrasound assessment of the contralateral leg.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Another alternative is performing a point-of-care 3-point compression ultrasound (3PCUS), which has a sensitivity of 90% and a specificity of 98% in the affected extremity. It is advisable for the examiner to leave a precise topographic description of the findings as well as the characteristics (acute-chronic) of the thrombus.<a class="elsevierStyleCrossRefs" href="#bib0020">4,16</a> Doppler ultrasound sensitivity is lower when evaluating distal or non-compressible veins (iliac vein) and in asymptomatic patients. The addition of the color Doppler system improves the test yield in these cases as well as in post-surgical patients or those with previous residual thrombosis. If the result of the CDUS of the entire extremity is negative, no further examinations are required. However, in patients with high clinical suspicion without a diagnostic alternative, a positive DD, and a negative 2-3PCUS, close clinical follow-up and having an expert professional repeat the ultrasound examination after seven days is recommended to rule out progression to proximal and safely rule out DVT.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, diagnostic algorithm).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Once DVT has been diagnosed, the possibility of associated pulmonary embolism should be clinically considered. That is, evaluate whether the patient also has dyspnea, pleuritic pain, tachycardia, hemoptysis, previous history of VTD, or occult neoplasm. If the clinical probability of pulmonary embolism is intermediate or high, the necessary additional diagnostic tests, namely a CT angiogram or ventilation/perfusion scintigraphy, should be performed. Otherwise, in the absence of symptoms, it is not necessary to perform additional tests aimed at ruling out PE. In patients with DVT without an identified triggering factor, there is an incidence of occult cancer of around 4%–10% at one year after diagnosis.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> It is important to take a comprehensive case history and physical examination as well as to request a basic blood and urine analysis and a chest X-ray. A targeted study should be considered in patients in whom an occult neoplasm is suspected after this initial evaluation. On the contrary, in those in whom there is no suspicion, population screening guidelines for specific cancers (lung, colon, breast, cervix, prostate) should be recommended according to the patient’s age and sex; routine extensive screening for occult cancer is not recommended.<a class="elsevierStyleCrossRefs" href="#bib0090">18,19</a>Routine thrombophilia testing is not recommended. It should only be considered if hereditary thrombophilia is suspected (young patients <50 years with a first-degree family history, atypical locations) always at least 12 weeks from the event, when its result will have an impact on clinical decision-making regarding anticoagulant treatment (secondary thromboprophylaxis) or on first-degree family members (primary thromboprophylaxis).<a class="elsevierStyleCrossRef" href="#bib0100">20</a>TreatmentIn general, the treatment approach for most patients with acute DVT of the extremities is on an outpatient basis. The mainstay is full-dose anticoagulation, which should be maintained for at least three months in the absence of contraindications. It is essential to know the vein affected by the thrombosis because in select cases, invasive endovascular procedures by vascular surgeons and/or interventional radiologists may be required and in some cases, even non-anticoagulation may be considered (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>, management algorithm).<a class="elsevierStyleCrossRef" href="#bib0020">4</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>AnticoagulationThere are three phases in the treatment of DVT: initial (first five to 21 days), long-term (first three months), and extended (beyond the third month) (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). This article addresses treatment in the first two phases, which include the first three months after diagnosis. The decision to maintain anticoagulant therapy beyond three months should be made on an individual basis in a VTD consultation.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>The aim of anticoagulation is to provide symptomatic relief, prevent progression and migration of the thrombus in the form of PE, reduce the risk of recurrence, improve the rate of venous recanalization, and reduce the risk of post-thrombotic syndrome.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Direct oral anticoagulants (DOAC) (rivaroxaban, apixaban, dabigatran, or edoxaban) are the treatment of choice in most patients with DVT of the extremities (except in special populations and those with contraindications). However, they are not currently funded by Spain’s National Health System for this indication, so vitamin K antagonists such as acenocoumarol or warfarin are often used for habitual INR ranges of 2–3. Initial treatment with low-molecular-weight heparins (LMWH)—or unfractionated heparin (UFH) in very select cases—is preferable in patients with DVT who are admitted with hemodynamic instability or in those in whom invasive procedures are foreseen, those with a high bleeding risk, those with a high suspicion of antiphospholipid syndrome (APS), or patients with active cancer (especially if it affects the gastrointestinal or genitourinary mucosa). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the different anticoagulants indicated for DVT, including conventional dosage, dose adjustment criteria in special situations, and contraindications.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> DOACs and LMWH have the advantage of not requiring monitoring, although there is currently the possibility of monitoring anti-Xa levels and determining plasma levels of DOACs for exceptional cases (Table 3, Annex I).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Major bleeding is the most feared complication in the anticoagulated DVT patient, with an incidence of 2% to 5% per year (and 0.5%–1% per year for fatal bleeding).<a class="elsevierStyleCrossRef" href="#bib0110">22</a> The risk of bleeding is greater in the first three months—the mandatory anticoagulation period for DVT in the LE. During this period, the consequence of a (temporary) interruption of anticoagulation due to active bleeding can lead to a higher risk of recurrent VTD.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Therefore, in every patient with acute DVT, the clinician must assess the risk of bleeding before and during anticoagulant treatment based on clinical judgment according to each patient’s individual characteristics and/or with the support of a bleeding risk scale developed for this purpose (Table 5, Annex I). This bleeding risk stratification helps to identify patients at higher risk of bleeding in whom the risk/benefit range of anticoagulation is narrower and for whom more continuous follow-up should be performed and/or careful adjustments should be made to the most suitable intensity, type of drug, and duration of anticoagulation (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>, checklist).<a class="elsevierStyleCrossRef" href="#bib0115">23</a><elsevierMultimedia ident="fig0025"></elsevierMultimedia>Mobilization and venous compressionEarly walking together with early use of local mechanical measures such as elastic compression stockings (ECS) or multilayer bandaging are beneficial for controlling symptoms associated with acute proximal DVT.<a class="elsevierStyleCrossRefs" href="#bib0030">6,24</a> Although there is no firm evidence on the benefit of ECS in the prevention of PTS, they are recommended during the first three to six months and can be suspended thereafter if complete recanalization has been achieved and there are no symptoms suggestive of PTS (defined by a Villalta scale score <5) (Table 4, Annex I). Long compression stockings show no greater benefit than short, below-the-knee stockings in the prevention of PTS and the latter are better tolerated. They are contraindicated in patients with severe peripheral arterial disease.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>Inferior vena cava filterPlacement of a removable inferior vena cava filter (IVCF) is indicated in patients with DVT of the LE when there is an absolute contraindication to anticoagulation (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>) or the need for urgent surgery that requires suspension of anticoagulation after very recent DVT (<1 month). After placement of an IVCF, anticoagulation should be initiated as soon as bleeding risk permits, ensuring adequate follow-up and coordinating its removal as soon as anticoagulant doses are reached and before three to six months in order to avoid long-term complications (4). In addition, a removable IVCF could be considered in select cases of recurrent DVT despite anticoagulation, mainly if the risk of bleeding prevents taking other measures such as increasing the anticoagulation dose and the pulmonary reserve is small, although the evidence in these cases is scarce and there is a greater risk of recurrent DVT and thrombotic inferior vena cava syndrome.<a class="elsevierStyleCrossRef" href="#bib0125">25</a>Patient follow-up and educationAll patients with DVT should have clinical follow-up in a specific VTD clinic to evaluate possible complications of anticoagulation, adherence to anticoagulation, and the onset of complications (PE and/or PTS). Performing a CDUS at three to six months to assess recanalization of the affected vein will be proposed and the duration of anticoagulant treatment will be decided taking into account the risk/benefit of continuing the anticoagulant, risk of recurrence, and bleeding risk as well as patient preference and the availability and cost of the drug.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> This point is especially recommended in cases of unprovoked DVT in which withdrawal of anticoagulation is considered. This is because in the event residual thrombosis persists and the bleeding risk is low-moderate, the recommendation of extended anticoagulation will be considered and, in cases of high bleeding risk in which anticoagulation is suspended and a second event occurs with an indication for extended anticoagulation, a previous ultrasound scan allows for knowing the new baseline status of the affected vessel.During follow-up, health education on DVT is essential. The clinician should explain the possible risk factors for recurrence of VTD and the importance of treatment adherence to the patient, ensuring that he/she understands the risks and peculiarities of his/her anticoagulant treatment and knows how to identify the warning signs (signs of bleeding or recurrence of thrombosis).During the entire anticoagulation period, it is important to follow bleeding prevention strategies, such as identifying and addressing modifiable bleeding risk factors (adjustment of hypertension treatment, review and modification of polypharmacy to avoid drug interactions, management and prevention of possible kidney and liver function deterioration, warning of the danger of alcohol abuse, etc.) and monitoring for signs of bleeding as an early detection measure. If bleeding occurs, it is necessary to minimize its duration and intensity by eliminating its causes, evaluate the possibility of reintroducing anticoagulation, and then maintaining closer clinical monitoring to avoid rebleeding<a class="elsevierStyleCrossRefs" href="#bib0045">9,12,23</a> (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>, checklist).<a class="elsevierStyleCrossRef" href="#bib0105">21</a>DVT in locations with special considerationsIliofemoral DVTIn general, it is recommended that these patients be admitted to the hospital and that anticoagulation with LMWH be started for clinical monitoring and completing the study. A CT angiogram of the abdomen or pelvis or MRI angiography should be considered to rule out anatomical abnormalities (IVC agenesis or hypoplasia or left iliac vein compression [May-Thurner syndrome]). In select very symptomatic young people with left iliofemoral thrombosis, a multidisciplinary assessment with vascular surgery or interventional vascular radiology specialists should be performed to consider endovascular early thrombus removal treatments (elective catheter-directed thrombolysis) with the aim of ensuring vascular patency and reducing the risk and severity of PTS, assuming a higher risk of bleeding.<a class="elsevierStyleCrossRefs" href="#bib0010">2,4,8</a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>)<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Isolated distal DVTThe management of isolated distal DVT is controversial since many episodes resolve spontaneously and its emboligenic potential is lower than proximal DVTs.As with proximal DVTs, starting full-dose anticoagulation for at least three months is recommended in patients with highly symptomatic isolated distal DVT or with risk factors for proximal thrombus progression (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). In the absence of these risk factors for DVT progression or in patients with asymptomatic isolated distal DVT or with a high bleeding risk, several options can be considered: LMWH at reduced doses for four to six weeks or not starting anticoagulation and monitoring with serial Doppler ultrasound scans at seven to 14 days. Then, if no thrombotic progression is observed on the scans, it is recommended to continue clinical monitoring without anticoagulation, but if there is thrombus progression, it is recommended to initiate anticoagulation.Primary upper extremity DVT VPrimary DVT of the upper extremity (UE) encompasses Paget-Schroetter syndrome (PSS) and idiopathic thrombosis. They are rare and, unlike central venous catheter-associated DVT of the UE, there are no firm recommendations for them. PSS is rare, is associated with compression of the subclavian vein as it passes through the thoracic operculum, usually affects young people who perform repeated UE exercises, and can cause significant functional sequelae.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> Meanwhile, idiopathic DVT of the UE occurs more frequently in older adult patients and is associated with a higher risk of occult neoplasm (in up to 25% of patients) and a worse prognosis compared to patients with PSS.Generally, although there is little evidence in the literature, initial anticoagulation with LMWH is recommended followed by oral anticoagulation with VKA for at least three months. Although there is no formal indication in guidelines on the use of DOACs in this scenario, there are some encouraging data on DOACs as an anticoagulant alternative in DVT of the UE. In patients with PSS, early assessment by the thoracic or vascular surgery department is necessary or, if appropriate, referral to a multidisciplinary reference unit to evaluate other therapeutic options such as catheter-directed local thrombolysis (within the first two weeks from symptoms onset), associated or not with decompression surgery (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<a class="elsevierStyleCrossRef" href="#bib0125">25</a>DVT in special populationsDVT in pregnancyPregnancy leads to a four- to five-fold increase in the risk of VTD, with the postpartum period entailing the greatest mortality risk. DVT occurs with equal frequency during pregnancy and the postpartum period whereas PE is more frequent in the postpartum period.<a class="elsevierStyleCrossRefs" href="#bib0020">4,24</a> The diagnosis of DVT during gestation can be difficult because of clinical nonspecificity, the limited usefulness of DD given that it increases physiologically, and the poor reliability of predictive scales developed for the general population.Recommendations on the treatment of pregnant patients with DVT are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>. LMWH at therapeutic doses is the anticoagulant of choice throughout pregnancy and the postpartum period. Women who become pregnant while receiving VKAs or DOACs should switch to LMWH. In the postpartum period, LMWH at therapeutic doses or UFH can be restarted 24h after removal of the epidural anesthesia catheter, six to 12h after vaginal delivery, or 12–24hours after a cesarean section.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4,27,28</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DVT in extreme weightsThere are no firm, specific recommendations for patients with extreme weights, defined either as low body weight (<50kg) or extremely high body weight (>150kg, BMI>40kg/m2), in whom there are physiological changes in drug pharmacokinetics (such as absorption rate, volume of distribution, and renal clearance) that could lead to the over- or under-dosing of anticoagulants.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> The treatment recommendations for this population are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.DVT in advanced kidney diseaseThe evidence regarding anticoagulant therapy in patients with DVT and advanced chronic kidney disease (CKD) (CrCl <30mL/min) is mainly based on observational registries, as this is a population with a fragile balance between VTD and bleeding risk. Patients with advanced CKD are at increased risk for a first VTD event, thrombotic recurrence, major bleeding, and short- and long-term all-cause mortality after a thrombotic event.<a class="elsevierStyleCrossRefs" href="#bib0055">11,29</a> The treatment recommendations for this population are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.DVT in older adultsOlder adult patients have a higher incidence of VTD, higher VTD-related mortality and morbidity, and increased risk of major bleeding associated with anticoagulation. In these patients, more extensive DVTs are diagnosed, they occur more frequently with concomitant PE, and they are at higher risk of developing PTS compared to the younger population. Pluripathology (kidney failure, liver failure, anemia, cancer), polypharmacy, malnutrition, frailty, cognitive impairment, and risk of falls are factors that increase the risk of major and fatal bleeding events. Likewise, this population is underrepresented in pivotal clinical trials on anticoagulants and therefore, recommendations for this group come from observational studies. The treatment recommendations for this population are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.DVT in patients with liver failureThis population group is excluded from pivotal trials on anticoagulation in VTD. Patients with cirrhosis not only have a greater bleeding risk, but also a higher thrombotic risk, with an unstable hemostatic balance that can be easily become unbalanced by precipitating factors (liver decompensation, sepsis, kidney failure, or invasive procedures). The most common thrombotic complication in patients with advanced cirrhosis is portal thrombosis. Likewise, patients with advanced cirrhosis who receive anticoagulant therapy have a greater mortality rate and a very high risk of major bleeding compared to anticoagulated patients without cirrhosis. The treatment recommendations for this population are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.DVT in thrombocytopeniaThe platelet count must be determined before initiating antithrombotic treatment, since it is a limiting factor for anticoagulant use. Thrombocytopenia (TP) does not reduce the risk of recurrent thrombosis and exposes patients to an increased risk of bleeding. Patients with VTD and moderate-severe TP (<80,000 platelets/μL) have an almost three-fold risk of major bleeding and almost twice the risk of fatal bleeding than those with a normal platelet count.Anticoagulation in the context of TP has the added challenge of balancing the competing risks of bleeding and recurrent VTD. When assessing a patient’s risk of recurrent or progressive DVT, factors such as thrombus burden (size, location, and impact), etiology, and time since the index event should be taken into account. Similarly, the risk of bleeding can be determined by the medical history of bleeding; concurrent coagulopathy (e.g., DIC); liver or kidney failure; infection; and, in the case of solid tumors; the type and location of the primary tumor and metastases. Additional considerations include the need for procedures; the etiology, severity and duration of the PT; and comorbidities such as kidney or liver failure that affect the anticoagulation choice and treatment.The treatment recommendations for this population are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.Recurrent DVTThe diagnosis of recurrent DVT in the same location is usually more difficult to establish than a first episode of venous thrombosis. A flare-up of symptoms may be a recurrence or PTS from the previous event, which can occur in 20%–45% of patients with proximal DVT. In the case of confirming recurrent DVT during anticoagulation, the first step is to assess treatment adherence and confirm full doses and the absence of drug interactions. Second, causes of hypercoagulability, such as occult or progressing neoplasms, antiphospholipid syndrome (APS), or heparin-induced thrombocytopenia (HIT), should be ruled out. Once these causes have been ruled out, for patients who have recurrence under treatment with VKAs or DOACs, it is suggested to switch to LMWH for at least four weeks (and then consider switching to DOACs or returning to VKAs with the possibility of raising the target INR to 2.5–3.5). In patients who have recurrence under treatment with LMWH, it is suggested to increase the LMWH dose by 10%–25%.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>DiscussionThis document includes recommendations for the management of lower extremity DVT from the Spanish Society of Internal Medicine’s Working Group on Thromboembolic Disease. It is part of a series of four documents on VTD that aim to reach a consensus on a series of useful recommendations based on the current literature for guiding clinicians in the management of VTD. It is intended for any physician responsible for caring for patients with DVT in their daily clinical practice, regardless of their specialty. Although international guidelines and consensus documents on the management of VTD have been published in recent years,<a class="elsevierStyleCrossRefs" href="#bib0015">3–7</a> this document provides simple, clear, brief algorithms that can be used in clinical practice for DVT of the extremities. In addition, it aims to narrow the gap between clinical practice and current scientific evidence, addressing the management of special but relatively common situations, such as older adult patients, patients with obesity, or patients with kidney or liver failure, in which there is still a great degree of uncertainty.The main limitations are that the group of internists which developed this document is not multidisciplinary and the suggestions or recommendations do not include a cost-benefit analysis. In addition to treatment safety and efficacy, the cost/benefit is a factor that health professionals must evaluate when making decisions. Furthermore, the document makes suggestions that are not indicated in the technical datasheet and the emergence of new evidence may lead to a revision of these indications.Compliance with ethical guidelinesThis article is based on previously conducted studies and does not contain any new studies with human or animal participants conducted by any of the authors.Conflicts of interestNuria Ruiz-Giménez has worked as a consultant; served as a speaker; and received compensation for lectures from Sanofi, Rovi, Leo-Farma, Bayer, and Boehringer Ingelheim.Aída Gil Díaz has served as a speaker and received compensation for lectures from Sanofi and Rovi.Pedro Parra Caballero has served as a speaker, performed paid work, and received compensation for lectures from Sanofi, Rovi, and Bayer.Nuria Muñoz Rivas has worked as a consultant; served as a speaker; performed paid work; and received compensation for lectures from Sanofi, Rovi, Leo-Farma, Bayer, and Boehringer IngelheimGabriel Puche Palao has served as a speaker and received compensation for lectures from Viatris and Rovi.Javier Miguel Martín Guerra has served as a speaker and received compensation for lectures from Daiichi-Sankyo and LEO Pharma.Members of the committee of expertsMiguel Martín Asenjo, Olga Madridano Cobo, Carme Font, Ángeles Fidalgo, Javier Pagán Escribano, Mar Martín Pozo, Alberto Rodriguez Iglesias, Cristina Sánchez del Hoyo, Esther Usandizaga de Antonio, María Ortiz." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres2153249" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1827628" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1827627" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres2153250" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1827629" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 7 => array:3 [ "identificador" => "sec0015" "titulo" => "Results and recommendations" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Treatment" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Anticoagulation" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Mobilization and venous compression" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Inferior vena cava filter" ] 5 => array:2 [ "identificador" => "sec0045" "titulo" => "Patient follow-up and education" ] 6 => array:3 [ "identificador" => "sec0050" "titulo" => "DVT in locations with special considerations" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Iliofemoral DVT" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Isolated distal DVT" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Primary upper extremity DVT V" ] ] ] 7 => array:3 [ "identificador" => "sec0070" "titulo" => "DVT in special populations" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "DVT in pregnancy" ] 1 => array:2 [ "identificador" => "sec0080" "titulo" => "DVT in extreme weights" ] 2 => array:2 [ "identificador" => "sec0085" "titulo" => "DVT in advanced kidney disease" ] 3 => array:2 [ "identificador" => "sec0090" "titulo" => "DVT in older adults" ] 4 => array:2 [ "identificador" => "sec0095" "titulo" => "DVT in patients with liver failure" ] 5 => array:2 [ "identificador" => "sec0100" "titulo" => "DVT in thrombocytopenia" ] 6 => array:2 [ "identificador" => "sec0105" "titulo" => "Recurrent DVT" ] ] ] ] ] 8 => array:2 [ "identificador" => "sec0110" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0115" "titulo" => "Compliance with ethical guidelines" ] 10 => array:2 [ "identificador" => "sec0120" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "sec0125" "titulo" => "Members of the committee of experts" ] 12 => array:2 [ "identificador" => "xack747187" "titulo" => "Acknowledgements" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-12-23" "fechaAceptado" => "2024-03-08" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1827628" "palabras" => array:6 [ 0 => "Anticoagulation" 1 => "Diagnosis" 2 => "Deep vein thrombosis" 3 => "Extremities" 4 => "Treatment" 5 => "Bleeding risk" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1827627" "palabras" => array:27 [ 0 => "DOACs" 1 => "VKA" 2 => "CrCl" 3 => "DD" 4 => "DUS" 5 => "EDc" 6 => "2-3PCUS" 7 => "PE" 8 => "VTD" 9 => "TDS" 10 => "LMWH" 11 => "UFH" 12 => "ECS" 13 => "UE" 14 => "LE" 15 => "DVT" 16 => "CRPTE" 17 => "APS" 18 => "MTS" 19 => "PSS" 20 => "PTS" 21 => "MT" 22 => "TP" 23 => "ERT" 24 => "CDT" 25 => "PPI" 26 => "NSAIDs" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1827629" "palabras" => array:6 [ 0 => "Anticoagulación" 1 => "Diagnóstico" 2 => "Trombosis venosa profunda" 3 => "Extremidades" 4 => "Tratamiento" 5 => "Riesgo hemorrágico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Deep vein thrombosis (DVT) of the limbs is a common disease and causes significant morbidity and mortality. It is frequently the prelude to pulmonary embolism (PE), it can recur in 30% of patients and in 25–40% of cases they can develop post-thrombotic syndrome (PTS), with a significant impact in functional status and quality of life. This document contains the recommendations on the diagnosis and treatment of acute DVT from the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI).PE and thrombosis of unusual venous territories (cerebral, renal, mesenteric, superficial, etc.) are outside its scope, as well as thrombosis associated with catheter and thrombosis associated with cancer, which due to their peculiarities will be the subject of other positioning documents of the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI)." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La trombosis venosa profunda (TVP) de miembros es una enfermedad frecuente y conlleva una morbimortalidad importante. Es, con frecuencia, la antesala de la embolia de pulmón (EP), puede recurrir en el 30% de los pacientes y en el 25–40% de los casos pueden desarrollar el síndrome postrombótico (SPT), con un importante impacto funcional y en la calidad de vida. En este documento se recogen las recomendaciones sobre el diagnóstico y tratamiento de la TVP aguda del grupo de Enfermedad Tromboembólica de la Sociedad Española de Medicina Interna (SEMI). Quedan fuera del alcance del mismo la EP y las trombosis de territorios venosos inusuales (cerebral, renal, mesentérica, superficiales, etc.), así como la trombosis asociada a catéter y la asociada a cáncer, que por sus peculiaridades serán objeto de otros documentos de posicionamiento del grupo de Enfermedad Tromboembólica de la Sociedad Española de Medicina Interna (SEMI)." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0135" ] ] ] ] "multimedia" => array:18 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1849 "Ancho" => 2088 "Tamanyo" => 370015 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Superficial and deep venous system of the lower extremities." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1653 "Ancho" => 3008 "Tamanyo" => 846819 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Diagnostic algorithm for deep venous thrombosis of the lower extremities." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1390 "Ancho" => 2508 "Tamanyo" => 450134 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Algorithm for the therapeutic management of deep vein thrombosis of the LE." ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 847 "Ancho" => 2091 "Tamanyo" => 208853 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Phases of anticogulation. Modified from Stevens et al. CHEST 2021." ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 4211 "Ancho" => 2341 "Tamanyo" => 1096227 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Checklist for anticoagulation in VTD." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "VKA: vitamin K antagonists; UFH: unfractionated heparin; LMWH: low-molecular-weight heparin; IU: international units; GFR: glomerular filtration rate;IV: intravenous; SC: subcutaneous; aPTT: activated partial thromboplastin time; HIT: heparin-induced thrombocytopenia; P-gp: P-glycoprotein; C450: cytochrome P450." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Drug \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Route of administration \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Conventional dosage \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Adjustment for renal disease \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Need for monitoring \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Criteria for dose adjustment \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Contraindications<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Drug interactions \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">VKA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Oral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">every 24h<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Yes (INR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Maintain INR 2−3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Pregnancy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Multiple \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">UFH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Bolus 5000 IU (or 80 IU/kg) followed by continuous infusion of 18 IU/kg/h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Yes (aPTT or anti-Xa) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">aPTT <35 sec: bolus 80 IU/kg and increase infusion 4 IU/kg/haPTT 35–45 sec: bolus 40 IU/kg and increase infusion 2 IU/ kg/haPTT 46–70 sec: maintain doseaPTT 71–90 sec: reduce infusion 2 IU/kg/haPTT >90 sec: stop infusion 2h and reduce 3 IU/kg/h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">ICT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">UFH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Bolus 5000 IU IV followed by 10,000–20000 IU SC and continue with 8000−10000 IU every 8h SC or 17500 IU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Yes (aPTT or anti-Xa) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">According to aPTT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">ICT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Enoxaparin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 IU anti-Xa/kg/12h or 150 IU anti-Xa/ kg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No assess anti-Xa in GFR<30ml/min and extreme weights \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">GFR<30ml/min: caution,close clinical follow-up and assess monitoring of anti-Xa levels,individualize dosage adjustment<a class="elsevierStyleCrossRef" href="#tblfn0020">d</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ICT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bemiparin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">115 IU anti-Xa/kg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tinzaparin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">175 IU anti-Xa/kg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Dalteparin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">100 IU anti-Xa/kg/12h or 200 IU anti-Xa/kg/day (from 2nd month 150 IU/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Fondaparinux \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Weight <50kg: 5mg/dayWeight 50–100 kg: 7.5mg/dayWeight >100 kg: 10mg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">GFR<30ml/minNot advisable in pregnancy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Rivaroxaban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Oral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">15mg/12h first 21 days, then 20mg/24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No (specific anti-Xa in select cases) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">FGFR 15–49ml/min: 15mg/day depending on bleeding risk.Reduce to 10mg/24h after 6 months.except in individual situations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Pregnancy GFR<15ml/ minTriple-positive APS not recommended \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">P-gp Inhibitors C450 Inhibitors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Apixaban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Oral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">10mg/12h first 7 days, then 5mg/12h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No (specific anti-Xa in select cases) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Reduce to 2.5mg every 12h after 6 months except in individual situations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Pregnancy GFR <15 ml/ min Triple-positive APS not recommended \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">P-gp Inhibitors C450 Inhibitors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Edoxaban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Oral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">60mg/24h<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No (specific anti-Xa in select cases) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Weight ≤60 kg: 30mg/dayGFR 15–50ml/min: 30mg/day Concomitant treatment with potent P-gp inhibitors: 30mg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Pregnancy GFR <15 ml/ min Triple-positive APS not recommended \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">P-gp Inhibitors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dabigatran \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">150mg/12h<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No (specific anti-Xa in select cases) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age >80 years: 110mg/12h Concomitant treatment with Verapamil: 110mg/12hGFR 30–50ml/min or age 75–79 years: consider reducing the dose according to bleeding risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pregnancy GFR<30ml/min(Triple-positive APS not recommended) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">P-gp Inhibitors \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3548634.png" ] ] ] "notaPie" => array:4 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Start after at least one dose of heparin or Fondaparinux, overlapping for at least 5 days and until 2 consecutive INR>2 are achieved." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Start after at least 5 days of parenteral anticoagulant treatment." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "Specific contraindications, beyond bleeding." ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "d" "nota" => "Enoxaparin: reduce dose to 100 IU/kg (1mg/kg) body weight SC once daily. Bemiparin: dose adjustment to 75% (approximately 85 IU anti-Xa/kg once daily) is recommended. Tinzaparin: available evidence demonstrates no accumulation until GFR levels up to 20ml/min." ] ] ] "descripcion" => array:1 [ "en" => "Dosage of anticoagulants indicated for VTD." ] ] 6 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Very symptomatic iliofemoral DVT<elsevierMultimedia ident="202405260720015221"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">They require hospital admission (and starting LMWH treatment).In young patients with left iliofemoral DVT, it is recommended that May-Thurner syndrome be ruled out. If it is confirmed, an assessment by a radiology and vascular surgery specialist should be requested.Consider early endovascular thrombus removal therapies in patients with massive iliofemoral DVT with arterial circulation compromise (phlegmasia cerulea dolens) in the absence of contraindications and on a highly individualized basis in patients with good functional status, life expectancy ≥1 year, low bleeding risk, in experienced centers, and always within the first two weeks after symptoms onset. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Isolated distal TVP<elsevierMultimedia ident="202405260720015222"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Full-dose anticoagulation for three months is recommended if there are RF for progression: male, age >50 years, high DD, extensive DVT, unprovoked DVT, DVT in hospitalized patients, or in the presence of persistent RF (active cancer, thrombophilia, and previous VTD).Consider not starting anticoagulation in asymptomatic distal DVT with high bleeding risk or due to patient preference or in patients with low risk of progression: intramuscular DVT, those associated with transient RF (splints, trauma, long-distance travel) if full mobilization is guaranteed and those associated with hormonal contraception if said treatment has been discontinued.If anticoagulation is not started, a follow-up Doppler ultrasound should be performed in seven to ten days to rule out progression (in which case starting anticoagulation is recommended). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary DVT of the LE (PSS and idiopathic)<elsevierMultimedia ident="202405260720015223"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider performing a CT angiogram or MRI if there is an indeterminate ultrasound to evaluate the extension and if there is suspicion of concomitant conditions: neoplasm or adenopathies or vascular compression of any anatomical structure (anomalies of the first rib, clavicle, subclavius muscle, costoclavicular ligament, or anterior scalene muscle).Full-dose anticoagulation for three months is recommended. Extending anticoagulation beyond three months will depend on the RF associated with the index event.In select cases of PSS (young, very symptomatic, with high risk of post-thrombotic syndrome sequelae), consider early thrombolysis followed by surgical decompression (resection of the first rib or scalene musculature).The use of compression sleeves is not routinely recommended (lack of evidence). \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3548633.png" ] ] ] ] "descripcion" => array:1 [ "en" => "DVT recommendations in special locations." ] ] 7 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0055" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "DOACs (rivaroxaban, apixaban, dabigatran, or edoxaban) are not funded by Spain’s public health system for this indication, so if the patient prefers treatment with them, he or she must pay the full cost. IVCF: inferior vena cava filter. DOACs (direct acting anticoagulants), BMI (body mass index), CKD (chronic kidney disease), LMWH (low-molecular-weight heparin), VTE (venous thromboembolism), DVT (deep vein thrombosis), PE (pulmonary embolism), EGD (esophagogastroduodenoscopy), TDS (technical datasheet), CrCl (creatinine clearance)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Special situation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pregnancy<elsevierMultimedia ident="202405260720015224"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preferable: LMWH at therapeutic doses in a single daily dose throughout pregnancy and continue during the postpartum period (six weeks) and at least three months from the thrombotic event.Monitoring of anti-Xa levels is not routinely recommended. It can be assessed in selected cases, such as pregnant women at extreme weights and with advanced kidney failure or high bleeding risk.VKAs (due to teratogenicity) and DOACs (due to possible toxicity and lack of evidence) are contraindicated.The peripartum period must be managed by an expert multidisciplinary team and scheduling delivery can minimize the risk of complications.If a pregnant woman is diagnosed with DVT less than two weeks prior to the due date, admission and scheduled delivery with the use of intravenous UFH is recommended, in addition to considering placement of a temporary peripartum inferior vena cava filter. Breastfeeding women can continue with LMWH. DOACs are contraindicated in the postpartum period due to lack of safety data \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="middle">Extreme weights<elsevierMultimedia ident="202405260720015225"></elsevierMultimedia></td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Any DOAC can be used in patients with obesity with a body mass index (BMI) of 30–40kg/m2.VKA is preferable in patients with a BMI of 40–50kg/m2, although apixaban or rivaroxaban can be considered.VKA should be used in patients with obesity with a BMI>50kg/m2.The LMWH dose should be adjusted according to the technical datasheet. Monitoring of anti-Xa levels is not routinely recommended, but can be considered in select patients with BMI≥40kg/m2 (weight >150kg or BMI>50kg/m2, hemodynamic instability, occurrence of thromboembolic or bleeding complications, prolonged treatment for more than ten days, or coexistence of advanced CKD (GFR<30mL/min). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The use of apixaban and edoxaban (dose adjustment according to TDS) is suggested in patients with DVT who weigh between 60 and 40kg.In patients who weigh <40kg, the use of VKA is suggested or, if treatment with DOACs is indicated, plasma levels should be measured. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kidney failure <elsevierMultimedia ident="202405260720015226"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In CKD stages 1–3 (CrCl 30–59ml/min), DOACs are recommended as the first choice (with dose adjustment according to the TDS).In stage 4 CKD (CrCl 15–29ml/min), treatment should be individualized, adjusted according to the TDS, and precaution should be taken with all AC. Tinzaparin is the LMWH with the least renal clearance (safe for GFR up to 20ml/min), the rest with dose adjustment according to TDS. Monitoring anti-Xa activity could be considered in prolonged treatment with SC LMWH for more than ten days. Dabigatran is contraindicated. The rest of DOACs with dose adjustment.In stage 5 CKD (CrCl <15mL/min), VKAs are the treatment of choice. DOACs are not recommended. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Older adults<elsevierMultimedia ident="202405260720015227"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Greater caution with anticoagulant therapy (narrow risk/benefit margin). Dose adjustment for actual weight and renal function. Comprehensive evaluation of bleeding risk and closer monitoring.DOACs are the treatment of choice: oral administration, lower rate of major bleeding, no need for monitoring, and fewer drug and dietary interactions than VKA.Treatment with LMWH (preferably a single daily dose, adjusted according to weight and renal function) is another safe and effective alternative to conventional therapy (LMWH+AVK) that avoids monitoring and drug interactions, although the cost and subcutaneous administration are disadvantages. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Liver dysfunction<elsevierMultimedia ident="202405260720015228"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The prognosis of chronic liver disease, mainly cirrhosis, should be assessed using the Child-Pugh classificationEGD should be performed to detect/rule out esophageal varices as well as alcohol use disorder screening and counseling.If Child-Pugh A cirrhosis: DOACs or VKAs can be used.If Child-Pugh B cirrhosis: VKA or, with caution, DOACs (apixaban and edoxaban) can be used. Rivaroxaban is contraindicated and dabigatran is contraindicated in patients with possibly life-threatening liver disease.If Child-Pugh C cirrhosis: AVK of choice. DOACs are contraindicated. Anticoagulation should be discontinued if severe thrombocytopenia is also present and the risk/benefit ratio should be carefully assessed in patients with poor vital prognosis and very high risk of bleeding. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thrombocytopenia (TP)<50×10⁹/L<elsevierMultimedia ident="202405260720015229"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">When the platelet count is <50×109/L, the thrombotic and bleeding risk as well as expected duration of TP should be reevaluated.If mild TP (platelet count ≥50×109/L), it is suggested to maintain anticoagulant therapy at full doses.In the case of moderate TP (platelet count between 20×10⁹/L and 50×10⁹/L), a 50% LMWH dose reduction is suggested.If severe TP (platelet count equal to or less than 20×10⁹/L: in the acute phase of VTD (<30 days), IVCF placement should be considered, especially if TP is expected to last longer than five to seven days as well as in patients with extensive DVT or PE with low cardiopulmonary reserve or recurrent thrombosis). Platelet transfusion could be considered to maintain platelet counts above 20×109/L (possibly starting anticoagulation at intermediate doses of LMWH) or 50×109/L (possibly starting full-dose anticoagulation). Discontinuation of anticoagulant therapy is suggested in patients with thrombocytopenia <50×109/L and subacute (30–90 days since the event) or isolated distal DVT. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3548635.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations in special populations." ] ] 8 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.docx" "ficheroTamanyo" => 103404 ] ] 9 => array:5 [ "identificador" => "202405260720015221" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 189 "Ancho" => 117 "Tamanyo" => 4879 ] ] ] 10 => array:5 [ "identificador" => "202405260720015222" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx2.jpeg" "Alto" => 150 "Ancho" => 158 "Tamanyo" => 4109 ] ] ] 11 => array:5 [ "identificador" => "202405260720015223" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx3.jpeg" "Alto" => 192 "Ancho" => 129 "Tamanyo" => 4912 ] ] ] 12 => array:5 [ "identificador" => "202405260720015224" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx4.jpeg" "Alto" => 106 "Ancho" => 100 "Tamanyo" => 2158 ] ] ] 13 => array:5 [ "identificador" => "202405260720015225" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx5.jpeg" "Alto" => 121 "Ancho" => 146 "Tamanyo" => 3466 ] ] ] 14 => array:5 [ "identificador" => "202405260720015226" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx6.jpeg" "Alto" => 97 "Ancho" => 150 "Tamanyo" => 4904 ] ] ] 15 => array:5 [ "identificador" => "202405260720015227" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx7.jpeg" "Alto" => 116 "Ancho" => 106 "Tamanyo" => 3376 ] ] ] 16 => array:5 [ "identificador" => "202405260720015228" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx8.jpeg" "Alto" => 162 "Ancho" => 234 "Tamanyo" => 3253 ] ] ] 17 => array:5 [ "identificador" => "202405260720015229" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx9.jpeg" "Alto" => 87 "Ancho" => 133 "Tamanyo" => 4458 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The epidemiology of venous thromboembolism" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.A. 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Diagnosis and treatment of deep vein thrombosis of the lower and upper limbs. 2024 recommendations of the venous thromboembolism group of the Spanish Society of Internal Medicine

Diagnóstico y tratamiento de la trombosis venosa profunda de las extremidades inferiores y superiores. Recomendaciones del grupo de enfermedad tromboembólica de la Sociedad Española de Medicina Interna 2024

A. Gil-Díaza,b, J. Martín Guerrac, P. Parra Caballerod,e, G. Puche Palaof, N. Muñoz-Rivasg,h,

Corresponding author

nurmun02@ucm.es

Corresponding author.

, N. Ruiz-Giménez Arrietad,e,*

a Servicio de Medicina Interna, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain

b Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain

c Servicio Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, Spain

d Servicio Medicina Interna, Hospital Universitario de la Princesa, Madrid, Spain

e Universidad Autónoma Madrid, Madrid, Spain

f Unidad de Enfermedad Tromboembólica Avanzada, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain

g Servicio Medicina Interna, Hospital Universitario Infanta Leonor, Madrid, Spain

h Universidad Complutense Madrid, Madrid, Spain

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It entails a high morbidity and mortality and has a recurrence rate between 5&#37; and 10&#37; per year and a mortality rate of 4&#46;6&#37; in the first month &#40;and 10&#37; in those who develop PE&#41;&#44; a rate that is higher in DVT associated with cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In the long term&#44; between 20&#37; and 45&#37; of patients will develop post-thrombotic syndrome &#40;PTS&#41;&#44; which will be severe in 5&#37;&#44; causing considerable detriment to quality of life with occupational and financial repercussions&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To avoid these complications&#44; it is necessary to reach a diagnosis and start the correct treatment as early as possible&#46; The management of DVT often requires the intervention of different levels of care &#40;emergency&#44; primary care&#44; hospital&#41;&#44; different specialists &#40;internists&#44; vascular surgeons&#44; hematologists&#44; etc&#46;&#41;&#44; and different clinical scenarios&#46; This requires proper coordination in order to standardize criteria and optimize management with a patient-centered perspective&#46; The SEMI Thromboembolic Disease Group has created this document with the aim of proposing recommendations through diagnostic and treatment algorithms to facilitate decision making by the professionals involved in caring for DVT in the extremities&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">In order to prepare this consensus document&#44; a team was formed to review and summarize the available evidence in order to draw conclusions and make recommendations&#46; This process entailed a comprehensive review of the literature on the PubMed&#44; Cochrane&#44; and Scopus &#40;Web of Science&#41; databases that focused on identifying evidence related to the subject of the consensus document&#46; The recommendations of the most recent international guidelines on thrombosis<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;8</span></a> were considered in the preparation of this document&#44; selecting randomized clinical trials and systematic and narrative reviews published in recent years&#44; especially those on special situations in which the evidence is less robust&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;14</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">This document consists of three parts&#58; the first includes diagnostic recommendations&#44; the second addresses treatment recommendations&#44; and the third focuses on particular considerations regarding specific venous territories &#40;isolated distal DVT&#44; 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This document uses a classification based on the venous territory affected&#44; given its implications for treatment and morbidity and mortality&#46; Accordingly&#44; proximal DVT is defined as when the iliofemoral or popliteal territory is involved and distal DVT is defined as when only the infrapopliteal veins &#40;tibioperoneal trunk&#44; soleus-gastrocnemius veins and their tributaries&#44; and perforating veins&#41; are involved &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The clinical presentation of DVT in the LE &#40;unilateral pain and edema&#41; is not very specific and its differential diagnosis is broad &#40;Table 1&#44; Annex I&#41;&#46; In order to optimize the indication for performing complementary examinations&#44; pretest predictive models have been developed that include clinical variables and D-dimer &#40;DD&#41; determinations&#46; DD has a high sensitivity for diagnosing acute DVT and allows for ruling it out when the result is normal&#46; However&#44; its specificity is low&#44; since it can be elevated in multiple clinical situations &#40;advanced age&#44; cancer&#44; inflammation&#44; trauma&#44; pregnancy&#44; etc&#46;&#41; and it is not useful in patients with medium or high clinical probability&#46; To reach a diagnosis of DVT&#44; the pretest clinical probability should be evaluated &#40;which can be done using the validated Wells scale&#41;&#44; identifying the predisposing and&#47;or precipitating risk factors &#40;RF&#41; involved in VTD &#40;Table 2&#44; Annex I&#41;&#46; Analytical tests &#40;including DD&#41; and a compression ultrasound should be performed&#44; which will allow for obtaining a confirmatory diagnosis in most cases &#40;MR angiography or CT venography are also diagnostic techniques&#44; although they are not the first choice due to their higher cost and lower availability&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Compression ultrasound &#40;CUS&#41; is the diagnostic technique of choice&#46; Its main diagnostic criterion is a lack of compression of the venous segment examined&#46; When available&#44; it is recommended to perform a color Doppler ultrasound &#40;CDUS&#41; of the entire affected extremity and at least a two-point &#40;femoral and iliac&#41; ultrasound assessment of the contralateral leg&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Another alternative is performing a point-of-care 3-point compression ultrasound &#40;3PCUS&#41;&#44; which has a sensitivity of 90&#37; and a specificity of 98&#37; in the affected extremity&#46; It is advisable for the examiner to leave a precise topographic description of the findings as well as the characteristics &#40;acute-chronic&#41; of the thrombus&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;16</span></a> Doppler ultrasound sensitivity is lower when evaluating distal or non-compressible veins &#40;iliac vein&#41; and in asymptomatic patients&#46; The addition of the color Doppler system improves the test yield in these cases as well as in post-surgical patients or those with previous residual thrombosis&#46; If the result of the CDUS of the entire extremity is negative&#44; no further examinations are required&#46; However&#44; in patients with high clinical suspicion without a diagnostic alternative&#44; a positive DD&#44; and a negative 2-3PCUS&#44; close clinical follow-up and having an expert professional repeat the ultrasound examination after seven days is recommended to rule out progression to proximal and safely rule out DVT&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#44; diagnostic algorithm&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Once DVT has been diagnosed&#44; the possibility of associated pulmonary embolism should be clinically considered&#46; That is&#44; evaluate whether the patient also has dyspnea&#44; pleuritic pain&#44; tachycardia&#44; hemoptysis&#44; previous history of VTD&#44; or occult neoplasm&#46; If the clinical probability of pulmonary embolism is intermediate or high&#44; the necessary additional diagnostic tests&#44; namely a CT angiogram or ventilation&#47;perfusion scintigraphy&#44; should be performed&#46; Otherwise&#44; in the absence of symptoms&#44; it is not necessary to perform additional tests aimed at ruling out PE&#46; In patients with DVT without an identified triggering factor&#44; there is an incidence of occult cancer of around 4&#37;&#8211;10&#37; at one year after diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> It is important to take a comprehensive case history and physical examination as well as to request a basic blood and urine analysis and a chest X-ray&#46; A targeted study should be considered in patients in whom an occult neoplasm is suspected after this initial evaluation&#46; On the contrary&#44; in those in whom there is no suspicion&#44; population screening guidelines for specific cancers &#40;lung&#44; colon&#44; breast&#44; cervix&#44; prostate&#41; should be recommended according to the patient&#8217;s age and sex&#59; routine extensive screening for occult cancer is not recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Routine thrombophilia testing is not recommended&#46; It should only be considered if hereditary thrombophilia is suspected &#40;young patients &#60;50 years with a first-degree family history&#44; atypical locations&#41; always at least 12 weeks from the event&#44; when its result will have an impact on clinical decision-making regarding anticoagulant treatment &#40;secondary thromboprophylaxis&#41; or on first-degree family members &#40;primary thromboprophylaxis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Treatment</span><p id="par0060" class="elsevierStylePara elsevierViewall">In general&#44; the treatment approach for most patients with acute DVT of the extremities is on an outpatient basis&#46; The mainstay is full-dose anticoagulation&#44; which should be maintained for at least three months in the absence of contraindications&#46; It is essential to know the vein affected by the thrombosis because in select cases&#44; invasive endovascular procedures by vascular surgeons and&#47;or interventional radiologists may be required and in some cases&#44; even non-anticoagulation may be considered &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#44; management algorithm&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Anticoagulation</span><p id="par0065" class="elsevierStylePara elsevierViewall">There are three phases in the treatment of DVT&#58; initial &#40;first five to 21 days&#41;&#44; long-term &#40;first three months&#41;&#44; and extended &#40;beyond the third month&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; This article addresses treatment in the first two phases&#44; which include the first three months after diagnosis&#46; The decision to maintain anticoagulant therapy beyond three months should be made on an individual basis in a VTD consultation&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The aim of anticoagulation is to provide symptomatic relief&#44; prevent progression and migration of the thrombus in the form of PE&#44; reduce the risk of recurrence&#44; improve the rate of venous recanalization&#44; and reduce the risk of post-thrombotic syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Direct oral anticoagulants &#40;DOAC&#41; &#40;rivaroxaban&#44; apixaban&#44; dabigatran&#44; or edoxaban&#41; are the treatment of choice in most patients with DVT of the extremities &#40;except in special populations and those with contraindications&#41;&#46; However&#44; they are not currently funded by Spain&#8217;s National Health System for this indication&#44; so vitamin K antagonists such as acenocoumarol or warfarin are often used for habitual INR ranges of 2&#8211;3&#46; Initial treatment with low-molecular-weight heparins &#40;LMWH&#41;&#8212;or unfractionated heparin &#40;UFH&#41; in very select cases&#8212;is preferable in patients with DVT who are admitted with hemodynamic instability or in those in whom invasive procedures are foreseen&#44; those with a high bleeding risk&#44; those with a high suspicion of antiphospholipid syndrome &#40;APS&#41;&#44; or patients with active cancer &#40;especially if it affects the gastrointestinal or genitourinary mucosa&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the different anticoagulants indicated for DVT&#44; including conventional dosage&#44; dose adjustment criteria in special situations&#44; and contraindications&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> DOACs and LMWH have the advantage of not requiring monitoring&#44; although there is currently the possibility of monitoring anti-Xa levels and determining plasma levels of DOACs for exceptional cases &#40;Table 3&#44; Annex I&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Major bleeding is the most feared complication in the anticoagulated DVT patient&#44; with an incidence of 2&#37; to 5&#37; per year &#40;and 0&#46;5&#37;&#8211;1&#37; per year for fatal bleeding&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> The risk of bleeding is greater in the first three months&#8212;the mandatory anticoagulation period for DVT in the LE&#46; During this period&#44; the consequence of a &#40;temporary&#41; interruption of anticoagulation due to active bleeding can lead to a higher risk of recurrent VTD&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Therefore&#44; in every patient with acute DVT&#44; the clinician must assess the risk of bleeding before and during anticoagulant treatment based on clinical judgment according to each patient&#8217;s individual characteristics and&#47;or with the support of a bleeding risk scale developed for this purpose &#40;Table 5&#44; Annex I&#41;&#46; This bleeding risk stratification helps to identify patients at higher risk of bleeding in whom the risk&#47;benefit range of anticoagulation is narrower and for whom more continuous follow-up should be performed and&#47;or careful adjustments should be made to the most suitable intensity&#44; type of drug&#44; and duration of anticoagulation &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#44; checklist&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Mobilization and venous compression</span><p id="par0080" class="elsevierStylePara elsevierViewall">Early walking together with early use of local mechanical measures such as elastic compression stockings &#40;ECS&#41; or multilayer bandaging are beneficial for controlling symptoms associated with acute proximal DVT&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;24</span></a> Although there is no firm evidence on the benefit of ECS in the prevention of PTS&#44; they are recommended during the first three to six months and can be suspended thereafter if complete recanalization has been achieved and there are no symptoms suggestive of PTS &#40;defined by a Villalta scale score &#60;5&#41; &#40;Table 4&#44; Annex I&#41;&#46; Long compression stockings show no greater benefit than short&#44; below-the-knee stockings in the prevention of PTS and the latter are better tolerated&#46; They are contraindicated in patients with severe peripheral arterial disease&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Inferior vena cava filter</span><p id="par0085" class="elsevierStylePara elsevierViewall">Placement of a removable inferior vena cava filter &#40;IVCF&#41; is indicated in patients with DVT of the LE when there is an absolute contraindication to anticoagulation &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; or the need for urgent surgery that requires suspension of anticoagulation after very recent DVT &#40;&#60;1 month&#41;&#46; After placement of an IVCF&#44; anticoagulation should be initiated as soon as bleeding risk permits&#44; ensuring adequate follow-up and coordinating its removal as soon as anticoagulant doses are reached and before three to six months in order to avoid long-term complications &#40;4&#41;&#46; In addition&#44; a removable IVCF could be considered in select cases of recurrent DVT despite anticoagulation&#44; mainly if the risk of bleeding prevents taking other measures such as increasing the anticoagulation dose and the pulmonary reserve is small&#44; although the evidence in these cases is scarce and there is a greater risk of recurrent DVT and thrombotic inferior vena cava syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patient follow-up and education</span><p id="par0090" class="elsevierStylePara elsevierViewall">All patients with DVT should have clinical follow-up in a specific VTD clinic to evaluate possible complications of anticoagulation&#44; adherence to anticoagulation&#44; and the onset of complications &#40;PE and&#47;or PTS&#41;&#46; Performing a CDUS at three to six months to assess recanalization of the affected vein will be proposed and the duration of anticoagulant treatment will be decided taking into account the risk&#47;benefit of continuing the anticoagulant&#44; risk of recurrence&#44; and bleeding risk as well as patient preference and the availability and cost of the drug&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This point is especially recommended in cases of unprovoked DVT in which withdrawal of anticoagulation is considered&#46; This is because in the event residual thrombosis persists and the bleeding risk is low-moderate&#44; the recommendation of extended anticoagulation will be considered and&#44; in cases of high bleeding risk in which anticoagulation is suspended and a second event occurs with an indication for extended anticoagulation&#44; a previous ultrasound scan allows for knowing the new baseline status of the affected vessel&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">During follow-up&#44; health education on DVT is essential&#46; The clinician should explain the possible risk factors for recurrence of VTD and the importance of treatment adherence to the patient&#44; ensuring that he&#47;she understands the risks and peculiarities of his&#47;her anticoagulant treatment and knows how to identify the warning signs &#40;signs of bleeding or recurrence of thrombosis&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">During the entire anticoagulation period&#44; it is important to follow bleeding prevention strategies&#44; such as identifying and addressing modifiable bleeding risk factors &#40;adjustment of hypertension treatment&#44; review and modification of polypharmacy to avoid drug interactions&#44; management and prevention of possible kidney and liver function deterioration&#44; warning of the danger of alcohol abuse&#44; etc&#46;&#41; and monitoring for signs of bleeding as an early detection measure&#46; If bleeding occurs&#44; it is necessary to minimize its duration and intensity by eliminating its causes&#44; evaluate the possibility of reintroducing anticoagulation&#44; and then maintaining closer clinical monitoring to avoid rebleeding<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;12&#44;23</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#44; checklist&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">DVT in locations with special considerations</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Iliofemoral DVT</span><p id="par0105" class="elsevierStylePara elsevierViewall">In general&#44; it is recommended that these patients be admitted to the hospital and that anticoagulation with LMWH be started for clinical monitoring and completing the study&#46; A CT angiogram of the abdomen or pelvis or MRI angiography should be considered to rule out anatomical abnormalities &#40;IVC agenesis or hypoplasia or left iliac vein compression &#91;May-Thurner syndrome&#93;&#41;&#46; In select very symptomatic young people with left iliofemoral thrombosis&#44; a multidisciplinary assessment with vascular surgery or interventional vascular radiology specialists should be performed to consider endovascular early thrombus removal treatments &#40;elective catheter-directed thrombolysis&#41; with the aim of ensuring vascular patency and reducing the risk and severity of PTS&#44; assuming a higher risk of bleeding&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;8</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Isolated distal DVT</span><p id="par0110" class="elsevierStylePara elsevierViewall">The management of isolated distal DVT is controversial since many episodes resolve spontaneously and its emboligenic potential is lower than proximal DVTs&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">As with proximal DVTs&#44; starting full-dose anticoagulation for at least three months is recommended in patients with highly symptomatic isolated distal DVT or with risk factors for proximal thrombus progression &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In the absence of these risk factors for DVT progression or in patients with asymptomatic isolated distal DVT or with a high bleeding risk&#44; several options can be considered&#58; LMWH at reduced doses for four to six weeks or not starting anticoagulation and monitoring with serial Doppler ultrasound scans at seven to 14 days&#46; Then&#44; if no thrombotic progression is observed on the scans&#44; it is recommended to continue clinical monitoring without anticoagulation&#44; but if there is thrombus progression&#44; it is recommended to initiate anticoagulation&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Primary upper extremity DVT V</span><p id="par0120" class="elsevierStylePara elsevierViewall">Primary DVT of the upper extremity &#40;UE&#41; encompasses Paget-Schroetter syndrome &#40;PSS&#41; and idiopathic thrombosis&#46; They are rare and&#44; unlike central venous catheter-associated DVT of the UE&#44; there are no firm recommendations for them&#46; PSS is rare&#44; is associated with compression of the subclavian vein as it passes through the thoracic operculum&#44; usually affects young people who perform repeated UE exercises&#44; and can cause significant functional sequelae&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Meanwhile&#44; idiopathic DVT of the UE occurs more frequently in older adult patients and is associated with a higher risk of occult neoplasm &#40;in up to 25&#37; of patients&#41; and a worse prognosis compared to patients with PSS&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Generally&#44; although there is little evidence in the literature&#44; initial anticoagulation with LMWH is recommended followed by oral anticoagulation with VKA for at least three months&#46; Although there is no formal indication in guidelines on the use of DOACs in this scenario&#44; there are some encouraging data on DOACs as an anticoagulant alternative in DVT of the UE&#46; In patients with PSS&#44; early assessment by the thoracic or vascular surgery department is necessary or&#44; if appropriate&#44; referral to a multidisciplinary reference unit to evaluate other therapeutic options such as catheter-directed local thrombolysis &#40;within the first two weeks from symptoms onset&#41;&#44; associated or not with decompression surgery &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">DVT in special populations</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">DVT in pregnancy</span><p id="par0130" class="elsevierStylePara elsevierViewall">Pregnancy leads to a four- to five-fold increase in the risk of VTD&#44; with the postpartum period entailing the greatest mortality risk&#46; DVT occurs with equal frequency during pregnancy and the postpartum period whereas PE is more frequent in the postpartum period&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;24</span></a> The diagnosis of DVT during gestation can be difficult because of clinical nonspecificity&#44; the limited usefulness of DD given that it increases physiologically&#44; and the poor reliability of predictive scales developed for the general population&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Recommendations on the treatment of pregnant patients with DVT are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; LMWH at therapeutic doses is the anticoagulant of choice throughout pregnancy and the postpartum period&#46; Women who become pregnant while receiving VKAs or DOACs should switch to LMWH&#46; In the postpartum period&#44; LMWH at therapeutic doses or UFH can be restarted 24<span class="elsevierStyleHsp" style=""></span>h after removal of the epidural anesthesia catheter&#44; six to 12<span class="elsevierStyleHsp" style=""></span>h after vaginal delivery&#44; or 12&#8211;24<span class="elsevierStyleHsp" style=""></span>hours after a cesarean section&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4&#44;27&#44;28</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">DVT in extreme weights</span><p id="par0140" class="elsevierStylePara elsevierViewall">There are no firm&#44; specific recommendations for patients with extreme weights&#44; defined either as low body weight &#40;&#60;50<span class="elsevierStyleHsp" style=""></span>kg&#41; or extremely high body weight &#40;&#62;150<span class="elsevierStyleHsp" style=""></span>kg&#44; BMI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; in whom there are physiological changes in drug pharmacokinetics &#40;such as absorption rate&#44; volume of distribution&#44; and renal clearance&#41; that could lead to the over- or under-dosing of anticoagulants&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The treatment recommendations for this population are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">DVT in advanced kidney disease</span><p id="par0145" class="elsevierStylePara elsevierViewall">The evidence regarding anticoagulant therapy in patients with DVT and advanced chronic kidney disease &#40;CKD&#41; &#40;CrCl &#60;30<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#41; is mainly based on observational registries&#44; as this is a population with a fragile balance between VTD and bleeding risk&#46; Patients with advanced CKD are at increased risk for a first VTD event&#44; thrombotic recurrence&#44; major bleeding&#44; and short- and long-term all-cause mortality after a thrombotic event&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;29</span></a> The treatment recommendations for this population are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">DVT in older adults</span><p id="par0150" class="elsevierStylePara elsevierViewall">Older adult patients have a higher incidence of VTD&#44; higher VTD-related mortality and morbidity&#44; and increased risk of major bleeding associated with anticoagulation&#46; In these patients&#44; more extensive DVTs are diagnosed&#44; they occur more frequently with concomitant PE&#44; and they are at higher risk of developing PTS compared to the younger population&#46; Pluripathology &#40;kidney failure&#44; liver failure&#44; anemia&#44; cancer&#41;&#44; polypharmacy&#44; malnutrition&#44; frailty&#44; cognitive impairment&#44; and risk of falls are factors that increase the risk of major and fatal bleeding events&#46; Likewise&#44; this population is underrepresented in pivotal clinical trials on anticoagulants and therefore&#44; recommendations for this group come from observational studies&#46; The treatment recommendations for this population are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">DVT in patients with liver failure</span><p id="par0155" class="elsevierStylePara elsevierViewall">This population group is excluded from pivotal trials on anticoagulation in VTD&#46; Patients with cirrhosis not only have a greater bleeding risk&#44; but also a higher thrombotic risk&#44; with an unstable hemostatic balance that can be easily become unbalanced by precipitating factors &#40;liver decompensation&#44; sepsis&#44; kidney failure&#44; or invasive procedures&#41;&#46; The most common thrombotic complication in patients with advanced cirrhosis is portal thrombosis&#46; Likewise&#44; patients with advanced cirrhosis who receive anticoagulant therapy have a greater mortality rate and a very high risk of major bleeding compared to anticoagulated patients without cirrhosis&#46; The treatment recommendations for this population are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">DVT in thrombocytopenia</span><p id="par0160" class="elsevierStylePara elsevierViewall">The platelet count must be determined before initiating antithrombotic treatment&#44; since it is a limiting factor for anticoagulant use&#46; Thrombocytopenia &#40;TP&#41; does not reduce the risk of recurrent thrombosis and exposes patients to an increased risk of bleeding&#46; Patients with VTD and moderate-severe TP &#40;&#60;80&#44;000 platelets&#47;&#956;L&#41; have an almost three-fold risk of major bleeding and almost twice the risk of fatal bleeding than those with a normal platelet count&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Anticoagulation in the context of TP has the added challenge of balancing the competing risks of bleeding and recurrent VTD&#46; When assessing a patient&#8217;s risk of recurrent or progressive DVT&#44; factors such as thrombus burden &#40;size&#44; location&#44; and impact&#41;&#44; etiology&#44; and time since the index event should be taken into account&#46; Similarly&#44; the risk of bleeding can be determined by the medical history of bleeding&#59; concurrent coagulopathy &#40;e&#46;g&#46;&#44; DIC&#41;&#59; liver or kidney failure&#59; infection&#59; and&#44; in the case of solid tumors&#59; the type and location of the primary tumor and metastases&#46; Additional considerations include the need for procedures&#59; the etiology&#44; severity and duration of the PT&#59; and comorbidities such as kidney or liver failure that affect the anticoagulation choice and treatment&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The treatment recommendations for this population are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Recurrent DVT</span><p id="par0175" class="elsevierStylePara elsevierViewall">The diagnosis of recurrent DVT in the same location is usually more difficult to establish than a first episode of venous thrombosis&#46; A flare-up of symptoms may be a recurrence or PTS from the previous event&#44; which can occur in 20&#37;&#8211;45&#37; of patients with proximal DVT&#46; In the case of confirming recurrent DVT during anticoagulation&#44; the first step is to assess treatment adherence and confirm full doses and the absence of drug interactions&#46; Second&#44; causes of hypercoagulability&#44; such as occult or progressing neoplasms&#44; antiphospholipid syndrome &#40;APS&#41;&#44; or heparin-induced thrombocytopenia &#40;HIT&#41;&#44; should be ruled out&#46; Once these causes have been ruled out&#44; for patients who have recurrence under treatment with VKAs or DOACs&#44; it is suggested to switch to LMWH for at least four weeks &#40;and then consider switching to DOACs or returning to VKAs with the possibility of raising the target INR to 2&#46;5&#8211;3&#46;5&#41;&#46; In patients who have recurrence under treatment with LMWH&#44; it is suggested to increase the LMWH dose by 10&#37;&#8211;25&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discussion</span><p id="par0180" class="elsevierStylePara elsevierViewall">This document includes recommendations for the management of lower extremity DVT from the Spanish Society of Internal Medicine&#8217;s Working Group on Thromboembolic Disease&#46; It is part of a series of four documents on VTD that aim to reach a consensus on a series of useful recommendations based on the current literature for guiding clinicians in the management of VTD&#46; It is intended for any physician responsible for caring for patients with DVT in their daily clinical practice&#44; regardless of their specialty&#46; Although international guidelines and consensus documents on the management of VTD have been published in recent years&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;7</span></a> this document provides simple&#44; clear&#44; brief algorithms that can be used in clinical practice for DVT of the extremities&#46; In addition&#44; it aims to narrow the gap between clinical practice and current scientific evidence&#44; addressing the management of special but relatively common situations&#44; such as older adult patients&#44; patients with obesity&#44; or patients with kidney or liver failure&#44; in which there is still a great degree of uncertainty&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The main limitations are that the group of internists which developed this document is not multidisciplinary and the suggestions or recommendations do not include a cost-benefit analysis&#46; In addition to treatment safety and efficacy&#44; the cost&#47;benefit is a factor that health professionals must evaluate when making decisions&#46; Furthermore&#44; the document makes suggestions that are not indicated in the technical datasheet and the emergence of new evidence may lead to a revision of these indications&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Compliance with ethical guidelines</span><p id="par0190" class="elsevierStylePara elsevierViewall">This article is based on previously conducted studies and does not contain any new studies with human or animal participants conducted by any of the authors&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">Nuria Ruiz-Gim&#233;nez has worked as a consultant&#59; served as a speaker&#59; and received compensation for lectures from Sanofi&#44; Rovi&#44; Leo-Farma&#44; Bayer&#44; and Boehringer Ingelheim&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">A&#237;da Gil D&#237;az has served as a speaker and received compensation for lectures from Sanofi and Rovi&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Pedro Parra Caballero has served as a speaker&#44; performed paid work&#44; and received compensation for lectures from Sanofi&#44; Rovi&#44; and Bayer&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Nuria Mu&#241;oz Rivas has worked as a consultant&#59; served as a speaker&#59; performed paid work&#59; and received compensation for lectures from Sanofi&#44; Rovi&#44; Leo-Farma&#44; Bayer&#44; and Boehringer Ingelheim</p><p id="par0215" class="elsevierStylePara elsevierViewall">Gabriel Puche Palao has served as a speaker and received compensation for lectures from Viatris and Rovi&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Javier Miguel Mart&#237;n Guerra has served as a speaker and received compensation for lectures from Daiichi-Sankyo and LEO Pharma&#46;</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Members of the committee of experts</span><p id="par0225" class="elsevierStylePara elsevierViewall">Miguel Mart&#237;n Asenjo&#44; Olga Madridano Cobo&#44; Carme Font&#44; &#193;ngeles Fidalgo&#44; Javier Pag&#225;n Escribano&#44; Mar Mart&#237;n Pozo&#44; Alberto Rodriguez Iglesias&#44; Cristina S&#225;nchez del Hoyo&#44; Esther Usandizaga de Antonio&#44; Mar&#237;a Ortiz&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Materials and methods"
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          "titulo" => "Results and recommendations"
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              "titulo" => "Mobilization and venous compression"
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              "titulo" => "Inferior vena cava filter"
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                  "titulo" => "Iliofemoral DVT"
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                  "titulo" => "Isolated distal DVT"
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                2 => array:2 [
                  "identificador" => "sec0065"
                  "titulo" => "Primary upper extremity DVT V"
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                  "identificador" => "sec0080"
                  "titulo" => "DVT in extreme weights"
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                  "titulo" => "DVT in advanced kidney disease"
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                3 => array:2 [
                  "identificador" => "sec0090"
                  "titulo" => "DVT in older adults"
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                  "identificador" => "sec0095"
                  "titulo" => "DVT in patients with liver failure"
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                5 => array:2 [
                  "identificador" => "sec0100"
                  "titulo" => "DVT in thrombocytopenia"
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                  "identificador" => "sec0105"
                  "titulo" => "Recurrent DVT"
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            0 => "Anticoagulation"
            1 => "Diagnosis"
            2 => "Deep vein thrombosis"
            3 => "Extremities"
            4 => "Treatment"
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        1 => array:4 [
          "clase" => "abr"
          "titulo" => "Abbreviations"
          "identificador" => "xpalclavsec1827627"
          "palabras" => array:27 [
            0 => "DOACs"
            1 => "VKA"
            2 => "CrCl"
            3 => "DD"
            4 => "DUS"
            5 => "EDc"
            6 => "2-3PCUS"
            7 => "PE"
            8 => "VTD"
            9 => "TDS"
            10 => "LMWH"
            11 => "UFH"
            12 => "ECS"
            13 => "UE"
            14 => "LE"
            15 => "DVT"
            16 => "CRPTE"
            17 => "APS"
            18 => "MTS"
            19 => "PSS"
            20 => "PTS"
            21 => "MT"
            22 => "TP"
            23 => "ERT"
            24 => "CDT"
            25 => "PPI"
            26 => "NSAIDs"
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            0 => "Anticoagulaci&#243;n"
            1 => "Diagn&#243;stico"
            2 => "Trombosis venosa profunda"
            3 => "Extremidades"
            4 => "Tratamiento"
            5 => "Riesgo hemorr&#225;gico"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Deep vein thrombosis &#40;DVT&#41; of the limbs is a common disease and causes significant morbidity and mortality&#46; It is frequently the prelude to pulmonary embolism &#40;PE&#41;&#44; it can recur in 30&#37; of patients and in 25&#8211;40&#37; of cases they can develop post-thrombotic syndrome &#40;PTS&#41;&#44; with a significant impact in functional status and quality of life&#46; This document contains the recommendations on the diagnosis and treatment of acute DVT from the Thromboembolic Disease group of the Spanish Society of Internal Medicine &#40;SEMI&#41;&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">PE and thrombosis of unusual venous territories &#40;cerebral&#44; renal&#44; mesenteric&#44; superficial&#44; etc&#46;&#41; are outside its scope&#44; as well as thrombosis associated with catheter and thrombosis associated with cancer&#44; which due to their peculiarities will be the subject of other positioning documents of the Thromboembolic Disease group of the Spanish Society of Internal Medicine &#40;SEMI&#41;&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La trombosis venosa profunda &#40;TVP&#41; de miembros es una enfermedad frecuente y conlleva una morbimortalidad importante&#46; Es&#44; con frecuencia&#44; la antesala de la embolia de pulm&#243;n &#40;EP&#41;&#44; puede recurrir en el 30&#37; de los pacientes y en el 25&#8211;40&#37; de los casos pueden desarrollar el s&#237;ndrome postromb&#243;tico &#40;SPT&#41;&#44; con un importante impacto funcional y en la calidad de vida&#46; En este documento se recogen las recomendaciones sobre el diagn&#243;stico y tratamiento de la TVP aguda del grupo de Enfermedad Tromboemb&#243;lica de la Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;&#46; Quedan fuera del alcance del mismo la EP y las trombosis de territorios venosos inusuales &#40;cerebral&#44; renal&#44; mesent&#233;rica&#44; superficiales&#44; etc&#46;&#41;&#44; as&#237; como la trombosis asociada a cat&#233;ter y la asociada a c&#225;ncer&#44; que por sus peculiaridades ser&#225;n objeto de otros documentos de posicionamiento del grupo de Enfermedad Tromboemb&#243;lica de la Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;&#46;</p></span>"
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            "apendice" => "<p id="par0240" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
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            "titulo" => "Supplementary data"
            "identificador" => "sec0135"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Superficial and deep venous system of the lower extremities&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Phases of anticogulation&#46; Modified from Stevens et al&#46; CHEST 2021&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Checklist for anticoagulation in VTD&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Yes &#40;INR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Maintain INR 2&#8722;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Pregnancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Multiple&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">UFH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Bolus 5000 IU &#40;or 80 IU&#47;kg&#41; followed by continuous infusion of 18 IU&#47;kg&#47;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Yes &#40;aPTT or anti-Xa&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">aPTT &#60;35 sec&#58; bolus 80 IU&#47;kg and increase infusion 4 IU&#47;kg&#47;haPTT 35&#8211;45 sec&#58; bolus 40 IU&#47;kg and increase infusion 2 IU&#47; kg&#47;haPTT 46&#8211;70 sec&#58; maintain doseaPTT 71&#8211;90 sec&#58; reduce infusion 2 IU&#47;kg&#47;haPTT &#62;90 sec&#58; stop infusion 2<span class="elsevierStyleHsp" style=""></span>h and reduce 3 IU&#47;kg&#47;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">ICT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">UFH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">SC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Bolus 5000 IU IV followed by 10&#44;000&#8211;20000 IU SC and continue with 8000&#8722;10000 IU every 8<span class="elsevierStyleHsp" style=""></span>h SC or 17500 IU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Yes &#40;aPTT or anti-Xa&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">According to aPTT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">ICT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Enoxaparin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100 IU anti-Xa&#47;kg&#47;12<span class="elsevierStyleHsp" style=""></span>h or 150 IU anti-Xa&#47; kg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No assess anti-Xa in GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ml&#47;min and extreme weights&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#58; caution&#44;close clinical follow-up and assess monitoring of anti-Xa levels&#44;individualize dosage adjustment<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ICT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bemiparin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">115 IU anti-Xa&#47;kg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tinzaparin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">175 IU anti-Xa&#47;kg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Dalteparin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">100 IU anti-Xa&#47;kg&#47;12<span class="elsevierStyleHsp" style=""></span>h or 200 IU anti-Xa&#47;kg&#47;day &#40;from 2nd month 150 IU&#47;kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Fondaparinux&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">SC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Weight &#60;50<span class="elsevierStyleHsp" style=""></span>kg&#58; 5<span class="elsevierStyleHsp" style=""></span>mg&#47;dayWeight 50&#8211;100 kg&#58; 7&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dayWeight &#62;100 kg&#58; 10<span class="elsevierStyleHsp" style=""></span>mg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ml&#47;minNot advisable in pregnancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Rivaroxaban&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Oral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">15<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h first 21 days&#44; then 20<span class="elsevierStyleHsp" style=""></span>mg&#47;24h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No &#40;specific anti-Xa in select cases&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">FGFR 15&#8211;49<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#58; 15<span class="elsevierStyleHsp" style=""></span>mg&#47;day depending on bleeding risk&#46;Reduce to 10<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h after 6 months&#46;except in individual situations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Pregnancy GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>ml&#47; min<span class="elsevierStyleItalic">Triple-positive APS not recommended</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">P-gp Inhibitors C450 Inhibitors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Apixaban&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Oral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">10<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h first 7 days&#44; then 5<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No &#40;specific anti-Xa in select cases&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Reduce to 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h after 6 months except in individual situations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Pregnancy GFR &#60;<span class="elsevierStyleHsp" style=""></span>15 ml&#47; min <span class="elsevierStyleItalic">Triple-positive APS not recommended</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">P-gp Inhibitors C450 Inhibitors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Edoxaban&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Oral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">60<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No &#40;specific anti-Xa in select cases&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Weight &#8804;60 kg&#58; 30<span class="elsevierStyleHsp" style=""></span>mg&#47;dayGFR 15&#8211;50<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#58; 30<span class="elsevierStyleHsp" style=""></span>mg&#47;day Concomitant treatment with potent P-gp inhibitors&#58; 30<span class="elsevierStyleHsp" style=""></span>mg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Pregnancy GFR &#60;<span class="elsevierStyleHsp" style=""></span>15 ml&#47; min <span class="elsevierStyleItalic">Triple-positive APS not recommended</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">P-gp Inhibitors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dabigatran&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">150<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No &#40;specific anti-Xa in select cases&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#62;80 years&#58; 110<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h Concomitant treatment with Verapamil&#58; 110<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>hGFR 30&#8211;50<span class="elsevierStyleHsp" style=""></span>ml&#47;min or age 75&#8211;79 years&#58; consider reducing the dose according to bleeding risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pregnancy GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#40;<span class="elsevierStyleItalic">Triple-positive APS not recommended</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">P-gp Inhibitors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3548634.png"
              ]
            ]
          ]
          "notaPie" => array:4 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Start after at least one dose of heparin or Fondaparinux&#44; overlapping for at least 5 days and until 2 consecutive INR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2 are achieved&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Start after at least 5 days of parenteral anticoagulant treatment&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Specific contraindications&#44; beyond bleeding&#46;</p>"
            ]
            3 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "d"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Enoxaparin&#58; reduce dose to 100 IU&#47;kg &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41; body weight SC once daily&#46; Bemiparin&#58; dose adjustment to 75&#37; &#40;approximately 85 IU anti-Xa&#47;kg once daily&#41; is recommended&#46; Tinzaparin&#58; available evidence demonstrates no accumulation until GFR levels up to 20<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Dosage of anticoagulants indicated for VTD&#46;</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0050"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Very symptomatic iliofemoral DVT<elsevierMultimedia ident="202405260720015221"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">They require hospital admission &#40;and starting LMWH treatment&#41;&#46;In young patients with left iliofemoral DVT&#44; it is recommended that May-Thurner syndrome be ruled out&#46; If it is confirmed&#44; an assessment by a radiology and vascular surgery specialist should be requested&#46;Consider early endovascular thrombus removal therapies in patients with massive iliofemoral DVT with arterial circulation compromise &#40;phlegmasia cerulea dolens&#41; in the absence of contraindications and on a highly individualized basis in patients with good functional status&#44; life expectancy &#8805;1 year&#44; low bleeding risk&#44; in experienced centers&#44; and always within the first two weeks after symptoms onset&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Isolated distal TVP<elsevierMultimedia ident="202405260720015222"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Full-dose anticoagulation for three months is recommended if there are RF for progression&#58; male&#44; age &#62;50 years&#44; high DD&#44; extensive DVT&#44; unprovoked DVT&#44; DVT in hospitalized patients&#44; or in the presence of persistent RF &#40;active cancer&#44; thrombophilia&#44; and previous VTD&#41;&#46;Consider not starting anticoagulation in asymptomatic distal DVT with high bleeding risk or due to patient preference or in patients with low risk of progression&#58; intramuscular DVT&#44; those associated with transient RF &#40;splints&#44; trauma&#44; long-distance travel&#41; if full mobilization is guaranteed and those associated with hormonal contraception if said treatment has been discontinued&#46;If anticoagulation is not started&#44; a follow-up Doppler ultrasound should be performed in seven to ten days to rule out progression &#40;in which case starting anticoagulation is recommended&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Primary DVT of the LE &#40;PSS and idiopathic&#41;<elsevierMultimedia ident="202405260720015223"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consider performing a CT angiogram or MRI if there is an indeterminate ultrasound to evaluate the extension and if there is suspicion of concomitant conditions&#58; neoplasm or adenopathies or vascular compression of any anatomical structure &#40;anomalies of the first rib&#44; clavicle&#44; subclavius muscle&#44; costoclavicular ligament&#44; or anterior scalene muscle&#41;&#46;Full-dose anticoagulation for three months is recommended&#46; Extending anticoagulation beyond three months will depend on the RF associated with the index event&#46;In select cases of PSS &#40;young&#44; very symptomatic&#44; with high risk of post-thrombotic syndrome sequelae&#41;&#44; consider early thrombolysis followed by surgical decompression &#40;resection of the first rib or scalene musculature&#41;&#46;The use of compression sleeves is not routinely recommended &#40;lack of evidence&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3548633.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">DVT recommendations in special locations&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0055"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">DOACs &#40;rivaroxaban&#44; apixaban&#44; dabigatran&#44; or edoxaban&#41; are not funded by Spain&#8217;s public health system for this indication&#44; so if the patient prefers treatment with them&#44; he or she must pay the full cost&#46; IVCF&#58; inferior vena cava filter&#46; DOACs &#40;direct acting anticoagulants&#41;&#44; BMI &#40;body mass index&#41;&#44; CKD &#40;chronic kidney disease&#41;&#44; LMWH &#40;low-molecular-weight heparin&#41;&#44; VTE &#40;venous thromboembolism&#41;&#44; DVT &#40;deep vein thrombosis&#41;&#44; PE &#40;pulmonary embolism&#41;&#44; EGD &#40;esophagogastroduodenoscopy&#41;&#44; TDS &#40;technical datasheet&#41;&#44; CrCl &#40;creatinine clearance&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Special situation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pregnancy<elsevierMultimedia ident="202405260720015224"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Preferable&#58; LMWH at therapeutic doses in a single daily dose throughout pregnancy and continue during the postpartum period &#40;six weeks&#41; and at least three months from the thrombotic event&#46;Monitoring of anti-Xa levels is not routinely recommended&#46; It can be assessed in selected cases&#44; such as pregnant women at extreme weights and with advanced kidney failure or high bleeding risk&#46;VKAs &#40;due to teratogenicity&#41; and DOACs &#40;due to possible toxicity and lack of evidence&#41; are contraindicated&#46;The peripartum period must be managed by an expert multidisciplinary team and scheduling delivery can minimize the risk of complications&#46;If a pregnant woman is diagnosed with DVT less than two weeks prior to the due date&#44; admission and scheduled delivery with the use of intravenous UFH is recommended&#44; in addition to considering placement of a temporary peripartum inferior vena cava filter&#46; Breastfeeding women can continue with LMWH&#46; DOACs are contraindicated in the postpartum period due to lack of safety data&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="middle">Extreme weights<elsevierMultimedia ident="202405260720015225"></elsevierMultimedia></td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Any DOAC can be used in patients with obesity with a body mass index &#40;BMI&#41; of 30&#8211;40<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#46;VKA is preferable in patients with a BMI of 40&#8211;50<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; although apixaban or rivaroxaban can be considered&#46;VKA should be used in patients with obesity with a BMI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#46;The LMWH dose should be adjusted according to the technical datasheet&#46; Monitoring of anti-Xa levels is not routinely recommended&#44; but can be considered in select patients with BMI<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> &#40;weight &#62;150<span class="elsevierStyleHsp" style=""></span>kg or BMI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; hemodynamic instability&#44; occurrence of thromboembolic or bleeding complications&#44; prolonged treatment for more than ten days&#44; or coexistence of advanced CKD &#40;GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">The use of apixaban and edoxaban &#40;dose adjustment according to TDS&#41; is suggested in patients with DVT who weigh between 60 and 40<span class="elsevierStyleHsp" style=""></span>kg&#46;In patients who weigh &#60;40<span class="elsevierStyleHsp" style=""></span>kg&#44; the use of VKA is suggested or&#44; if treatment with DOACs is indicated&#44; plasma levels should be measured&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Kidney failure <elsevierMultimedia ident="202405260720015226"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">In CKD stages 1&#8211;3 &#40;CrCl 30&#8211;59<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#44; DOACs are recommended as the first choice &#40;with dose adjustment according to the TDS&#41;&#46;In stage 4 CKD &#40;CrCl 15&#8211;29<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#44; treatment should be individualized&#44; adjusted according to the TDS&#44; and precaution should be taken with all AC&#46; Tinzaparin is the LMWH with the least renal clearance &#40;safe for GFR up to 20<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#44; the rest with dose adjustment according to TDS&#46; Monitoring anti-Xa activity could be considered in prolonged treatment with SC LMWH for more than ten days&#46; Dabigatran is contraindicated&#46; The rest of DOACs with dose adjustment&#46;In stage 5 CKD &#40;CrCl &#60;15<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#41;&#44; VKAs are the treatment of choice&#46; DOACs are not recommended&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Older adults<elsevierMultimedia ident="202405260720015227"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Greater caution with anticoagulant therapy &#40;narrow risk&#47;benefit margin&#41;&#46; Dose adjustment for actual weight and renal function&#46; Comprehensive evaluation of bleeding risk and closer monitoring&#46;DOACs are the treatment of choice&#58; oral administration&#44; lower rate of major bleeding&#44; no need for monitoring&#44; and fewer drug and dietary interactions than VKA&#46;Treatment with LMWH &#40;preferably a single daily dose&#44; adjusted according to weight and renal function&#41; is another safe and effective alternative to conventional therapy &#40;LMWH<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>AVK&#41; that avoids monitoring and drug interactions&#44; although the cost and subcutaneous administration are disadvantages&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Liver dysfunction<elsevierMultimedia ident="202405260720015228"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">The prognosis of chronic liver disease&#44; mainly cirrhosis&#44; should be assessed using the Child-Pugh classificationEGD should be performed to detect&#47;rule out esophageal varices as well as alcohol use disorder screening and counseling&#46;If Child-Pugh A cirrhosis&#58; DOACs or VKAs can be used&#46;If Child-Pugh B cirrhosis&#58; VKA or&#44; with caution&#44; DOACs &#40;apixaban and edoxaban&#41; can be used&#46; Rivaroxaban is contraindicated and dabigatran is contraindicated in patients with possibly life-threatening liver disease&#46;If Child-Pugh C cirrhosis&#58; AVK of choice&#46; DOACs are contraindicated&#46; Anticoagulation should be discontinued if severe thrombocytopenia is also present and the risk&#47;benefit ratio should be carefully assessed in patients with poor vital prognosis and very high risk of bleeding&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Thrombocytopenia &#40;TP&#41;&#60;50<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10&#8313;&#47;L<elsevierMultimedia ident="202405260720015229"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">When the platelet count is &#60;50<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#44; the thrombotic and bleeding risk as well as expected duration of TP should be reevaluated&#46;If mild TP &#40;platelet count &#8805;50<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#41;&#44; it is suggested to maintain anticoagulant therapy at full doses&#46;In the case of moderate TP &#40;platelet count between 20<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10&#8313;&#47;L and 50<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10&#8313;&#47;L&#41;&#44; a 50&#37; LMWH dose reduction is suggested&#46;If severe TP &#40;platelet count equal to or less than 20<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10&#8313;&#47;L&#58; in the acute phase of VTD &#40;&#60;30 days&#41;&#44; IVCF placement should be considered&#44; especially if TP is expected to last longer than five to seven days as well as in patients with extensive DVT or PE with low cardiopulmonary reserve or recurrent thrombosis&#41;&#46; Platelet transfusion could be considered to maintain platelet counts above 20<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L &#40;possibly starting anticoagulation at intermediate doses of LMWH&#41; or 50<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L &#40;possibly starting full-dose anticoagulation&#41;&#46; Discontinuation of anticoagulant therapy is suggested in patients with thrombocytopenia &#60;50<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L and subacute &#40;30&#8211;90 days since the event&#41; or isolated distal DVT&#46;&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "The epidemiology of venous thromboembolism"
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                          "autores" => array:3 [
                            0 => "J&#46;A&#46; Heit"
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                        "tituloSerie" => "J Thromb Thrombolysis&#46;"
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                        "volumen" => "41"
                        "numero" => "1"
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                0 => array:2 [
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                          "etal" => false
                          "autores" => array:2 [
                            0 => "O&#46; Pikovsky"
                            1 => "A&#46; Rabinovich"
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                      "doi" => "10.1016/j.thromres.2017.07.008"
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                        "tituloSerie" => "Thromb Res&#46;"
                        "fecha" => "2018"
                        "volumen" => "164"
                        "paginaInicial" => "116"
                        "paginaFinal" => "124"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28736157"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Editor&#8217;s Choice - European Society for Vascular Surgery &#40;ESVS&#41; 2021 clinical practice guidelines on the management of venous thrombosis"
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                            3 => "R&#46; Bauersachs"
                            4 => "S&#46; Bellmunt-Montoya"
                            5 => "S&#46;A&#46; Black"
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                      "titulo" => "Second consensus document on diagnosis and management of acute deep vein thrombosis&#58; updated document elaborated by the ESC Working Group on aorta and peripheral vascular diseases and the ESC Working Group on pulmonary circulation and right ventricular function"
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                      "titulo" => "American society of hematology 2020 guidelines for management of venous thromboembolism&#58; treatment of deep vein thrombosis and pulmonary embolism"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antithrombotic therapy for VTE disease&#58; second update of the CHEST guideline and expert panel report"
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                          "etal" => true
                          "autores" => array:6 [
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                            3 => "H&#46; Bounameaux"
                            4 => "K&#46; Doerschug"
                            5 => "G&#46;J&#46; Geersing"
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                        "volumen" => "160"
                        "numero" => "6"
                        "paginaInicial" => "e545"
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                  "contribucion" => array:1 [
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                      "titulo" => "Venous thromboembolic diseases&#58; diagnosis&#44; management and thrombophilia testing&#58; observations on NICE guideline &#91;NG158&#93;"
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                          "etal" => false
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2024.04.004

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