Management of DVT

management of DVT? The simple rule is that if you have somebody who has a symptomatic deep vein thrombosis or VTE that they should be treated with anticoagulation. The duration of the anticoagulation can be discussed. Usually people would suggest for first deep vein thrombosis that it should be for up to three months and sometimes depending on various risk factors and assessment up to six months. If you have got somebody who presents with a recurrent deep vein thrombosis, i.e. their second deep vein thrombosis, that is an indication to consider lifelong anticoagulation. There are many reasons that you should consider the anticoagulation because it one reduces your risk of developing a further deep vein thrombosis or pulmonary embolus and it also decreases your risk of dying from AVTE. The only exception where you may not offer somebody anticoagulation it would be if you looked at the risk-benefit ratio and they had a significant bleeding risk that would put them at a significant risk of not being able to tolerate the anticoagulation and having a bleed be that either in the gut or into the brain such that it would end up and result in their death. There's a very small number of patients who have mild symptoms in the calf and only have a calf deep vein thrombosis who you may do serial ultrasound scanning and decide as to whether to put them onto anticoagulation. However, the majority of people have now moved over to if somebody has actual symptoms that have warranted them to be scanned of actually treating these patients with anticoagulation. But like all things, everything is a risk benefit. The other thing that then needs to be considered once patients have taken their anticoagulation for three months and we can then consider whether these are provoked or unprovoked DVTs is as to whether you are going to stop their anticoagulation completely, whether you might want to put them on to a low-dose anticoagulant, or you might want to put them on to an antiplatelet medication. There are various arguments for doing any of these. We know that the evidence to date shows that if you continue people on a low dose of the DOAC medication or onto aspirin, you do actually reduce their subsequent risk of developing a further VTE event. However, the other things that need to be considered with respect to treatment are whether you want to offer them compression hosiery at the moment. The NICE and the ACCP guidelines recommend against the use, standardly, of graduate compression stockings to reduce the risk of the post-robotic syndrome. However, this is controversial because many physicians believe that there is a benefit so that to that end the UK government are funding a trial in the UK to assess whether we should actually be recommending the use of compression hosiery to those patients who present initially with a deep vein thrombosis. thrombosis. What is important is that when you present and have your treatment for your deep vein thrombosis that you have discussed this with a clinician who is a specialist in the area. Most hospitals now will have an acute deep vein thrombosis service which may mean that this is run by a nurse practitioner but it is very important that this is often a protocolised service and by being entered into the protocol and then seeing either a haematologist, a vascular surgeon or a physician who has an interest in VTE that you will get the most appropriate treatment for yourself. Are there any risks or side effects of treatment? The main side effects of treatment such as the use of anti-coagulation and the major thing that we're concerned about is any increased risk of bleeding. Other than for the increased risk of bleeding, there really are very few risks other than the one thing that is just worthwhile mentioning in patients who may be offered extended low molecular weight heparin, particularly in ladies, there is an increased risk of patients developing osteoporosis and osteopenia. However, the risks are very small. What this risk is with the direct oral anticoagulants that are obviously of a heparinoid are basically very much unknown. And finally, can a patient go on a flight whilst having treatment for a DVT? With respect to flights, once somebody is fully anticoagulated and wearing compression hosiery then you have actually minimised their risk of developing a further VTE, therefore there should be minimal risk to them due to the flight. So my own personal view is that providing you are properly anticoagulated and are wearing compression hosiery there is no reason why you cannot fly. It is very important that you should discuss this with your healthcare professional before you fly. If you have previously had a deep vein thrombosis and are no longer taking anticoagulation and you are due to go on a long-haul flight or a long journey, and by a long-haul flight I mean anything over six hours, that you should undoubtedly think about wearing compression hosiery and there are many clinicians around the world who will prescribe you heparin, either in the form of low molecular weight heparin or as a direct oral anticoagulant which is an oral tablet such as rivoxaban and a pixaban and a recommendation being that for the long-haul flight you take either the oral tablet or the injection the morning of the flight and for the two successive days after that and similarly on your return. One of the other things that is also of importance to note is that if you are doing a long-haul flight and then going on to receive a surgical intervention that you put yourself at an increased risk of developing a deep vein thrombosis within the first two weeks of having had a long-haul flight and this is something that is often not considered that actually having going on a flight puts you at an increased operative risk and should be considered by all patients and clinicians who are offering interventional procedures to patients after they've had a long-haul flight. Thank you.