dvt treatment guidelines 2020
Indefinite antithrombotic therapy also showed a risk for reduction of DVT in the study population (RR, 0.20; 95% CI, 0.12-0.34; ARR, 50 fewer per 1000 patients; 95% CI, 56 fewer to 42 fewer; high-certainty evidence), as well as for patients with unprovoked VTE at 1 year269,274 (ARR, 33 fewer per 1000 patients; 95% CI, 36 fewer to 27 fewer). A randomized study, Secondary prevention of venous thromboembolism with the oral direct thrombin inhibitor ximelagatran, Residual vein thrombosis to establish duration of anticoagulation after a first episode of deep vein thrombosis: the Duration of Anticoagulation based on Compression UltraSonography (DACUS) study, The development of persistent thrombotic masses in patients with deep venous thrombosis randomized to long-term anticoagulation treatment, Risk of recurrence after a first episode of symptomatic venous thromboembolism provoked by a transient risk factor: a systematic review, Dynamics of case-fatalilty rates of recurrent thromboembolism and major bleeding in patients treated for venous thromboembolism, Cost-effectiveness analysis of extended duration anticoagulation with rivaroxaban to prevent recurrent venous thromboembolism, Duration of anticoagulation for the management of venous thromboembolism in inflammatory bowel disease: a decision analysis, Oral anticoagulation strategies after a first idiopathic venous thromboembolic event, Patient-reported treatment satisfaction with oral rivaroxaban versus standard therapy in the treatment of acute symptomatic deep-vein thrombosis, Identifying unprovoked thromboembolism patients at low risk for recurrence who can discontinue anticoagulant therapy, Systematic review of prognostic models for recurrent venous thromboembolism (VTE) post-treatment of first unprovoked VTE, Risk assessment of recurrence in patients with unprovoked deep vein thrombosis or pulmonary embolism: the Vienna Prediction Model, Risk assessment model to predict recurrence in patients with unprovoked deep vein thrombosis or pulmonary embolism, D-dimer levels over time and the risk of recurrent venous thromboembolism: an update of the Vienna prediction model, Prediction of risk of recurrence of venous thromboembolism following treatment for a first unprovoked venous thromboembolism: systematic review, prognostic model and clinical decision rule, and economic evaluation, D-dimer levels over time and the risk of recurrent venous thromboembolism: an update of the Vienna Prediction Model, The use of the REVERSE study clinical prediction rule for risk stratification after initial anticoagulation results in decreased recurrences in patients with idiopathic venous thromboembolism, External validation and updating of the Vienna Prediction Model for recurrent venous thromboembolism using a pooled individual patient data database, Risk assessment for recurrent venous thromboembolism (VTE) after 6-14 months of anticoagulant treatment, The REVERSE I and II studies: impact of using. As noted above, 4 panel members believed that this should be a strong recommendation because systemic thrombolysis is not considered appropriate therapy in the United States. ASH staff supported panel appointments and coordinated meetings but had no role in choosing the guideline questions or determining the recommendations. In all of these studies, LMWH was used for home management, whereas UFH was primarily used in hospital management.42-45. This recommendation does not apply to patients with a recent acute coronary event or coronary intervention. In populations with a high risk for bleeding, the use of indefinite antithrombotic therapy instead of a defined duration of anticoagulation led to an increase of 18 more bleeding events per 1000 patients (95% CI, 6 more to 35 more; high-certainty evidence). Three analyses showed that the extended strategy was cost-effective compared with the limited antithrombotic therapy,112,270,271 whereas 1 analysis suggested that longer initial conventional-intensity anticoagulation with warfarin was cost-effective in younger patients, and 3 months of anticoagulation was preferred in elderly patients (≥80 years old).272 The panel considered that cost-effectiveness varies with patients, the chronic risk factor(s) contributing to risk for recurrent VTE, and drug used. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. We identified 5 reports based on real-world data that compared the treatment cost of home management vs hospital management.30,32,38-40 All reports showed that home management is cost saving compared with inpatient management. The other main limitation of the evidence supporting this decision was imprecision of the estimates. Finally, we considered DOACs to be acceptable and feasible to implement in most scenarios. Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques, Systemic or local thrombolysis in high-risk pulmonary embolism, Systemic thrombolysis increases hemorrhagic stroke risk without survival benefit compared with catheter-directed intervention for the treatment of acute pulmonary embolism, Thrombolysis (catheter directed/systemic) in pulmonary embolism: predictors and etiologies of readmissions, Catheter directed thrombolysis versus systemic thrombolysis for the treatment of pulmonary embolism, Using inferior vena cava filters to prevent pulmonary embolism, Evidence-based evaluation of inferior vena cava filter complications based on filter type, Postthrombotic syndrome in relation to vena cava filter placement: a systematic review, Clinical outcomes of retrievable inferior vena cava filter plus anticoagulation versus anticoagulation alone on high-risk patients: a meta-analysis, The short-term efficacy of vena cava filters for the prevention of pulmonary embolism in patients with venous thromboembolism receiving anticoagulation: meta-analysis of randomized controlled trials, Clinical review: inferior vena cava filters in the age of patient-centered outcomes, Vena caval filters for the prevention of pulmonary embolism. Acquired (environmental) risk factors for DVT and/or PE that are considered chronic include cancer (discussed in a future guideline document from ASH), certain autoimmune disorders (eg, inflammatory bowel disease or antiphospholipid syndrome), and chronic immobility (Table 3).237 Some of these risk factors may fluctuate over time (eg, the autoimmune disorders), but many of these patients are considered to be at a higher risk for recurrent thromboembolism if anticoagulant therapy is discontinued. The membership of the panel and the GRADE Centre team is described in Supplement 1. If an IVC filter is going to be deployed, the panel recommends use of a retrievable filter, with removal once the patient is able to be safely treated with anticoagulant therapy. Our choice of terminology reflects the distinct clinical intentions of the different phases of VTE management, linking them to important clinical decisions addressed in the guidelines, rather than using terms reflecting the relative duration of therapy. This risk has been estimated to be as high as 10% by 1 year and up to 30% by 5 to 10 years.10,11,313 The ASH guideline panel has provided a conditional recommendation for continuing antithrombotic therapy indefinitely after completion of primary treatment for patients with unprovoked VTE, based on moderate certainty in the evidence of effects. This recommendation applies to the patient who sustains a VTE related to a transient risk factor, who also has a history of VTE that was unprovoked or provoked by a chronic risk factor (Recommendation 24a) or who has a history of VTE that was provoked by a transient risk factor (Recommendation 24b). This exception is in accordance with the exceptional circumstances that allow strong recommendations based on low-certainty evidence in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) ASH rules. For DVT, the certainty in the evidence was judged high. Phase 1 results: a cooperative study, Tissue plasminogen activator for the treatment of acute pulmonary embolism. In the subgroup analysis performed, there are 2 cases in which the quality of the evidence differed from the original analysis. In health systems with good primary care, home treatment is feasible and safe. Last guideline approval: September 2020 Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health care for specific clinical conditions. We used existing systematic reviews as a way to identify relevant trials, but we conducted our own meta-analyses for all of the questions following the principles outlined in the Cochrane Handbook for Systematic Reviews of Interventions (https://training.cochrane.org/handbook). We did find studies evaluating the prognostic performance of the different tools: an individual patient meta-analysis of observational studies and 1 RCT (n = 2527)300 showed an independent association of residual vein thrombosis and recurrent VTE (HR, 1.32; 95% CI, 1.06-1.65). Based on 1 very small trial and 3 observational studies, the use of catheter-directed thrombolysis might reduce mortality (RCT estimate: RR, 0.06; 95% CI, 0-0.96; ARR, 157 fewer per 1000 patients; 95% CI, 7 fewer to 167 fewer; very-low-certainty evidence; observational studies estimate: odds ratio [OR], 0.59; 95% CI, 0.33-1.04; ARR during hospitalization, 48 fewer per 1000 patients; 95% CI, 81 fewer to 4 more; very low certainty). Panelists recommended or suggested courses of action based on the evidence available at the moment of development of this guideline. These patients need to undergo decisions about initial management (Recommendations 1 to 11) and primary treatment (Recommendations 12 to 14), just as with their first event. However, when we considered only the trials with a low risk for bias, this potential benefit was not observed (RR, 1.01; 95% CI, 0.76-1.33). Finally, we considered that thrombolysis is acceptable and feasible to implement in most scenarios. All of the identified trials, with the exception of the SOX trial, compared the use of stockings vs no stockings for patients with proximal DVT. In populations with a high risk for bleeding,98 the use of a DOAC instead of a VKA may lead to a reduction of 8 fewer bleeding events per 1000 (95% CI, 11 fewer to 3 fewer; high-certainty evidence). Initial management (yellow box) spans the first 5 to 21 days following diagnosis of a new VTE and includes issues concerning whether the patient can be treated at home or requires admission to the hospital, use of thrombolytic therapy, whether an IVC filter needs to be placed, and initial anticoagulant therapy. These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about treatment of VTE. For patients who will be treated with a VKA, initiation must be overlapped with UFH or LMWH for a minimum of 5 days and a therapeutic INR is achieved for 24 hours, at which time the heparin is discontinued. However, some patients may experience discomfort, skin breakdown, allergic reaction, or significant cost to acquire the stockings. Remarks: These recommendations are intended to address the duration of primary anticoagulant treatment for all patients with DVT and/or PE, defined as the minimal length of time for treatment of the initial VTE (Figure 1). We identified 1 systematic review evaluating prognostic scores,275 which included 20 observational studies.276-293 Additionally, we identified 4 systematic reviews294-297 and 1 relevant randomized trial298 assessing the role of D-dimer testing, as well as 5 systematic reviews299-303 and 1 relevant trial304 evaluating the use of ultrasound assessment for residual thrombosis from an initial DVT to guide the duration of anticoagulation. and indefinite anticoagulation for patients with recurrent unprovoked VTE. After completion of the primary treatment phase, subsequent decisions (discussed in Recommendation 19) would determine whether to discontinue anticoagulant therapy or continue indefinitely for secondary prevention of recurrent VTE (Figure 2). Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. To diagnose deep vein thrombosis, your doctor will ask you about your symptoms. Active cancer is addressed in a future guideline document from ASH and is not considered in this article. One Markov model272 compared an unlimited duration of conventional-intensity anticoagulation (INR range, 2.0-3.0) vs low-intensity anticoagulation (INR range, 1.5-2.0) with warfarin. It should be noted that patients with chronic risk factors for VTE may also have 1 (or more) transient risk factor (eg, surgery) or other nonenvironmental risk factors, such as an inherited thrombophilia, older age, or male sex.237 These additional risk factors do not change this recommendation for duration of the primary treatment phase for the thromboembolic event. As noted above, in the case of prognostic scores, at the time of our systematic review, we did not find any trial assessing their impact in patient-important outcomes, and the evidence regarding their discrimination ability and their validation was limited. When using a DOAC for a longer course of anticoagulation, the risk of DVT was reduced in the study population (RR, 0.21; 95% CI, 0.11-0.41; ARR, 62 fewer per 1000 patients; 95% CI, 70 fewer to 46 fewer; moderate-certainty evidence), as well as in the low-risk population274 (ARR, 42 fewer per 1000 patients; 95% CI, 47 fewer to 31 fewer; moderate-certainty evidence). However, 4 panel members believed the recommendation should have been graded as strong based on the lack of evidence showing meaningful clinical benefits outweighing the known bleeding risks associated with systemic thrombolysis. Three analyses showed that the extended strategy was cost-effective compared with limited antithrombotic therapy,112,270,271 whereas 1 analysis suggested that longer initial conventional-intensity anticoagulation with warfarin was cost-effective in younger patients and 3 months of anticoagulation was preferred in elderly patients (80-year-old subgroup).272 The panel considered that cost-effectiveness varies with patients, any risk factor(s) contributing to the increased risk of recurrent VTE, and the specific anticoagulant used. The “Adolopment” model of guideline adoption, adaptation, and development359 offers an approach to adapt the recommendations of this article to a specific context, taking advantage of the EtD frameworks accompanying each recommendation. Blood Adv 2020; 4 (19): 4693–4738. The EtD framework is shown online at: https://guidelines.gradepro.org/profile/B7293C21-767F-B3F8-8BB2-A4E5173CDAC3. All panel members reviewed the recommendations and remarks. Recommendations 20 to 22 address the antithrombotic therapies that might be considered for patients who continue indefinite therapy. In a low-risk population,268 a longer course of anticoagulation also reduced the risk of DVT (ARR, 18 fewer per 1000 patients; 95% CI, 21 fewer to 14 fewer). Major bleeding events may occur in ∼1% to 3% of patients on VKAs each year, compared to an ∼30% lower relative risk for major bleeding with DOACs.15, The incidence of VTE increases with age, ranging from ∼1 in 10 000 in individuals younger than 20 years of age to as high as ∼1 in 100 in individuals who are 80 years of age and older.16 VTE affects all races and ethnicities, with black persons having a higher incidence than white persons in most studies and individuals of Asian descent having a lower incidence than other races.17-19 Certain acquired characteristics identify subsets of individuals at higher risk for VTE, including individuals who are currently or were recently hospitalized, residents in long-term care facilities, and patients undergoing surgical procedures.4. of primary treatment (about three to six months) and prophylaxis to prevent recurrence The certainty in the evidence from the included RCTs was judged low for short-term and long-term mortality, PE, DVT, and major bleeding because of the small number of events and wide CI that covered appreciable benefit and harm. In this case, the high mortality of patients with PE and hemodynamic compromise, as well as the potential lifesaving effect of thrombolytics, warranted a strong recommendation. The panel considered that avoidance of PE, DVT, PTS, and major bleeding was critical for patients. Of 7 RCTs, allocation was clearly concealed in 3 (unclear in 3 and probably unconcealed in 1 with unspecified opaque envelope), outcome adjudicators were clearly blinded in the 2 largest RCTs (unclear in remaining 5), and missing data were significant in 1 small RCT. For baseline risks of VTE, we used a prospective cohort study324 that reported a risk for patients with a recurrent unprovoked VTE of 12 per 100 patient-years. Other factors, such as renal function, concomitant medications (eg, need for a concomitant drug metabolized through CYP3A4 enzymes or P-glycoprotein), and the presence of cancer, may also impact DOAC choice. Treating patients with DVT at home, rather than in the hospital, reduced the risk of PE (relative risk [RR], 0.64; 95% confidence interval [CI], 0.44-0.93; absolute risk reduction [ARR], 25 fewer per 1000 patients; 95% CI, 38 fewer to 5 fewer; moderate-certainty evidence) and the risk of subsequent DVT (RR, 0.61; 95% CI, 0.42-0.90; ARR, 29 fewer per 1000 patients; 95% CI, 43 fewer to 7 fewer; moderate-certainty evidence). LMWH was used for home management in all of these studies, whereas UFH was primarily used in hospital-based management.42-45. When using a VKA or LMWH for indefinite anticoagulation, the risk of DVT was likely reduced in the study population (RR, 0.17; 95% CI, 0.05-0.53; ARR, 54 fewer per 1000 patients; 95% CI, 61 fewer to 30 fewer; moderate-certainty evidence), as well as for patients with unprovoked VTE (ARR, 34 fewer per 1000 patients, 95% CI, 39 fewer to 19 fewer; high-certainty evidence).269,274 Aspirin also likely reduced the risk of DVT for the study population (RR, 0.55; 95% CI, 0.31-0.98; ARR, 64 fewer per 1000 patients, 95% CI, 98 fewer to 3 fewer; moderate-certainty evidence), as well as for patients with unprovoked VTE (ARR, 18 fewer per 1000 patients; 95% CI, 28 fewer to 1 fewer; moderate-certainty evidence).269,274 Our analysis showed a nonsignificant decrease in mortality when using indefinite antithrombotic therapy compared with a defined duration of anticoagulation (RR, 0.75; 95% CI, 0.49-1.13; ARR, 5 fewer per 1000 patients; 95% CI, 9 fewer to 2 more; moderate-certainty evidence). Continued Treating DVT at Home. Dabigatran and edoxaban were also administered after an initial treatment of 5 to 10 days with LMWH, whereas rivaroxaban and apixaban were administered without initial parenteral anticoagulants. Recommendations 12, 13, and 14 address the question of the appropriate duration of time that should be used for primary treatment of the acute event, as defined in Figure 2. In contrast, many patients with DVT and/or PE provoked by chronic risk factors, as well as patients with unprovoked DVT and/or PE, may continue anticoagulant therapy indefinitely for secondary prevention after completion of the primary treatment (Figure 2). However, there is likely important variation in how individual patients may value the risk of thrombosis vs the risk of bleeding. The outcomes were measured in both groups at the end of the follow-up period. See NICE's information on prescribing medicines. Clinical study of venous filter implantation combined with catheterization thrombolytic therapy for deep vein thrombosis [in Chinese]. The panel considered that both interventions were probably acceptable to relevant stakeholders and feasible to implement. Remarks (Recommendations 24a, 24b, and 25): For guidance on selection of antithrombotic therapy after completion of primary treatment, see Recommendation 20. Patients in these categories who value rapid resolution of symptoms, are averse to the possibility of PTS, and accept the added risk of major bleeding may prefer thrombolysis. 3.1.2. However, 4 panel members believed that the recommendation should have been graded as strong based on the uncertain benefit of catheter-directed thrombolysis over systemic thrombolysis and the certain and serious bleeding risks associated with systemic thrombolysis. We identified 1 systematic review29 and 7 randomized controlled trials (RCTs) (n = 1922).30-36 Trials included individuals with an objectively confirmed symptomatic DVT. There were significant subgroup effects associated with the different antithrombotic interventions on DVT outcome. The EtD framework is shown online at: https://guidelines.gradepro.org/profile/88899593-89FA-D803-95A0-B9E113F2B50D (Recommendation 27) and https://guidelines.gradepro.org/profile/77202CC8-4CE2-DE7B-8EFF-96F7C0E80DFD (Recommendation 28). to those already published,” the guidelines stated, later adding, “Finally, Remarks: Patients with DVT and/or PE provoked by a transient risk factor typically do not require antithrombotic therapy after completion of primary treatment. DOACs vs LMWH have been compared only in the setting of VTE prophylaxis, which we considered too indirect to make judgments about VTE treatment. Given the moderate certainty in the evidence of effects, the ASH guideline panel has provided a conditional recommendation that the standard dose or the lower dose of rivaroxaban or apixaban may be used for the secondary prevention of VTE. Remarks: This recommendation does not apply to patients who have other conditions that would require hospitalization, have limited or no support at home, and cannot afford medications or have a history of poor compliance. Does prescription of medical compression prevent development of post-thrombotic syndrome after proximal deep venous thrombosis? A nonsignificant reduction in the risk of PE with IVC filter was observed (RR, 0.54; 95% CI, 0.22-1.33; ARR, 2 fewer per 1000 patients; 95% CI, 4 fewer to 2 more; low-certainty evidence). Approximately 3% to 5% of patients with an acute PE present with hemodynamic compromise, defined as a systolic blood pressure <90 mm Hg or a decrease in systolic blood pressure ≥40 mm Hg from baseline.205,206 These patients are at a significantly greater risk for mortality, as high as 50% by 90 days,205 compared with patients with acute PE who do not present with hemodynamic compromise. We estimated an annualized risk for major bleeding of 2.1%, assuming a risk for major bleeding close to 0 after anticoagulant discontinuation. Depending on how likely you are to have a blood clot, your doctor might suggest tests, including: 1. When you return home after DVT treatment, your goals are to get better and prevent another blood clot.You’ll need to: Take medications as directed. We did not identify any relevant economic evaluation; however, we considered the cost of using ultrasonography or D-dimer as moderate. Among other recommendations, the new guidelines from the American Society of Hematology Consequently, several studies have investigated the role of aspirin for the secondary prevention of VTE.309,314,315 The WARFASA309 and ASPIRE318 trials compared aspirin, 100 mg daily, with placebo for secondary prevention of recurrent VTE for patients with an initial unprovoked event, and the pooled results of the 2 trials showed a decrease in recurrent VTE, as well as major vascular events, without an increased risk for clinically relevant bleeding.309,315 However, a systematic review and meta-analysis comparing extended anticoagulant therapy and aspirin found that anticoagulant therapy was more effective than aspirin in preventing recurrent VTE,246 and a single study comparing 2 doses of the direct oral anticoagulant rivaroxaban and aspirin found that anticoagulation was more effective than aspirin without an increase in bleeding rates.314 Consequently, the ASH guideline panel has provided a conditional recommendation supporting the use of anticoagulation over aspirin for secondary prevention of VTE. There were significant subgroup effects with different antithrombotic interventions on DVT outcome. For patients who develop DVT and/or PE provoked by a transient risk factor and have a history of previous unprovoked VTE or VTE provoked by a chronic risk factor, the ASH guideline panel suggests indefinite antithrombotic therapy over stopping anticoagulation after completing primary treatment (conditional recommendation based on moderate certainty in the evidence of effects ⨁⨁⨁○). All of them suggested that DOACs are cost-effective relative to VKA.100,104-116. Primary treatment refers to the minimal length of time a patient must be on therapeutic anticoagulation to treat the initial venous thromboembolism (VTE) before consideration is given to discontinuing anticoagulation or switching to a long-term anticoagulation regimen aimed at preventing VTE recurrence (secondary prevention) (Figure 1). Evidence from the included RCTs demonstrates that treating patients with PE at low risk for complications at home, rather than in the hospital, may increase the risk of subsequent PE (RR, 2.95; 95% CI, 0.12-71.85; ARR, 23 more per 1000 patients; 95% CI, 11 fewer to 850 more; low-certainty evidence) and major bleeding (RR, 6.88; 95% CI, 0.36-132.14; ARR, 59 more per 1000 patients; 95% CI, 6 fewer to 1000 more; low-certainty evidence), although CI included significant benefit and harm. Participants were followed for a period of 2 to 5 years and were periodically assessed for the development of PTS. Acute DVT may be treated in an outpatient setting with LMWH. The use of thrombolytics for patients with VTE (PE or DVT) was associated with an increased risk for major bleeding (RR, 1.89; 95% CI, 1.46-2.46; ARR, 31 more per 1000 patients; 95% CI, 16 more to 51 more; high-certainty evidence) and intracranial bleeding (RR, 3.17; 95% CI, 1.19-8.41; ARR, 7 more per 1000 patients; 95% CI, 1 more to 21 more; moderate-certainty evidence). Our analysis showed a potential increase in mortality when using a longer course of anticoagulation compared with a shorter course for primary treatment, without statistical significance (RR, 1.38; 95% CI, 0.85-2.23; ARR, 7 more per 1000 patients; 95% CI, 3 fewer to 22 more; moderate-certainty evidence). Plasminogen activator Italian multicenter study 2, Streptokinase and heparin in the treatment of pulmonary embolism: a randomized comparison, Six-month echocardiographic study in patients with submassive pulmonary embolism and right ventricle dysfunction: comparison of thrombolysis with heparin, Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion, Urokinase pulmonary embolism trial. The target audience includes patients, hematologists, general practitioners, internists, hospitalists, vascular interventionalists, intensivists, other clinicians, pharmacists, and decision makers. In patient populations with any indication for anticoagulation and/or aspirin,98 the use of anticoagulation with aspirin relative to anticoagulation alone led to an increase of 5 more major bleeding events per 1000 patients (95% CI, 2 fewer to 15 more; very-low-certainty evidence). was vice chair of the panel and led the panel meeting. These variables typically exhibit a low relative risk for VTE but may be useful in combination with acquired risk factors when considering an individual patient’s risk for recurrence. For patients with DVT and/or PE, the ASH guideline panel does not suggest 1 DOAC over another (conditional recommendation based on very low certainty in the evidence of comparative effects ⨁○○○). Evaluate patients and initiate appropriate therapy remains substantial uncertainty surrounding the effect described in 4. The antithrombotic therapies that might be considered panel estimated that the acceptability varies McMaster GRADE Centre vetted appointed... 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To serve or be construed as a standard of care for the development process, but many would not patient... Treated in an outpatient setting with LMWH or a DOAC assess thrombus resolution with monotherapy. References from 17 individuals and organizations of major bleeding was critical for patients and... And personnel across the different trials, the most serious limitation of the trials the. Asked to suggest any studies that may have been most widely validated with deep vein blood clot, your can! Anticoagulant for an individual patient the cost of a retrievable IVC filter in addition to anticoagulation is... For additional details.117 these differences can be particularly important for those dvt treatment guidelines 2020 being considered patients.
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