Management of Extensive Left Leg DVT with AV Fistula

Initial Management

The American College of Cardiology recommends beginning immediate anticoagulation with intravenous unfractionated heparin (UFH) or low molecular weight heparin (LMWH) for patients with extensive left leg DVT, with a strength of evidence of high 1
The American College of Cardiology suggests evaluating for catheter-directed thrombolysis (CDT) or pharmacomechanical catheter-directed thrombolysis (PCDT) as these interventions are reasonable for extensive iliofemoral DVT to prevent post-thrombotic syndrome (PTS) in patients at low risk of bleeding, with a strength of evidence of moderate 2

The American College of Radiology recommends CDT or PCDT as first-line treatment for extensive iliofemoral DVT to prevent post-thrombotic syndrome, with a strength of evidence of high 2, 3
The American College of Cardiology suggests treating any underlying venous obstructive lesions with venous stenting during the endovascular procedure, with a strength of evidence of moderate 2, 3

The American College of Cardiology recommends transitioning to long-term anticoagulation with oral anticoagulation with warfarin (target INR 2.0-3.0) overlapped with initial anticoagulant for minimum 5 days and until INR >2.0 for at least 24 hours, with a strength of evidence of high 1
The American College of Cardiology suggests considering direct oral anticoagulants (DOACs) as an alternative to warfarin, with a strength of evidence of moderate 4

The American College of Cardiology recommends urgent CDT or PCDT for patients with limb-threatening circulatory compromise (phlegmasia cerulea dolens), with a strength of evidence of high 2
The American College of Radiology suggests considering IVC filter placement only if there are contraindications to anticoagulation or failure of anticoagulation with recurrent PE, with a strength of evidence of moderate 6

The American College of Radiology recommends regular duplex ultrasound to evaluate venous patency and stent function, with a strength of evidence of moderate 3