ESVS GUIDELINES ON VENOUS THROMBOSIS
ESVS

Comment to: Kakkos SK, Gohel M, Baekgaard N, Bauersachs R, Bellmunt-Montoya S, Black SA, Ten Cate-Hoek AJ, Elalamy I, Enzmann FK, Geroulakos G, Gottsäter A, Hunt BJ, Mansilha A, Nicolaides AN, Sandset PM, Stansby G, Esvs Guidelines Committee, de Borst GJ, Bastos Gonçalves F, Chakfé N, Hinchliffe R, Kolh P, Koncar I, Lindholt JS, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, De Maeseneer MG, Comerota AJ, Gloviczki P, Kruip MJHA, Monreal M, Prandoni P, Vega de Ceniga M. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg. 2021 Jan;61(1):9-82. doi: 10.1016/j.ejvs.2020.09.023. Epub 2020 Dec 15. PMID: 33334670.

The European Society for Vascular Surgery (ESVS) recently released its first guidelines on venous thrombosis, addressing acute deep vein thrombosis (DVT) of the lower extremity, upper extremity DVT, superficial vein thrombosis, and thrombosis in unusual sites. The document is freely accessible in the European Journal of Vascular & Endovascular Surgery.

Since patient and public engagement improves the validity and increases the quality of decisions, the document considers also the patient’s perspective, in the same way as all recent ESVS guidelines. For that reason, a plain English summary was produced and evaluated by patients with a history of venous thrombosis in the UK National Health Service and lay members of the public without venous thrombosis. Firstly, both patients and lay members of the public recognised the importance of venous thrombosis and welcomed the engagement. Several respondents commented that other conditions seemed to get much more public attention than venous thrombosis. The authors of the document highlight that most feedback is related to the use of interventions to reduce long-term sequelae of venous thrombosis, particularly compression and early thrombus removal strategies for upper and lower extremity DVT. All respondents offered positive feedback about compression therapy, with the majority of patients with a history of venous thrombosis stating that this was not offered to them at the time of the initial presentation. The respondents appreciated that the recommendations were based on the latest published evidence but expressed that even if the benefit was uncertain or modest, it should be discussed with future patients. Clinical teams managing patients with venous thrombosis should consider this feedback and ensure that potential interventions are discussed with patients and the rationale for offering or not offering early thrombus removal is clearly explained to the patient1.

The guidelines underline that the likelihood of recurrent DVT after discontinuation of anticoagulation is high, particularly in patients with unprovoked DVT and in patients with provoked DVT and minor risk factors. The duration of treatment for lower extremity DVT depends on the balance of bleeding risk due to anticoagulation and the risk of recurrence with and without anticoagulation. Risk stratification for extended treatment is recommended to help the decision whether or not to continue anticoagulation. For patients with unprovoked proximal deep vein thrombosis who are at low or moderate bleeding risk, extended anticoagulation beyond three months, with periodic reevaluation of bleeding risk, is recommended. Among the strategies feasible to reduce the risk of recurrence, unfractionated heparin, low molecular weight heparins, vitamin K antagonists, direct oral anticoagulants, aspirin, and sulodexide are reported. For patients requiring extended anticoagulation beyond six months, use of a reduced dose of the direct oral anticoagulants should be considered, while aspirin is not recommended for extended antithrombotic therapy. Moreover, in agreement with the results of a multicentre, double blind study including 615 patients with first ever unprovoked venous thromboembolism (VTE) who had completed 3-12 months of oral anticoagulant treatment, the recurrent VTE rate was reduced at two years in patients treated with sulodexide and elastic stockings, compared with those on placebo and stockings (HR 0.49, 95% CI 0.27-0.92, p =0.02)2. Investigators conclude that in patients with unprovoked VTE, sulodexide reduces the risk of VTE recurrence after anticoagulation is stopped, without causing any bleeding1.

References

Kakkos SK, Gohel M, Baekgaard N, et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg. 2021;61(1):9-82. doi:10.1016/j.ejvs.2020.09.023
Andreozzi GM, Bignamini AA, Davì G, et al. Sulodexide for the Prevention of Recurrent Venous Thromboembolism: The Sulodexide in Secondary Prevention of Recurrent Deep Vein Thrombosis (SURVET) Study: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial. Circulation. 2015;132(20):1891-1897. doi:10.1161/CIRCULATIONAHA.115.016930