The goal of treatment is to primarily prevent the clot from growing, to ensure that it does not break off and lead to pulmonary embolism and to reduce the severity of long-term post-thrombotic syndrome.
The standard of care in the management of DVT is blood thinners (anticoagulation) and compression therapy. Modern minimal invasive techniques can nowadays be offered (in addition to blood thinners and compression) in selected patients with severe symptoms (e.g. significant leg swelling and pain).
These techniques involve immediate clot removal ("clot-busters" - thrombolysis).
Anticoagulants (Blood thinners)
Although anticoagulants do not remove the existing clots, they may keep them from growing. This therapy relies on the body to "dissolve" the clot.
In the acute period patients will receive heparin (intravenous or under the skin (subcutaneous) and they will then need transition to warfarin (Coumadin) that is taken orally. Treatment with blood thinners may last from three to six months, but depending on your medical history it may need to be lifelong.
A major disadvantage of Coumadin is its interaction with certain foods (mainly green vegetables) and the need for frequent blood tests to check the appropriateness of the dosage (too little increases your clot risk, too much increases your risk for bleeding).
New medications are currently available (e.g. dabigatran (Pradaxa), apixaban (Eliquis), rivaroxaban (Xarelto)) that may not have these disadvantages, they may however carry other risks (e.g. no antidote available to cease bleeding in case of injury).
The most common side effect of all blood-thinners is bleeding. You should discuss these options with your doctor.
Graduated compression stockings are essential to reduce the swelling associated with the DVT but have no effect on the clot. The swelling often occurs because the valves in the leg veins have become damaged or the vein remains blocked from the blood clot. Compression "squeezes" the venous blood out of the leg back to the heart. Most compression stockings are worn just below the knee.
These stockings are tight at the ankle and become looser as they go up the leg. This causes gentle external compression (or pressure) on your leg. It is recommended that the compression pressure is 30-40 mmHg and they should be worn daily, if possible, for at least 2 years to prevent post-thrombotic syndrome.
Blood thinners alone, do not remove the clot but allow time to the body to dissolve the clot.
Unfortunately, this does not occur always and the vein may remain blocked forever. Thrombolytics ("clot busters") can dissolve a clot quickly, over a period of a few hours to a couple of days.
The procedure involves a puncture usually behind the knee with the patient in the prone position. Under x-ray guidance wires and catheters are navigated to the blocked vein. Depending on how much clot is present and how old the clot is your vascular surgeon will determine which device to use. Some devices allow to administer the "clot-busting" drug directly into the clot. Other devices break up the clot into tiny pieces that are then removed with suction through the catheter. Often, these techniques uncover a particular narrowing of the vein (e.g. May-Thurner syndrome) that caused the blood clot to form and this can immediately be treated by implanting a stent to open the vein (venoplasty). The benefit treating this narrowing, is that it will likely decrease your risk of developing blood clots in the future. Immediate clot removal is also anticipated to reduce the occurrence of the long term complications of DVT, mainly the post-thrombotic syndrome. Patients with the best outcomes are patients that have had symptoms that are less than 30 days. The clot seems to respond very favorably when it is "fresh". The optimal outcomes are seen in patients with symptoms less than 14 days. As with any operation, thrombolysis of a DVT has several risks, the major one being bleeding. You will want to discuss these risks thoroughly with your vascular surgeon.
Vena Cava Filter
Inferior vena cava filters are used when you cannot take any of the blood thinners, or if you are taking blood thinners and continue to develop clots. Inferior vena cava is the large vein which is formed when the two large leg veins (iliac veins) merge in the pelvis. The vena cava transfers the blood back to the heart. The vena cava filter can catch blood clots that move from the leg veins to the lung (pulmonary embolism). During a small surgical procedure, the filter is inserted through a puncture in the groin or neck veins. Under x-ray guidance a catheter is navigated into the vena cava and the filter is deployed. This treatment will help prevent a pulmonary embolism, but will not prevent the development of more clots. Contemporary filters are retrievable and as soon as the risk period is over, your vascular surgeon will remove it, again with a small minimally invasive procedure.
Treatment of Chronic DVT
As clot does not always dissolve, over time it may turn to a scar and the vein will remain blocked not allowing the blood to flow easily back to the heart (chronic DVT). As described earlier, the blood pools in the leg and patients experience leg swelling, pain and often brownish discoloration of the lower leg skin. These symptoms of the so-called post-thrombotic syndrome at advanced stages may be accompanied by non-healing wounds (venous ulcers). In these situations patients typically need to wear compression stockings which can offer a significant symptom relief.
Modern minimally invasive treatments are available to re-open veins that have been blocked for years. These are done in a surgical setting. Through a skin puncture at the groin or behind the knee (with the patient in the prone position). Under x-ray guidance wires and catheters are navigated through the blocked vein. Once the blocked vein is crossed a stent is introduced and expanded. Typically, these are outpatient procedures and the patient is discharged the same day, able to walk.
Treatment of Superficial Thrombophlebitis
Superficial thrombophlebitis is treated with heat, elevation of the affected leg or arm, and anti-inflammatory medications. If the clot involves the main superficial vein of the leg (great saphenous vein) and is very close to the junction with the deep veins (saphenofemoral junction) your vascular surgeon may want to observe you closely with repeated duplex ultrasounds. Some physicians may suggest blood thinners for a short period or even suggest a small surgery to disconnect the saphenous vein at the junction with the deep vein. This is done with a small incision at the groin. The choice of treatment depends on your medical history so you will need to discuss these options with your doctor.