Reviews
Vol. 3 No. 2 (2024)
Distal deep vein thrombosis: is there a way out of this dark forest?
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Received: 7 March 2024
Accepted: 25 July 2024
Accepted: 25 July 2024
1008
Views
298
Downloads
Authors
Isolated distal deep vein thrombosis (IDDVT) represents a common manifestation of venous thromboembolism (VTE), accounting for up to 50% of cases involving lower-extremity deep vein thrombosis (DVT). In contrast to proximal DVT, IDDVT exhibits a higher association with transient risk factors and less frequently occurs spontaneously. IDDVT generally entails a substantially lower risk of proximal extension, pulmonary embolism, post-thrombotic syndrome, and recurrence compared to proximal DVT. Nevertheless, specific patient subgroups, including those with active cancer, prior VTE, unprovoked IDDVT, and involvement of more than one vein, demonstrate a noteworthy recurrence risk. Unlike proximal DVT, the optimal therapeutic management of IDDVT remains uncertain. In clinical practice, the predominant approach for managing IDDVT involves anticoagulation rather than ultrasound imaging surveillance, due to a significant reduction in the risk of proximal extension and recurrence. Conversely, serial imaging is typically preferred for individuals without risk factors for extension or at high risk for bleeding. Finally, anticoagulant duration relies on the different risk of VTE recurrence within the specific patient subgroups considered. This review offers an updated overview of the epidemiology, risk factors, and natural history of IDDVT, emphasizing therapeutic management in accordance with current guideline recommendations and the latest evidence, trying to provide a way out of this dark forest.
Downloads
Download data is not yet available.
Citations
Palareti G, Schellong S. Isolated distal deep vein thrombosis: what we know and what we are doing. J Thromb Haemost 2012;10:11-9. DOI: https://doi.org/10.1111/j.1538-7836.2011.04564.x
Goodacre S, Sampson F, Thomas S, et al. Systematic review and meta-analysis of the diagnostic accuracy of ultrasonography for deep vein thrombosis. BMC Med Imaging 2005;5:6. DOI: https://doi.org/10.1186/1471-2342-5-6
Elias A, Mallard L, Elias M, et al. A single complete ultrasound investigation of the venous network for the diagnostic management of patients with a clinically suspected first episode of deep venous thrombosis of the lower limbs. Thromb Haemost 2003;89:221-7. DOI: https://doi.org/10.1055/s-0037-1613435
Birdwell BG. The clinical validity of normal compression ultrasonography in outpatients suspected of having deep venous thrombosis. Ann Intern Med 1998;128:1. DOI: https://doi.org/10.7326/0003-4819-128-1-199801010-00001
Needleman L, Cronan JJ, Lilly MP, et al. Ultrasound for lower extremity deep venous thrombosis. Circulation 2018;137:1505-15. DOI: https://doi.org/10.1161/CIRCULATIONAHA.117.030687
Palareti G. How I treat isolated distal deep vein thrombosis (IDDVT). Blood 2014;123:1802-9. DOI: https://doi.org/10.1182/blood-2013-10-512616
Makedonov I, Galanaud JP, Kahn SR. Significance and management of isolated distal deep vein thrombosis. Curr Opin Hematol 2021;28:331-8. DOI: https://doi.org/10.1097/MOH.0000000000000670
Bikdeli B, Caraballo C, Trujillo-Santos J, et al. Clinical presentation and short- and long-term outcomes in patients with isolated distal deep vein thrombosis vs proximal deep vein thrombosis in the RIETE registry. JAMA Cardiol 2022;7:857. DOI: https://doi.org/10.1001/jamacardio.2022.1988
Schwarz T, Buschmann L, Beyer J, et al. Therapy of isolated calf muscle vein thrombosis: a randomized, controlled study. J Vasc Surg 2010;52:1246-50. DOI: https://doi.org/10.1016/j.jvs.2010.05.094
Dentali F, Pegoraro S, Barco S, et al. Clinical course of isolated distal deep vein thrombosis in patients with active cancer: a multicenter cohort study. J Thromb Haemost 2017;15:1757-63. DOI: https://doi.org/10.1111/jth.13761
Mazzolai L, Ageno W, Alatri A, et al. Second consensus document on diagnosis and management of acute deep vein thrombosis: updated document elaborated by the ESC Working Group on aorta and peripheral vascular diseases and the ESC Working Group on pulmonary circulation and right ventricular function. Eur J Prev Cardiol 2022;29:1248-63. DOI: https://doi.org/10.1093/eurjpc/zwab088
Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic therapy for VTE disease: second update of the CHEST guideline and expert panel report. Chest 2021;160:e545-608. DOI: https://doi.org/10.1016/j.chest.2021.07.055
Potere N, Ageno W. How to treat isolated distal deep vein thrombosis. Pol Arch Intern Med NLM (Medline) 2023;133. DOI: https://doi.org/10.20452/pamw.16543
Franco L, Giustozzi M, Agnelli G, Becattini C. Anticoagulation in patients with isolated distal deep vein thrombosis: a meta-analysis. J Thromb Haemost 2017;15:1142-54. DOI: https://doi.org/10.1111/jth.13677
Palareti G, Cosmi B, Lessiani G, et al. Evolution of untreated calf deep-vein thrombosis in high risk symptomatic outpatients: the blind, prospective CALTHRO study. Thromb Haemost 2010;104:1063-70. DOI: https://doi.org/10.1160/TH10-06-0351
Horner D, Hogg K, Body R, et al. The anticoagulation of calf thrombosis (ACT) project. Chest 2014;146:1468-77. DOI: https://doi.org/10.1378/chest.14-0235
Righini M, Galanaud JP, Guenneguez H, et al. Anticoagulant therapy for symptomatic calf deep vein thrombosis (CACTUS): a randomised, double-blind, placebo-controlled trial. Lancet Haematol 2016;3:e556-62. DOI: https://doi.org/10.1016/S2352-3026(16)30131-4
Galanaud JP, Sevestre MA, Genty C, et al. Incidence and predictors of venous thromboembolism recurrence after a first isolated distal deep vein thrombosis. J Thromb Haemost 2014;12:436-43. DOI: https://doi.org/10.1111/jth.12512
Donadini MP, Dentali F, Pegoraro S, et al. Long-term recurrence of venous thromboembolism after short-term treatment of symptomatic isolated distal deep vein thrombosis: a cohort study. Vasc Med 2017;22:518-24. DOI: https://doi.org/10.1177/1358863X17720531
Ageno W, Mantovani L, Haas S, et al. Patient management strategies and long-term outcomes in isolated distal deep-vein thrombosis versus proximal deep-vein thrombosis: findings from XALIA. TH Open 2019;3:e85-93. DOI: https://doi.org/10.1055/s-0039-1683968
Schellong SM, Goldhaber SZ, Weitz JI, et al. Isolated distal deep vein thrombosis: perspectives from the GARFIELD-VTE registry. Thromb Haemost 2019;119:1675-85. DOI: https://doi.org/10.1055/s-0039-1693461
Jørgensen CT, Tavoly M, Førsund E, et al. Incidence of bleeding and recurrence in isolated distal deep vein thrombosis: findings from the Venous Thrombosis Registry in Østfold Hospital. J Thromb Haemost 2023;21:2824-32. DOI: https://doi.org/10.1016/j.jtha.2023.06.028
Brown C, Brandt W, Wang TF, et al. Incidence of recurrent venous thromboembolism and bleeding complications in patients with cancer and isolated distal deep vein thrombosis. Thromb Res 2023;228:81-4. DOI: https://doi.org/10.1016/j.thromres.2023.05.027
Wang C, Shi C, Guo R, Wu T. Comparison of clinical outcomes among patients with isolated axial vs muscular calf vein thrombosis: a systematic review and meta-analysis. J Vasc Surg Venous Lymphat Disord 2023:101727. DOI: https://doi.org/10.1016/j.jvsv.2023.101727
Kahn SR. The post-thrombotic syndrome. Hematology 2016;2016:413-8. DOI: https://doi.org/10.1182/asheducation-2016.1.413
Turner BRH, Thapar A, Jasionowska S, et al. Systematic review and meta-analysis of the pooled rate of post-thrombotic syndrome after isolated distal deep venous thrombosis. Eur J Vasc Endovasc Surg 2023;65:291-7. DOI: https://doi.org/10.1016/j.ejvs.2022.10.018
Prandoni P, Haas S, Fluharty M, et al. Incidence and risk factors of post-thrombotic syndrome in patients with isolated calf vein thrombosis. Findings from the GARFIELD-VTE registry. Thromb Res 2024:235:75-8. DOI: https://doi.org/10.1016/j.thromres.2024.01.023
Lagerstedt C. Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis. Lancet 1985;326:515-8. DOI: https://doi.org/10.1016/S0140-6736(85)90459-3
Merriman E, Chunilal S, Brighton T, et al. Two weeks of low molecular weight heparin for isolated symptomatic distal vein thrombosis (TWISTER study). Thromb Res 2021;207:33-9. DOI: https://doi.org/10.1016/j.thromres.2021.09.004
Schulman S, Rhedin AS, Lindmarker P, et al. A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism. New Engl J Med 1995;332:1661-5. DOI: https://doi.org/10.1056/NEJM199506223322501
Ferrara F, Meli F, Amato C, et al. Optimal duration of treatment in surgical patients with calf venous thrombosis involving one or more veins. Angiology 2006;57:418-23. DOI: https://doi.org/10.1177/0003319706290745
Pinede L, Ninet J, Duhaut P, et al. Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis. Circulation 2001;103:2453-60. DOI: https://doi.org/10.1161/01.CIR.103.20.2453
Ageno W, Bertù L, Bucherini E, et al. Rivaroxaban treatment for six weeks versus three months in patients with symptomatic isolated distal deep vein thrombosis: randomised controlled trial. BMJ 2022;379:e072623. DOI: https://doi.org/10.1136/bmj-2022-072623
Yamashita Y, Morimoto T, Muraoka N, et al. Edoxaban for 12 months versus 3 months in cancer patients with isolated distal deep vein thrombosis (ONCO DVT study): an open-label, multicenter, randomized clinical trial. Circulation 2023;148:1665-76. DOI: https://doi.org/10.1161/CIRCULATIONAHA.123.066360
Sartori M, Iotti M, Camporese G, et al. Six‐week low‐molecular‐weight heparin versus 12‐week warfarin for calf deep vein thrombosis: a randomized, prospective, open‐label study. Am J Hematol 2024;99:854-61. DOI: https://doi.org/10.1002/ajh.27255
Robert-Ebadi H, Righini M. Management of distal deep vein thrombosis. Thromb Res 2017:149:48-55. DOI: https://doi.org/10.1016/j.thromres.2016.11.009
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 Jl Vasc Endovasc Surg 2021;61:9-82. DOI: https://doi.org/10.1016/j.ejvs.2020.09.023
Galanaud JP, Quenet S, Rivron-Guillot K, et al. Comparison of the clinical history of symptomatic isolated distal deep-vein thrombosis vs. proximal deep vein thrombosis in 11086 patients. J Thromb Haemost 2009;7:2028-34. DOI: https://doi.org/10.1111/j.1538-7836.2009.03629.x
Ageno W, Haas S, Weitz JI, et al. Characteristics and management of patients with venous thromboembolism: the GARFIELD-VTE registry. Thromb Haemost 2019;119:319-27. DOI: https://doi.org/10.1055/s-0038-1676611
How to Cite
1.
Guarascio M, Pititto GN, Abenante A, Donadini MP. Distal deep vein thrombosis: is there a way out of this dark forest?. Bleeding Thromb Vascul Biol [Internet]. 2024 Sep. 4 [cited 2025 Nov. 9];3(2). Available from: https://www.btvb.org/btvb/article/view/129
Copyright (c) 2024 The Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Share
Similar Articles
- Giovanni Di Minno, Gaia Spadarella, Ilenia Lorenza Calcaterra, Giancarlo Castaman, Paolo Simioni, Raimondo De Cristofaro, Cristina Santoro, Flora Peyvandi, Matteo Di Minno, The evolving landscape of gene therapy for congenital severe hemophilia: a 2024 state of the art , Bleeding, Thrombosis and Vascular Biology: Vol. 3 No. 2 (2024)
- Loredana Bury, Marco Malvestiti, Paolo Gresele, The 2024 Nobel prize in Medicine: impact on hemostasis and thrombosis research , Bleeding, Thrombosis and Vascular Biology: Vol. 3 No. 3 (2024)
- PO41 | Comparison of the haemorrhagic phenotype between female and male patients affected by autosomal inherited bleeding disorders in a single-centre cohort , Bleeding, Thrombosis and Vascular Biology: Vol. 4 No. s1 (2025)
- Marcello Baroni, Paolo Ferraresi, Nicole Ziliotto, Daria Bortolotti, Pierfilippo Acciarri, Nicola Martinelli, Giovanna Marchetti, Matteo Coen, Francesco Bernardi, Protein S on the surface of plasma lipoproteins: a potential mechanism for protein S delivery to the atherosclerotic plaques? , Bleeding, Thrombosis and Vascular Biology: Vol. 1 No. 3 (2022)
- CS02 | Functional and structural impairments of the cerebral microcirculation in a mouse model of hemophilia A , Bleeding, Thrombosis and Vascular Biology: Vol. 4 No. s1 (2025)
- Mattia Galli, C. Michael Gibson, Dominick J. Angiolillo, Factor XI inhibitors in adjunct to antiplatelet therapy: the ultimate dual-pathway inhibition? , Bleeding, Thrombosis and Vascular Biology: Vol. 2 No. 3 (2023)
- Paolo Prandoni, Personalized bleeding risk assessment for atrial fibrillation patients on direct oral anticoagulants: the DOAC score , Bleeding, Thrombosis and Vascular Biology: Vol. 2 No. 3 (2023)
- CO19 | Hypercoagulability in wild-type transthyretin amyloidosis: evidence from whole blood thromboelastometry , Bleeding, Thrombosis and Vascular Biology: Vol. 4 No. s1 (2025)
- Kristen M. Sanfilippo, Tzu-Fei Wang, Venous thromboembolism and mortality in patients with hematological malignancies , Bleeding, Thrombosis and Vascular Biology: Vol. 3 No. s1 (2024)
- CO32 | Major surgery in patients with severe hemophilia A without inhibitors receiving prophylaxis with fitusiran , Bleeding, Thrombosis and Vascular Biology: Vol. 4 No. s1 (2025)
You may also start an advanced similarity search for this article.
