Version July 2025
DOAC: direct oral anticoagulant; DVT: deep venous thrombosis; IVUS: intravascular ultrasound; LMWH: low molecular weight heparin.
* IVUS is typically used to determine whether angioplasty or stenting are appropriate by delineating the nature and severity of any underlying venous lesions in real time.
¶ Lesions are regarded as thrombotic (ie, DVT) or nonthrombotic. For thoracic central venous thrombosis, catheter-directed mechanical thrombectomy/pharmacologic thrombolysis is used first to remove clots and uncover any underlying venous stenosis.
Δ Angioplasty may not be warranted if there is no stenosis after thrombolysis or only a mild venous stenosis that is not flow-limiting. Patients with thoracic outlet syndrome require a subsequent surgical decompression procedure with or without concomitant venous angioplasty for durable long-term outcomes.
◊ Intravenous heparin is transitioned postprocedurally to the selected agent, typically LMWH or a DOAC. Patients should continue anticoagulation for at least 3 months depending on underlying venous pathology identified on IVUS examination, or lifelong anticoagulation if they have a history of recurrent DVT. Among patients treated for malignant obstruction, some continue systemic anticoagulation indefinitely if associated with a hypercoagulable state, provided no contraindications arise.
§ Antiplatelet therapy is individualized according to the risk of bleeding. Regimens are derived from expert opinion but there is no consensus on which approach provides better patency. For those with a hypercoagulable state related to malignancy, some may use LMWH or a DOAC instead of clopidogrel.
¥ For thrombotic lesions that do not require angioplasty or stenting, giving aspirin 81 mg orally once daily indefinitely after completion of therapeutic anticoagulation is an option, but is not required.
