Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:

Subscribers log in here

Related articles

Overview of the treatment of lower extremity deep vein thrombosis (DVT)


Deep vein thrombosis (DVT) and acute pulmonary embolism (PE) are two manifestations of venous thromboembolism (VTE). VTE contributes to significant morbidity and mortality both in the community and in hospital. The mainstay of therapy for DVT is anticoagulation, provided there is no contraindication. Following initial anticoagulation, patients with DVT are anticoagulated further to prevent future recurrences, embolism, and thrombosis-related death.

An overview of the treatment of lower extremity DVT (distal and proximal), including indications for anticoagulation, alternate therapies, and treatment of special populations of patients with DVT, are discussed in this topic. Initial, long-term, and extended (indefinite) anticoagulation for DVT, as well as the treatment of PE, upper extremity DVT, and the diagnosis and prevention of DVT are discussed in detail, separately. (See "Lower extremity deep venous thrombosis: Initiation of anticoagulation (first 10 days)" and "Lower extremity deep venous thrombosis: Long-term anticoagulation (10 days to three months)" and "Rationale and indications for indefinite anticoagulation in patients with venous thromboembolism" and "Anticoagulation in acute pulmonary embolism" and "Treatment of acute pulmonary embolism" and "Diagnosis of suspected deep vein thrombosis of the lower extremity" and "Prevention of venous thromboembolic disease in medical patients" and "Prevention of venous thromboembolic disease in surgical patients".)


For the purposes of discussion in this topic, the following terms apply:

The term unprovoked deep venous thrombosis (DVT) implies that no identifiable cause or provoking event for DVT is evident. In contrast, a provoked DVT is one that is usually caused by a known event (eg, surgery, hospital admission). Provoking events and risk factors associated with the development of DVT can be transient (ie, reversible; eg, estrogen therapy) or persistent. Persistent risk factors include reversible conditions (eg, prolonged immobility following surgery, pregnancy, or curable malignancy) and irreversible conditions such as inheritable thrombophilias, chronic heart failure, and metastatic end-stage malignancy. (See "Overview of the causes of venous thrombosis".)

Proximal DVT is one that is located in the popliteal, femoral, or iliac veins. Isolated distal DVT has no proximal component, is located below the knee, and is confined to the calf veins (peroneal, posterior, anterior tibial, and muscular veins) (table 1).


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Oct 2014. | This topic last updated: Nov 5, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
  1. Husted S, de Caterina R, Andreotti F, et al. Non-vitamin K antagonist oral anticoagulants (NOACs): No longer new or novel. Thromb Haemost 2014; 111:781.
  2. Browse NL, Thomas ML. Source of non-lethal pulmonary emboli. Lancet 1974; 1:258.
  3. Havig O. Deep vein thrombosis and pulmonary embolism. An autopsy study with multiple regression analysis of possible risk factors. Acta Chir Scand Suppl 1977; 478:1.
  4. Galanaud JP, Sevestre-Pietri MA, Bosson JL, et al. Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study. Thromb Haemost 2009; 102:493.
  5. BARRITT DW, JORDAN SC. Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. Lancet 1960; 1:1309.
  6. Carrier M, Le Gal G, Wells PS, Rodger MA. Systematic review: case-fatality rates of recurrent venous thromboembolism and major bleeding events among patients treated for venous thromboembolism. Ann Intern Med 2010; 152:578.
  7. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e419S.
  8. Palareti G, Cosmi B, Legnani C, et al. D-dimer to guide the duration of anticoagulation in patients with venous thromboembolism: a management study. Blood 2014; 124:196.
  9. Kearon C. Natural history of venous thromboembolism. Circulation 2003; 107:I22.
  10. Masuda EM, Kistner RL. The case for managing calf vein thrombi with duplex surveillance and selective anticoagulation. Dis Mon 2010; 56:601.
  11. Righini M, Paris S, Le Gal G, et al. Clinical relevance of distal deep vein thrombosis. Review of literature data. Thromb Haemost 2006; 95:56.
  12. Schwarz T, Schmidt B, Beyer J, Schellong SM. Therapy of isolated calf muscle vein thrombosis with low-molecular-weight heparin. Blood Coagul Fibrinolysis 2001; 12:597.
  13. Macdonald PS, Kahn SR, Miller N, Obrand D. Short-term natural history of isolated gastrocnemius and soleal vein thrombosis. J Vasc Surg 2003; 37:523.
  14. Gillet JL, Perrin MR, Allaert FA. Short-term and mid-term outcome of isolated symptomatic muscular calf vein thrombosis. J Vasc Surg 2007; 46:513.
  15. Lautz TB, Abbas F, Walsh SJ, et al. Isolated gastrocnemius and soleal vein thrombosis: should these patients receive therapeutic anticoagulation? Ann Surg 2010; 251:735.
  16. 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.
  17. Sales CM, Haq F, Bustami R, Sun F. Management of isolated soleal and gastrocnemius vein thrombosis. J Vasc Surg 2010; 52:1251.
  18. 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.
  19. De Martino RR, Wallaert JB, Rossi AP, et al. A meta-analysis of anticoagulation for calf deep venous thrombosis. J Vasc Surg 2012; 56:228.
  20. Boutitie F, Pinede L, Schulman S, et al. Influence of preceding length of anticoagulant treatment and initial presentation of venous thromboembolism on risk of recurrence after stopping treatment: analysis of individual participants' data from seven trials. BMJ 2011; 342:d3036.
  21. Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e152S.
  22. den Exter PL, van Es J, Erkens PM, et al. Impact of delay in clinical presentation on the diagnostic management and prognosis of patients with suspected pulmonary embolism. Am J Respir Crit Care Med 2013; 187:1369.
  23. Smith SB, Geske JB, Maguire JM, et al. Early anticoagulation is associated with reduced mortality for acute pulmonary embolism. Chest 2010; 137:1382.
  24. Koopman MM, Prandoni P, Piovella F, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. The Tasman Study Group. N Engl J Med 1996; 334:682.
  25. Levine M, Gent M, Hirsh J, et al. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med 1996; 334:677.
  26. Boccalon H, Elias A, Chalé JJ, et al. Clinical outcome and cost of hospital vs home treatment of proximal deep vein thrombosis with a low-molecular-weight heparin: the Vascular Midi-Pyrenees study. Arch Intern Med 2000; 160:1769.
  27. O'Shaughnessy D, Miles J, Wimperis J. UK patients with deep-vein thrombosis can be safely treated as out-patients. QJM 2000; 93:663.
  28. Grau E, Tenias JM, Real E, et al. Home treatment of deep venous thrombosis with low molecular weight heparin: Long-term incidence of recurrent venous thromboembolism. Am J Hematol 2001; 67:10.
  29. Dunn A, Bioh D, Beran M, et al. Effect of intravenous heparin administration on duration of hospitalization. Mayo Clin Proc 2004; 79:159.
  30. Dunn AS, Schechter C, Gotlin A, et al. Outpatient treatment of deep venous thrombosis in diverse inner-city patients. Am J Med 2001; 110:458.
  31. Segal JB, Bolger DT, Jenckes MW, et al. Outpatient therapy with low molecular weight heparin for the treatment of venous thromboembolism: a review of efficacy, safety, and costs. Am J Med 2003; 115:298.
  32. Chong BH, Brighton TA, Baker RI, et al. Once-daily enoxaparin in the outpatient setting versus unfractionated heparin in hospital for the treatment of symptomatic deep-vein thrombosis. J Thromb Thrombolysis 2005; 19:173.
  33. Daskalopoulos ME, Daskalopoulou SS, Tzortzis E, et al. Long-term treatment of deep venous thrombosis with a low molecular weight heparin (tinzaparin): a prospective randomized trial. Eur J Vasc Endovasc Surg 2005; 29:638.
  34. Ramacciotti E, Araújo GR, Lastoria S, et al. An open-label, comparative study of the efficacy and safety of once-daily dose of enoxaparin versus unfractionated heparin in the treatment of proximal lower limb deep-vein thrombosis. Thromb Res 2004; 114:149.
  35. Othieno R, Abu Affan M, Okpo E. Home versus in-patient treatment for deep vein thrombosis. Cochrane Database Syst Rev 2007; :CD003076.
  36. Douketis JD. Treatment of deep vein thrombosis: what factors determine appropriate treatment? Can Fam Physician 2005; 51:217.
  37. Rodger M, Bredeson C, Wells PS, et al. Cost-effectiveness of low-molecular-weight heparin and unfractionated heparin in treatment of deep vein thrombosis. CMAJ 1998; 159:931.
  38. O'Brien B, Levine M, Willan A, et al. Economic evaluation of outpatient treatment with low-molecular-weight heparin for proximal vein thrombosis. Arch Intern Med 1999; 159:2298.
  39. Bäckman K, Carlsson P, Kentson M, et al. Deep venous thrombosis: a new task for primary health care. A randomised economic study of outpatient and inpatient treatment. Scand J Prim Health Care 2004; 22:44.
  40. Huse DM, Cummins G, Taylor DC, Russell MW. Outpatient treatment of venous thromboembolism with low-molecular-weight heparin: an economic evaluation. Am J Manag Care 2002; 8:S10.
  41. Spyropoulos AC, Hurley JS, Ciesla GN, de Lissovoy G. Management of acute proximal deep vein thrombosis: pharmacoeconomic evaluation of outpatient treatment with enoxaparin vs inpatient treatment with unfractionated heparin. Chest 2002; 122:108.
  42. Tillman DJ, Charland SL, Witt DM. Effectiveness and economic impact associated with a program for outpatient management of acute deep vein thrombosis in a group model health maintenance organization. Arch Intern Med 2000; 160:2926.
  43. van den Belt AG, Bossuyt PM, Prins MH, et al. Replacing inpatient care by outpatient care in the treatment of deep venous thrombosis--an economic evaluation. TASMAN Study Group. Thromb Haemost 1998; 79:259.
  44. Segal JB, Streiff MB, Hofmann LV, et al. Management of venous thromboembolism: a systematic review for a practice guideline. Ann Intern Med 2007; 146:211.
  45. Gould MK, Dembitzer AD, Sanders GD, Garber AM. Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis. A cost-effectiveness analysis. Ann Intern Med 1999; 130:789.
  46. de Lissovoy G, Yusen RD, Spiro TE, et al. Cost for inpatient care of venous thrombosis: a trial of enoxaparin vs standard heparin. Arch Intern Med 2000; 160:3160.
  47. Hokusai-VTE Investigators, Büller HR, Décousus H, et al. Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med 2013; 369:1406.
  48. Schulman S, Kearon C, Kakkar AK, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med 2009; 361:2342.
  49. EINSTEIN Investigators, Bauersachs R, Berkowitz SD, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 2010; 363:2499.
  50. Agnelli G, Buller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med 2013; 369:799.
  51. Wells PS, Forgie MA, Rodger MA. Treatment of venous thromboembolism. JAMA 2014; 311:717.
  52. Kearon C, Akl EA. Duration of anticoagulant therapy for deep vein thrombosis and pulmonary embolism. Blood 2014; 123:1794.
  53. Sarwar S, Narra S, Munir A. Phlegmasia cerulea dolens. Tex Heart Inst J 2009; 36:76.
  54. Haimovici H. The ischemic forms of venous thrombosis. 1. Phlegmasia cerulea dolens. 2. Venous gangrene. J Cardiovasc Surg (Torino) 1965; 5:Suppl:164.
  55. Langeron P, Gillot C. [Phlegmasia caerulea dolens . Acute venous stasis and ischemic phlebothrombosis]. J Mal Vasc 1992; 17:116.
  56. Perkins JM, Magee TR, Galland RB. Phlegmasia caerulea dolens and venous gangrene. Br J Surg 1996; 83:19.
  57. Brockman SK, Vasko JS. Phlegmasia cerulea dolens. Surg Gynecol Obstet 1965; 121:1347.
  58. Kearon C, Kahn SR, Agnelli G, et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:454S.
  59. Meissner MH, Gloviczki P, Comerota AJ, et al. Early thrombus removal strategies for acute deep venous thrombosis: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2012; 55:1449.
  60. Tung CS, Soliman PT, Wallace MJ, et al. Successful catheter-directed venous thrombolysis in phlegmasia cerulea dolens. Gynecol Oncol 2007; 107:140.
  61. Oguzkurt L, Tercan F, Ozkan U. Manual aspiration thrombectomy with stent placement: rapid and effective treatment for phlegmasia cerulea dolens with impending venous gangrene. Cardiovasc Intervent Radiol 2008; 31:205.
  62. Vedantham S. Interventional approaches to acute venous thromboembolism. Semin Respir Crit Care Med 2008; 29:56.
  63. Casey ET, Murad MH, Zumaeta-Garcia M, et al. Treatment of acute iliofemoral deep vein thrombosis. J Vasc Surg 2012; 55:1463.
  64. Bashir R, Zack CJ, Zhao H, et al. Comparative outcomes of catheter-directed thrombolysis plus anticoagulation vs anticoagulation alone to treat lower-extremity proximal deep vein thrombosis. JAMA Intern Med 2014; 174:1494.
  65. Kearon C, Kahn SR, Agnelli G, et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:454S.
  66. Schellong SM, Schwarz T, Kropp J, et al. Bed rest in deep vein thrombosis and the incidence of scintigraphic pulmonary embolism. Thromb Haemost 1999; 82 Suppl 1:127.
  67. Partsch H, Blättler W. Compression and walking versus bed rest in the treatment of proximal deep venous thrombosis with low molecular weight heparin. J Vasc Surg 2000; 32:861.
  68. Aschwanden M, Labs KH, Engel H, et al. Acute deep vein thrombosis: early mobilization does not increase the frequency of pulmonary embolism. Thromb Haemost 2001; 85:42.
  69. Partsch H. Therapy of deep vein thrombosis with low molecular weight heparin, leg compression and immediate ambulation. Vasa 2001; 30:195.
  70. Aldrich D, Hunt DP. When can the patient with deep venous thrombosis begin to ambulate? Phys Ther 2004; 84:268.
  71. Anderson CM, Overend TJ, Godwin J, et al. Ambulation after deep vein thrombosis: a systematic review. Physiother Can 2009; 61:133.
  72. Aissaoui N, Martins E, Mouly S, et al. A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int J Cardiol 2009; 137:37.
  73. Kahn SR, Shrier I, Kearon C. Physical activity in patients with deep venous thrombosis: a systematic review. Thromb Res 2008; 122:763.
  74. Snow V, Qaseem A, Barry P, et al. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2007; 146:204.
  75. Prandoni P, Lensing AW, Prins MH, et al. Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial. Ann Intern Med 2004; 141:249.
  76. Brandjes DP, Büller HR, Heijboer H, et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997; 349:759.
  77. Kahn SR, Ginsberg JS. The post-thrombotic syndrome: current knowledge, controversies, and directions for future research. Blood Rev 2002; 16:155.
  78. Ginsberg JS, Hirsh J, Julian J, et al. Prevention and treatment of postphlebitic syndrome: results of a 3-part study. Arch Intern Med 2001; 161:2105.
  79. Partsch H, Kaulich M, Mayer W. Immediate mobilisation in acute vein thrombosis reduces post-thrombotic syndrome. Int Angiol 2004; 23:206.
  80. Aschwanden M, Jeanneret C, Koller MT, et al. Effect of prolonged treatment with compression stockings to prevent post-thrombotic sequelae: a randomized controlled trial. J Vasc Surg 2008; 47:1015.
  81. Kahn SR, Comerota AJ, Cushman M, et al. The postthrombotic syndrome: evidence-based prevention, diagnosis, and treatment strategies: a scientific statement from the american heart association. Circulation 2014; 130:1636.
  82. Kahn SR, Shapiro S, Wells PS, et al. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet 2014; 383:880.
  83. Mousa A, Henderson P, Dayal R, et al. Endoluminal recanalization in a patient with phlegmasia cerulea dolens using a multimodality approach. Vascular 2005; 13:313.
  84. Lin SC, Mousa A, Bernheim J, et al. Endoluminal recanalization in a patient with phlegmasia cerulea dolens using a multimodality approach-a case report. Vasc Endovascular Surg 2005; 39:273.
  85. Streiff MB. Vena caval filters: a comprehensive review. Blood 2000; 95:3669.
  86. Becker DM, Philbrick JT, Selby JB. Inferior vena cava filters. Indications, safety, effectiveness. Arch Intern Med 1992; 152:1985.
  87. Girard P, Stern JB, Parent F. Medical literature and vena cava filters: so far so weak. Chest 2002; 122:963.
  88. Muriel A, Jiménez D, Aujesky D, et al. Survival effects of inferior vena cava filter in patients with acute symptomatic venous thromboembolism and a significant bleeding risk. J Am Coll Cardiol 2014; 63:1675.
  89. Stein PD, Matta F. Vena cava filters in unstable elderly patients with acute pulmonary embolism. Am J Med 2014; 127:222.
  90. Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med 1998; 338:409.
  91. PREPIC Study Group. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d'Embolie Pulmonaire par Interruption Cave) randomized study. Circulation 2005; 112:416.
  92. Stein PD, Matta F, Keyes DC, Willyerd GL. Impact of vena cava filters on in-hospital case fatality rate from pulmonary embolism. Am J Med 2012; 125:478.
  93. Hajduk B, Tomkowski WZ, Malek G, Davidson BL. Vena cava filter occlusion and venous thromboembolism risk in persistently anticoagulated patients: a prospective, observational cohort study. Chest 2010; 137:877.
  94. Fox MA, Kahn SR. Postthrombotic syndrome in relation to vena cava filter placement: a systematic review. J Vasc Interv Radiol 2008; 19:981.
  95. Jaff MR, McMurtry MS, Archer SL, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011; 123:1788.
  96. Mismetti P, Rivron-Guillot K, Quenet S, et al. A prospective long-term study of 220 patients with a retrievable vena cava filter for secondary prevention of venous thromboembolism. Chest 2007; 131:223.
  97. Nicholson W, Nicholson WJ, Tolerico P, et al. Prevalence of fracture and fragment embolization of Bard retrievable vena cava filters and clinical implications including cardiac perforation and tamponade. Arch Intern Med 2010; 170:1827.
  98. Dabbagh O, Nagam N, Chitima-Matsiga R, et al. Retrievable inferior vena cava filters are not getting retrieved: where is the gap? Thromb Res 2010; 126:493.