Current issues in venous thromboembolism

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Venous thromboembolism (VTE) is the third most prevalent acute cardiovascular syndrome, behind myocardial infarction and stroke, and is associated with a significant disease burden [1]. Approximately 900 K cases of VTE/year occur in the U.S. There is an estimated death count of about 60–100 K people per year in the U.S. Up to 25% of Pulmonary Embolism cases may present with sudden death [2,3] Serious nonfatal sequelae may occur in up to 50% of patients. These include chronic thromboembolic pulmonary hypertension, post-thrombotic syndrome, and the post-PE syndrome with functional and exercise limitations. There is also a higher risk of MI and stroke in VTE patients [4]. With growing population and longer life expectancy, it is expected that the prevalence of this disorder will increase. Over the past decade there have been several advances in this arena. Most notably in 2012 DOACs (Direct acting oral anticoagulants) were approved for treatment of DVT and PE. Since approval of these oral agents, many patients with DVT are no longer being admitted to the hospital. There is also the potential to discharge low risk pulmonary embolism cases from the emergency department. Also with new diagnostic algorithms the number of CTA (CT angiogram) tests ordered to rule out pulmonary embolism have been reduced [5]. Another important advance has been the use of extended (indefinite) anticoagulation in patients with idiopathic VTE. If unprovoked VTE patients are to be anti-coagulated indefinitely then the need for thrombophilic testing for mutations such as Factor V Leiden and Prothrombin Gene 202010A will be reduced. Up until recently oncology patients with VTE have been treated with parenteral low molecular weight heparin. But new data is showing the DOACs are equally effective thus improving the quality of life of these patients in no small part by relieving them of the need for painful daily injections [6,7]. Also DOACs seem to have a role in VTE prophylaxis in these high risk people [8,9]. Finally, in 2020 a new clotting disorder has developed in the form of COVID-19. This is especially significant in the ICU population where a 31% incidence of thrombotic complications has been reported even in the face of standard VTE prophylaxis [10].

The purpose of this issue will be to discuss nine different issues regarding the arena of VTE. These papers written by an international faculty will focus on the current thoughts pertaining to the diagnosis and treatment of VTE.

The following topics will be included in this issue:

1. A review of upper extremity deep vein thrombosis

2. Outpatient treatment of emergency department patients diagnosed with VTE

3. VTE prophylaxis in high-risk orthopedic and cancer surgery

4. Prophylaxis and treatment of COVID-19 related VTE

5. Challenges in the diagnostic approach of suspected pulmonary embolism in COVID-19 patients

6. Catheter-directed thrombolysis and mechanical intervention in deep venous thrombosis: what is the status after the ATTRACT trial?

7. Post-hospital discharge VTE prophylaxis in medically ill patients

8. Radiologic mimics of pulmonary embolism

9. Use of DOACs in oncology patients for both prevention and treatment of VTE

Declaration of interest

The contents of the paper and the opinions expressed within are those of the authors, and it was the decision of the authors to submit the manuscript for publication.

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Funding

No funding was received to produce this article