›Target aPTT 1.5 to 3 times baseline
›Bivalirudin IV
›0.15 to 0.2 mg/kg/hour continuous infusion
›Renal dose adjustment required
›Target aPTT 1.5 to 2.5 times baseline
›Warfarin caution
›Avoid early warfarin initiation in PCD
›Risk of warfarin-induced venous gangrene via protein C depletion
›Especially dangerous in HIT and active malignancy contexts
›If warfarin ultimately used, overlap with parenteral anticoagulation minimum 5 days
›Ensure INR therapeutic for at least 24 hours before stopping parenteral agent
›Long-term anticoagulation transition
›DOACs preferred for most patients without contraindication
›Rivaroxaban 15 mg twice daily with food for 21 days then 20 mg daily
›Apixaban 10 mg twice daily for 7 days then 5 mg twice daily
›LMWH preferred for malignancy-associated VTE
›Enoxaparin 1 mg/kg subcutaneous every 12 hours
›Weight-based dosing with anti-Xa monitoring in renal impairment
Endovascular and surgical thrombus removal
›Catheter-directed thrombolysis (CDT)
›Strongly recommended as first-line for limb-threatening venous ischemia
›Grade 1A recommendation SVS/AVF guidelines
›Endovenous debulking reduced amputation and death by 70% versus anticoagulation alone
›Alteplase (tPA) CDT dosing
›0.5 to 1 mg/hour via infusion catheter embedded in thrombus
›Duration 12 to 24 hours depending on thrombus resolution
›UFH concurrent systemic anticoagulation at lower dose during CDT
›CDT contraindications
›Active internal bleeding
›Recent intracranial surgery or trauma within 3 months
›Intracranial malignancy or AVM
›Recent major surgery within 10 days relative contraindication
›Monitoring during CDT
›Fibrinogen level every 6 hours; hold if below 1 g/L
›aPTT and CBC every 6 hours
›Neurological checks every 2 hours
›Pharmacomechanical catheter-directed thrombectomy (PCDT)
›Combination of mechanical thrombus disruption and thrombolytic infusion
›AngioJet or Ekos ultrasound-accelerated CDT systems
›May reduce thrombolytic exposure time and dose
›SIR position statement supports endovascular management of acute iliofemoral DVT
›Society of Interventional Radiology 2023 position statement
›Surgical thrombectomy
›Reserved for patients with absolute contraindications to thrombolysis
›Fogarty catheter thrombectomy under general or regional anesthesia
›Intraoperative completion venography
›Concurrent IVC filter placement if anticoagulation contraindicated
›Retrievable filter preferred
›Consider when PE risk exceeds bleeding risk
›Iliac vein stenting
›When May-Thurner compression identified after thrombus clearance
›Reduces reocclusion risk
›Improves long-term venous patency
›Self-expanding stent deployed under fluoroscopic guidance
›Antiplatelet therapy post-stenting per institutional protocol
›IVC filter placement
›Consider if anticoagulation is contraindicated
›High risk of fatal PE without anticoagulation coverage
›Retrievable filter if anticoagulation anticipated later
›Not a substitute for anticoagulation when anticoagulation is feasible
›Fasciotomy
›Only if compartment pressures remain above 30 mmHg despite successful venous outflow restoration
›Four-compartment lower leg fasciotomy when indicated
›Should not precede or replace thrombus removal
›Post-fasciotomy wound management
›Negative pressure wound therapy consideration
›Delayed primary closure planning
›Opioid analgesia
›Morphine IV 0.1 mg/kg every 4 hours PRN
›Titrate to pain score below 4 out of 10
›Fentanyl IV alternative for renal impairment
›Refractory pain management
›IV lidocaine infusion reported as rescue analgesia
›Ketamine subanesthetic dose 0.3 mg/kg IV bolus consideration
›Positioning and comfort
›Limb elevation maintained
›Avoid compression or tourniquet
Rhabdomyolysis management
›Aggressive IV hydration
›Isotonic saline titrated to urine output above 0.5 mL/kg/hour
›Target 1 to 2 mL/kg/hour in significant rhabdomyolysis
›Monitor for fluid overload in cardiac-compromised patients
›Sodium bicarbonate consideration
›Alkalinize urine if severe rhabdomyolysis with myoglobinuria
›Evidence limited; consider in pH below 6.5 on urine dipstick