CAVT Flashcards
The NCCN Guidelines Panel for Cancer-Associated Venous Thromboembolic Disease recommends VTE prophylaxis for all patients hospitalized with cancer, excluding those with _______________.
Basal/squamous cell skin cancer
Has reduced deep vein thrombosis (DVT) and was associated with a lower risk of skin complications compared to graduated compression stockings (GCS)
Intermittent pneumatic compression (IPC)
VTE PROPHYLAXIS FOLLOWING DISCHARGE
For Surgical oncology setting, duration of anticoagulation following high-risk abdominal or pelvic cancer surgery:
* Surgery for gastrointestinal (GI) malignancies
* Patients with a previous history of VTE
* Anesthesia time >2 hours
* Bed rest ≥4 days
* Advanced-stage disease
* Patient age >60 years
4 weeks
VTE PROPHYLAXIS FOLLOWING DISCHARGE
Medical oncology setting
Patients with cancer (excluding multiple myeloma, acute leukemia, myeloproliferative neoplasms, and patients with primary/metastatic brain tumorsi) receiving/starting systemic therapy for their cancer:
Intermediate or high risk for VTE (Khorana score ≥2):
Low risk for VTE (Khorana score < 2):
Intermediate or high risk for VTE (Khorana score ≥2):6 months or longer, if risk persists
Low risk for VTE (Khorana score < 2):No routine VTE prophylaxis
Contraindications to Prophylactic Anticoagulation
- Active bleeding
- Thrombocytopenia (platelet count <50,000/μL or clinical judgment)
- Underlying hemorrhagic coagulopathy (eg, abnormal PT or aPTT excluding a lupus inhibitor/anticoagulant) or known bleeding disorder in the absence of replacement therapy (eg, hemophilia, von Willebrand disease)
- Indwelling neuraxial catheters (contraindication for apixaban, dabigatran, edoxaban, fondaparinux, rivaroxaban, or enoxaparin dose exceeding 40 mg daily)
- Neuraxial anesthesia/lumbar puncture
- Interventional spine and pain procedures
- Current or previous heparin-induced thrombocytopenia (HIT) (contraindication for LMWH and UFH)
For patients at high risk, prophylactic anticoagulation may be appropriate even if platelet count is as low as 25,000/μL.
Twice-daily prophylactic dose UFH (5000 units every 12 h) and once-daily LMWH (eg, enoxaparin 40 mg once daily) may be used with neuraxial anesthesia.
Contraindications to Mechanical Prophylaxis
Absolute
* Acute DVT (unless on therapeutic anticoagulation)
* Severe arterial insufficiency (pertains to GCS only)
Relative
* Large hematoma
* Skin ulcerations or woundse
* Mild arterial insufficiency (pertains to GCS only)
* Peripheral neuropathy (pertains to GCS only)
Timing of LMWH: For LMWH, placement or removal of a neuraxial catheter should be delayed for at least _______ hours after administration of prophylactic doses such as those used for prevention of DVT.
Longer delays (24 h) are appropriate to consider for patients receiving therapeutic doses of LMWH.
12 hours: prophylactic
Drug that is absorbed in the stomach, proximal small bowel, and colon. Patients who have had significant resections of these portions of the intestinal tract may be at
risk for suboptimal absorption.
DOAC
With the exception of apixaban, which is also partially absorbed in the colon
Drug approved for patients with gynecologic cancers.
Was initiated at investigator discretion once epidural anesthesia catheters were removed.
Duration of prophylaxis was 28 days.
Apixaban
DOAC approved for patients after laparoscopic surgery for colorectal cancer
Rivaroxaban
VTE RISK ASSESSMENT IN OUTPATIENTS WITH CANCER
Khorana Predictive Model for Chemotherapy-Associated VTE
- Site of primary cancer
Very high risk (stomach, pancreas) 2
High risk (lung, lymphoma, gynecologic, bladder, testicular) 1 - Prechemotherapy platelet count 350 x 109/L or higher
- Hemoglobin level less than 10 g/dL or use of red cell growth factors 1
- Prechemotherapy leukocyte count higher than 11 x 109/L 1
- BMI 35 kg/m2 or higher
0 Low 0.3–1.5%
1, 2 Intermediate 2.0–4.8%
3 or higher High 6.7–12.9%
Upper extremity SVT
- Median
- Basilic
- Cephalic veins
Lower extremity SVT
- Great and small saphenous veins
When to consider prophylactic dose anticoaguation in Acute Superficial Vein Thrombosis
- Lower extremity SVT >5 cm in length
- Lower extremity SVT extends above knee
Consider repeat US in 7–10 days if SVT <5 cm in length or below knee. If repeat US shows progression, considernanticoagulation
When to consider therapeutic dose anticoaguation in Acute Superficial Vein Thrombosis
- If the clot is in close proximitye to the deep venous system, 3 cm
- Lower extremity SVT within 3 cm of the saphenofemoral junction
Symptomatic treatment for SVT includes
- Warm compresses
- Nonsteroidal anti-inflammatory drugs (NSAIDs), and
- Elevation
TRUE OR FALSE
For patients with SVT associated with a peripherally inserted central catheter (PICC) line, catheter removal may not be necessary, especially if the patient is treated with anticoagulation and/or symptoms resolve.
TRUE
For patients with SVT associated with a peripherally inserted central catheter (PICC) line, catheter removal may not be necessary, especially if the patient is treated with anticoagulation and/or symptoms resolve.
Clinical signs/symptoms of DVT:
- Swelling of unilateral extremity
- Heaviness in extremity
- Pain in extremity
- Unexplained persistent calf cramping
- Swelling in face, neck, or supraclavicular space
- Catheter dysfunction
Types of Venous imaging:
- Venous US
- CT venogram (CTV) with contrast
- Magnetic resonance venogram (MRV) with contrast
DVT LOCATION
PROXIMAL LOWER EXTREMITY
DISTAL LOWER EXTREMITY
UPPER LIMB/CHEST
PROXIMAL LOWER EXTREMITY
* Pelvic/iliac/inferior vena cava (IVC)
* Femoral/popliteal
DISTAL LOWER EXTREMITY
* Peroneal, anterior and posterior tibial, and muscular (soleus and gastrocnemius)
UPPER LIMB/CHEST
* Brachiocephalic, subclavian, axillary, internal jugular,
brachial
* Superior vena cava (SVC)
Appropriate candidates for catheter-directed therapy may include:
- Patients at risk of limb loss (eg, phlegmasia cerulea dolens)
- Patients with central thrombus propagation despite anticoagulation
- Those with moderate to severely symptomatic proximal
DVT.
Candidates with high bleeding risk or contraindication to fibrinolytic may be candidates for percutaneous mechanical thrombectomy.
Clinical suspicion of catheter-related DVT:
- Unilateral limb swelling
- Pain in supraclavicular space or neck
- Dysfunctional catheter
Duration of anticoagulation in CATHETER-RELATED DVT
At least 3 months or as long as central venous access device (CVAD) is in placed
Consider catheter removal if symptoms persist or if the catheter is infected or dysfunctional or no longer necessary
TRUE OR FALSE
Anticoagulation without catheter removal is the preferred option for initial treatment, even for patients with symptomatic DVT, provided that the catheter is necessary, functional, and free of infection.
TRUE
Anticoagulation without catheter removal is the preferred option for initial treatment, even for patients with symptomatic DVT, provided that the catheter is necessary, functional, and free of infection.
Clinical suspicion of pulmonary embolism (PE):
- Current DVT or recent history of DVT
- Unexplained shortness of breath, chest pain, tachycardia, apprehension, or tachypnea
- Syncope
- Hypoxemia
Imaging for PE diagnosis
- CT angiography (CTA) with contrast
- X-ray pulmonary angiography with contrast (rarely used unless combined with clot extraction or thrombolytic therapy)
- Magnetic resonance angiography (MRA) with contrast
- Ventilation/perfusion (VQ) scan (lung scan) if CTA is contraindicated (eg, renal insufficiency, allergy refractory to anaphylaxis prophylaxis)
TRUE OR FALSE
D-dimer has limited utility in patients with cancer.
TRUE
D-dimer has limited utility in patients with cancer.
Hemodynamic instability in PE:
Consider Systemic or catheter-directed thrombolysis or embolectomy
- Acute PE with sustained hypotension (systolic blood pressure <90 mmHg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as
arrhythmia, hypovolemia, sepsis, or left ventricular [LV] dysfunction), pulselessness, or persistent profound bradycardia (heart rate <40 bpm with signs or symptoms of shock).
CLINICAL SUSPICION OF SPVT
- Abdominal or mid-abdominal colicky pain
- Abdominal distention
- Rebound tenderness
- Guarding
- Fever
- Anorexia
- Nausea, vomiting
- Diarrhea
- Gastrointestinal (GI) bleeding
- Hepatomegaly
- Ascites
Risk factors relevant to cancer population for SPVT:
- Recent abdominal surgery (eg, splenectomy)
- Abdominal mass
- Pancreatitis
- Cirrhosis
- Exogenous estrogens
- Paroxysmal nocturnal hemoglobinuria (PNH)
- Myeloproliferative neoplasms associated with the JAK2 V617F mutation (most common) or CALR mutation (rare)
Duration of SPVT
Acute
Chronic
Duration of SPVT
Acute: ≤8 weeks
Chronic: >8 weeks
Considered as one of the management option for patients with SPVT and portal hypertension
TIPS
Duration of Anticoagulation as Recommended by Guideline:
- Duration should be at least 3 months or as long as active cancer or cancer therapy.
- For non–catheter-associated DVT or PE recommend indefinite anticoagulation while cancer is active, under treatment, or if risk factors for recurrence persist.
- For symptomatic catheter-associated DVT, consider anticoagulation treatment for at least 3 months or as long as the catheter is in place.
- Providers should continue to discuss with patients the risks/benefits of anticoagulation to determine the appropriate duration of therapy.
Following initiation of anticoagulant: hemoglobin, hematocrit, and platelet count at least every _______ days for the first ______ days while in the inpatient setting and every 2 weeks thereafter or as clinically indicated.
2 to 3 days
First 14 days
TRUE OR FALSE
In the absence of contraindications, NCCN suggests that DOACs, LMWH, and warfarin can be considered for reatment of SPVT.
TRUE
In the absence of contraindications, NCCN suggests that DOACs, LMWH, and warfarin can be considered for reatment of SPVT.
TRUE OR FALSE
In patients with cancer, DOACs and LMWH are preferable to warfarin.
In patients with cancer, DOACs and LMWH are preferable to warfarin.
If warfarin is selected for chronic anticoagulation, initiate warfarin concurrently with the parenteral agent used for acute therapy and continue both therapies for
at least ____ days and until INR is ____.
5 days
INR is ≥2
During the transition to warfarin monotherapy, the INR should be measured at least twice weekly.
Once the patient is on warfarin alone, the INR should be measured initially at least once weekly
Once the patient is on a stable dose of warfarin with an INR of 2–3, INR testing can be gradually decreased to a frequency of no less than once a month.
Absolute contraindications to Anticoagulation
- Active bleeding (major)
- Indwelling neuraxial catheters
- Neuraxial anesthesia/lumbar puncture
- Interventional spine and pain procedures
Considered major bleeding:
- Active bleeding with >2 units red blood cells (RBCs) transfused
- Decrease in hemoglobin by ≥2 g/dL or
- Intracranial or intraspinal bleeding
Relative contraindications to Anticoagulation
- Chronic, clinically significant measurable bleeding >48 hours
- Thrombocytopenia (platelet count <30,000–50,000/μL or clinical judgment)
- Underlying hemorrhagic coagulopathy (eg, abnormal PT or aPTT excluding a lupus inhibitor/anticoagulant) or known bleeding disorder in the absence of replacement therapy (eg, hemophilia, von Willebrand disease)
- Severe platelet dysfunction
- Recent major operation at high risk for bleeding
- High risk for falls (head trauma)
- Primary and metastatic brain tumors
- Long-term antiplatelet therapy
CHEMOTHERAPY-INDUCED THROMBOCYTOPENIA
Generally, anticoagulation is considered safe with platelet counts ____________.
≥50,000/μL
Enoxaparin Dose Modification in the Setting of Thrombocytopenia
> 50,000/μL:
25,000–50,000/μL:
<25,000/μL:
> 50,000/μL: 1 mg/kg twice daily or 1.5 mg/kg daily
25,000–50,000/μL: 0.5 mg/kg twice daily
<25,000/μL Temporarily hold enoxaparin:
Testing done for patients with progression or new
thrombosis on therapeutic anticoagulation with drug on Therapeutic level:
Consider HIT and antiphospholipid
syndrome (APS) testing
Also consider conditions associated with venous stasis such as vascular compression by tumors or lymphatic masses or stasis associated with IVC filters.
Tests to measure drug level:
UFH:
LMWH:
Fondaparinux:
Warfarin:
Apixaban:
Dabigatran:
Edoxaban:
Rivaroxaban:
UFH: UFH anti-Xa or aPTT
LMWH: LMWH anti-Xa
Fondaparinux: Fondaparinux anti-Xa
Warfarin: INR
Apixaban: Apixaban anti-Xa
Dabigatran: Ecarin clotting time or diluted thrombin time (dTT)
Edoxaban: Edoxaban anti-Xa
Rivaroxaban Rivaroxaban anti-Xa
Thrombolytic agents used in DVT and PE
- Alteplase
- Reteplase
- Tenecteplase (only on PE)
Indications for Thrombolysis:
- Limb-threatening/life-threatening acute proximal DVT
- Symptomatic iliofemoral thrombosis
- Massive/life-threatening PE
- Intestinal SPVT with high risk of ischemia
Absolute Contraindications to Thrombolysis
- History of hemorrhagic stroke or stroke of unknown origin
- Intracranial tumor
- Ischemic stroke in previous 3 months
- History of major trauma, surgery, or head injury in previous 3 weeks
- Active bleeding
- Bleeding diathesis
Relative Contraindications to Thrombolysis
- Age >75 years
- Pregnancy or first postpartum week
- Non-compressible puncture sites
- Traumatic resuscitation
- Platelet count <100,000/μL
- Refractory hypertension (systolic pressure >180 mmHg; diastolic blood pressure >100 mmHg)
- Advanced liver disease
- Infective endocarditis
- Recent GI bleed (last 3 months)
- Life expectancy ≤1 year
Reversal for UFH, LMWH
Protamine
Dose
UHF and Dalteparin: 1 mg/100 units
Enoxaparin: 1 mg/mg of enoxaparin
Maximum dose: 50 mg
- Protamine 1 mg/mg of enoxaparin or 1 mg/100 units of dalteparin within 8 hours of dose
- Protamine 0.5 mg/mg of enoxaparin or 0.5 mg/100 units of dalteparin if dose administered >8 hours prior
No specific antidote exists for:
Bivalirudin
Argatroban
Fondaparinux
Reversal for Dabigatran
Idarucizumab
Dose: 2.5 g in 2 consecutive boluses
Oral charcoal if dose within 2 hours of ingestion
Hemodialysis
Hemodialysis with a charcoal filter
Reversal for Rivaroxaban, Apixaban, Edoxaban
Andexanet alfa
Alternative options may include:
◊ aPCC 25–50 units/kg IV
◊ 4-factor PCC 25–50 units per kg (based on units of Factor IX per kg of actual body weight) or fixed dose of 2000 units
◊ If 4-factor PCC is unavailable or patient is allergic to heparin and/or has a history of HIT in the last 12 months, then administer 3-factor PCC 50 units/kg (based on units of Factor IX per kg of actual body weig
The impact of warfarin dose changes can take at least ______ days to be fully manifested in the INR.
5 to 7 days
Reversal for Warfarin
INR 4.5–10, no bleeding:
INR >10, no bleeding:
INR 4.5–10, no bleeding: Follow INR closelyc (at least daily as an inpatient, every 1–2 days as outpatient).
INR >10, no bleeding: Small dose of oral vitamin K1 1–2.5 mg in patients at high risk of bleeding
INR 4.5–10, no bleeding: restart warfarin at reduced dose (10%–20% dose reduction)
INR >10, no bleeding: restart warfarin at reduced dose (at least 20% dose reduction)
Reversal for Warfarin
Management of urgent surgery
Within 24 hours:
Within 48 hours:
Within 24 hours: vitamin K 1–2.5 mg IV slowly
Repeat INR preoperative to determine need for supplemental FFP
Within 48 hours: vitamin K 2.5 mg orally
Repeat INR at 24 and 48 hours to assess need for supplemental vitamin K or FFP
Reversal for Warfarin
Life-threatening bleeding
- Vitamin K 10 mg
- 4-factor PCC
- FFP 15 mL/kg: 4-factor PCC unavailable or patient is allergic to heparin and/or a history of HIT in the last 12 months
- rhFVIIa 25 mcg/kg
HighBleeding Risk Procedures
- Neurosurgical procedure (intracranial or spinal)
- Cardiac surgery
- Urologic surgery
High Thromboembolic Risk Procedures
- Mitral mechanical valve (bileaflet)
- Single-leaflet or caged-ball mechanical valve
- Mechanical valve with recent stroke (<3 months)
- Atrial fibrillation (CHADSVasc ≥7)
- Atrial fibrillation with recent stroke (<3 months)
- Recent embolic stroke (<3 months)
- VTE within 3 months
- High-risk inherited thrombophilia (antithrombin deficiency, protein C deficiency, protein S deficiency, homozygous
Factor V Leiden or prothrombin gene mutation, compound heterozygous Factor V Leiden/prothrombin gene mutation
or other combined thrombophilic defects [eg, Factor V Leiden + protein C deficiency]) - APS
- Active high thrombotic risk cancera with previous thromboembolism
High thrombotic risk cancers include
- Pancreatic
- Liver
- Biliary
- Lung
- Stomach
- Brain
- Esophageal
Non-high thrombotic risk cancers include all other cancers, excluding non-melanoma skin cancer.
