CAVT

Question 1

The NCCN Guidelines Panel for Cancer-Associated Venous Thromboembolic Disease recommends VTE prophylaxis for all patients hospitalized with cancer, excluding those with _______________.

Answer 1

Basal/squamous cell skin cancer

Question 2

Has reduced deep vein thrombosis (DVT) and was associated with a lower risk of skin complications compared to graduated compression stockings (GCS)

Answer 2

Intermittent pneumatic compression (IPC)

Question 3

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

Answer 3

4 weeks

Question 4

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):

Answer 4

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

Question 5

Contraindications to Prophylactic Anticoagulation

Answer 5

• 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.

Question 6

Contraindications to Mechanical Prophylaxis

Answer 6

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)

Question 7

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.

Answer 7

12 hours: prophylactic

Question 8

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.

Answer 8

DOAC

With the exception of apixaban, which is also partially absorbed in the colon

Question 9

Drug approved for patients with gynecologic cancers.

Was initiated at investigator discretion once epidural anesthesia catheters were removed.
Duration of prophylaxis was 28 days.

Answer 9

Apixaban

Question 10

DOAC approved for patients after laparoscopic surgery for colorectal cancer

Answer 10

Rivaroxaban

Question 11

VTE RISK ASSESSMENT IN OUTPATIENTS WITH CANCER

Khorana Predictive Model for Chemotherapy-Associated VTE

Answer 11

• 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%

Question 12

Upper extremity SVT

Answer 12

• Median
• Basilic
• Cephalic veins

Question 13

Lower extremity SVT

Answer 13

• Great and small saphenous veins

Question 14

When to consider prophylactic dose anticoaguation in Acute Superficial Vein Thrombosis

Answer 14

• 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

Question 15

When to consider therapeutic dose anticoaguation in Acute Superficial Vein Thrombosis

Answer 15

• If the clot is in close proximitye to the deep venous system, 3 cm
• Lower extremity SVT within 3 cm of the saphenofemoral junction

Question 16

Symptomatic treatment for SVT includes

Answer 16

• Warm compresses
• Nonsteroidal anti-inflammatory drugs (NSAIDs), and
• Elevation

Question 17

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.

Answer 17

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.

Question 18

Clinical signs/symptoms of DVT:

Answer 18

• Swelling of unilateral extremity
• Heaviness in extremity
• Pain in extremity
• Unexplained persistent calf cramping
• Swelling in face, neck, or supraclavicular space
• Catheter dysfunction

Question 19

Types of Venous imaging:

Answer 19

• Venous US
• CT venogram (CTV) with contrast
• Magnetic resonance venogram (MRV) with contrast

Question 20

DVT LOCATION

PROXIMAL LOWER EXTREMITY

DISTAL LOWER EXTREMITY

UPPER LIMB/CHEST

Answer 20

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)

Question 21

Appropriate candidates for catheter-directed therapy may include:

Answer 21

• 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.

Question 22

Clinical suspicion of catheter-related DVT:

Answer 22

• Unilateral limb swelling
• Pain in supraclavicular space or neck
• Dysfunctional catheter

Question 23

Duration of anticoagulation in CATHETER-RELATED DVT

Answer 23

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

Question 24

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.

Answer 24

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.

Question 25

Clinical suspicion of pulmonary embolism (PE):

Answer 25

* Current DVT or recent history of DVT * Unexplained shortness of breath, chest pain, tachycardia, apprehension, or tachypnea * Syncope * Hypoxemia

Question 26

Imaging for PE diagnosis

Answer 26

* 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)

Question 27

# TRUE OR FALSE D-dimer has limited utility in patients with cancer.

Answer 27

TRUE D-dimer has limited utility in patients with cancer.

Question 28

Hemodynamic instability in PE: ## Footnote Consider Systemic or catheter-directed thrombolysis or embolectomy

Answer 28

* 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).

Question 29

CLINICAL SUSPICION OF SPVT

Answer 29

* Abdominal or mid-abdominal colicky pain * Abdominal distention * Rebound tenderness * Guarding * Fever * Anorexia * Nausea, vomiting * Diarrhea * Gastrointestinal (GI) bleeding * Hepatomegaly * Ascites

Question 30

Risk factors relevant to cancer population for SPVT:

Answer 30

* 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)

Question 31

Duration of SPVT Acute Chronic

Answer 31

Duration of SPVT Acute: ≤8 weeks Chronic: >8 weeks

Question 32

Considered as one of the management option for patients with SPVT and portal hypertension

Answer 32

TIPS

Question 33

Duration of Anticoagulation as Recommended by Guideline:

Answer 33

* 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.

Question 34

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**.

Answer 34

2 to 3 days First 14 days

Question 35

# TRUE OR FALSE In the absence of contraindications, NCCN suggests that DOACs, LMWH, and warfarin can be considered for reatment of SPVT.

Answer 35

TRUE In the absence of contraindications, NCCN suggests that **DOACs, LMWH, and warfarin** can be considered for reatment of **SPVT**.

Question 36

# TRUE OR FALSE In patients with cancer, DOACs and LMWH are preferable to warfarin.

Answer 36

In patients with **cancer**, **DOACs and LMWH** are preferable to warfarin.

Question 37

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 ____.

Answer 37

5 days INR is ≥2 ## Footnote 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.**

Question 38

**Absolute** contraindications to Anticoagulation

Answer 38

* Active bleeding (major) * Indwelling neuraxial catheters * Neuraxial anesthesia/lumbar puncture * Interventional spine and pain procedures

Question 39

Considered **major** bleeding:

Answer 39

* Active bleeding with >2 units red blood cells (RBCs) transfused * Decrease in hemoglobin by ≥2 g/dL or * Intracranial or intraspinal bleeding

Question 40

**Relative** contraindications to Anticoagulation

Answer 40

* 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

Question 41

# CHEMOTHERAPY-INDUCED THROMBOCYTOPENIA Generally, anticoagulation is considered safe with platelet counts ____________.

Answer 41

≥50,000/μL

Question 42

Enoxaparin Dose Modification in the Setting of Thrombocytopenia >50,000/μL: 25,000–50,000/μL: <25,000/μL:

Answer 42

>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:

Question 43

Testing done for patients with progression or new thrombosis on therapeutic anticoagulation with drug on Therapeutic level:

Answer 43

Consider HIT and antiphospholipid syndrome (APS) testing ## Footnote Also consider conditions associated with venous stasis such as vascular compression by tumors or lymphatic masses or stasis associated with IVC filters.

Question 44

Tests to measure drug level: UFH: LMWH: Fondaparinux: Warfarin: Apixaban: Dabigatran: Edoxaban: Rivaroxaban:

Answer 44

**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

Question 45

Thrombolytic agents used in DVT and PE

Answer 45

* Alteplase * Reteplase * Tenecteplase (only on PE)

Question 46

Indications for Thrombolysis:

Answer 46

* * Limb-threatening/life-threatening acute proximal DVT * * Symptomatic iliofemoral thrombosis * * Massive/life-threatening PE * * Intestinal SPVT with high risk of ischemia

Question 47

**Absolute** Contraindications to Thrombolysis

Answer 47

* 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

Question 48

**Relative** Contraindications to Thrombolysis

Answer 48

* 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

Question 49

Reversal for UFH, LMWH

Answer 49

**Protamine** Dose UHF and Dalteparin: 1 mg/100 units Enoxaparin: 1 mg/mg of enoxaparin ## Footnote 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

Question 50

No specific antidote exists for:

Answer 50

Bivalirudin Argatroban Fondaparinux

Question 51

Reversal for Dabigatran

Answer 51

Idarucizumab Dose: 2.5 g in 2 consecutive boluses ## Footnote Oral charcoal if dose within 2 hours of ingestion Hemodialysis Hemodialysis with a charcoal filter

Question 52

Reversal for Rivaroxaban, Apixaban, Edoxaban

Answer 52

Andexanet alfa ## Footnote 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

Question 53

The impact of warfarin dose changes can take at least ______ days to be fully manifested in the INR.

Answer 53

5 to 7 days

Question 54

Reversal for Warfarin INR 4.5–10, no bleeding: INR >10, no bleeding:

Answer 54

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 ## Footnote 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)

Question 55

Reversal for Warfarin Management of urgent surgery Within 24 hours: Within 48 hours:

Answer 55

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

Question 56

Reversal for Warfarin Life-threatening bleeding

Answer 56

* 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

Question 57

HighBleeding Risk Procedures

Answer 57

* Neurosurgical procedure (intracranial or spinal) * Cardiac surgery * Urologic surgery

Question 58

High Thromboembolic Risk Procedures

Answer 58

* 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

Question 59

High thrombotic risk cancers include

Answer 59

* Pancreatic * Liver * Biliary * Lung * Stomach * Brain * Esophageal ## Footnote Non-high thrombotic risk cancers include all other cancers, excluding non-melanoma skin cancer.