Deep Vein Thrombosis

Two-level Wells score first: ≥2 (likely) → proximal leg vein US (interim anticoagulation if scan >4h away); <2 (unlikely) → D-dimer. D-dimer only rules out, and only in low-probability patients. First-line treatment: DOAC; provoked = 3 months…

NICE NG158 VTE Pathway

The pathway

1 · Wells score

Cancer, immobility/surgery, tenderness, swelling >3cm difference, oedema, collaterals, previous DVT
≥2 likely / <2 unlikely

2 · Right test for the group

Likely → US within 4h (or interim anticoagulation + US within 24h)
Unlikely → D-dimer; negative excludes
Post-op/cancer: D-dimer uninterpretable

3 · Interim anticoagulation

Scan delayed >4h → treatment-dose DOAC/LMWH
Check bleeding risk + recent surgery with senior

4 · Treat confirmed DVT

Apixaban 10mg BD ×7d → 5mg BD (or rivaroxaban regimen)
Provoked: 3 months; unprovoked: ≥3 months + review
Cancer: DOAC or LMWH per subtype

5 · Limb-threat check

Dusky blue, agonising, massive swelling = phlegmasia
Urgent vascular/IR: lysis or thrombectomy

6 · Counsel & follow up

PE symptoms → immediate help
Post-thrombotic syndrome (20–50%)
3-month anticoagulation review is essential

Drugs

Drug	Dose	Route	Notes
Apixaban	10mg BD ×7 days → 5mg BD	PO	First-line; no bridging or monitoring.
Rivaroxaban	15mg BD ×21 days → 20mg OD	PO	Alternative first-line. With food.
Enoxaparin	1.5mg/kg OD	SC	Interim option; renal dose adjust; some cancer patients.

When to escalate

Suspected phlegmasia — vascular surgery/IR immediately,Bilateral DVT or IVC extension — imaging + specialist input,DVT with concurrent PE symptoms — treat as PE pathway,Anticoagulation contraindicated — discuss IVC filter with specialists

Reference: NICE NG158 / BTS + local VTE policy

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