今天的《Chest》网页发布了美国胸科医师协会（ACCP）的第8次抗凝与溶栓治疗临床询证指南——“Antithrombotic and Thrombolytic Therapy, 8th Ed: ACCP Guidelines”，这是ACCP继2001和2004年第6、7次抗凝溶栓指南之后的更新。
我已下载了全文，并制作成PDF格式的电子书，大约900页（7M, 已上传，地址保密，呵呵）其中有关肺栓塞与下肢深静脉血栓的治疗与预防是我阅读的重点，先看《Executive Summary》,也就是指南意见总结,是捷径，因字数限制只能copy部分内容如下，具体进展如果有时间我会一一道来：

Parenteral Anticoagulants
2.2.3 Monitoring Antithrombotic Effect
2.2.3. In patients treated with low-molecular-weight heparin (LMWH), we recommend against routine coagulation monitoring (Grade 1C). In pregnant women treated with therapeutic doses of LMWH, we recommend monitoring of anti-Xa levels (Grade 1C).
2.2.4 Dosing and Monitoring in Special Situations
2.2.4. In obese patients receiving LMWH prophylaxis or treatment, we suggest weight-based dosing (Grade 2C). In patients with severe renal insufficiency (creatinine clearance [CrCl] < 30 mL/min) who require therapeutic anticoagulation, we suggest the use of unfractionated heparin (UFH) instead of LMWH (Grade 2C). If LMWH is used in patients with severe renal insufficiency (CrCl < 30 mL/min) who require therapeutic anticoagulation, we suggest using 50% of the recommended dose (Grade 2C).
3.0 Direct Thrombin Inhibitors
3.0. In patients who receive either lepirudin or desirudin and have renal insufficiency (CrCl < 60 mL/min but > 30 mL/min), we recommend that the dose be reduced and the drug monitored using the activated partial thromboplastin time (APTT) [Grade 1C]. In patients with a CrCl < 30 mL/min, we recommend against the use of lepirudin or desirudin (Grade 1C). In patients who require anticoagulation and have previously received lepirudin or desirudin, we recommend against repeated use of these drugs because of the risk of anaphylaxis (Grade 1C).
3.1 Monitoring of Direct Thrombin Inhibitors
3.1. In patients receiving argatroban who are being transitioned to a vitamin K antagonist (VKA), we suggest that factor X levels, measured using a chromogenic assay, be used to adjust the dose of the VKA (Grade 2C).

Pharmacology and Management of VKAs (VKA = vitamin K antagonist)
2.1 Initiation and Maintenance Dosing
2.1.1. In patients beginning VKA therapy, we recommend the initiation of oral anticoagulation with doses between 5 and 10 mg for the first 1 or 2 days for most individuals, with subsequent dosing based on the international normalized ratio (INR) response (Grade 1B). At the present time, for patients beginning VKA therapy, without evidence from randomized trials, we suggest against the use of pharmacogenetic-based initial dosing to individualize warfarin dosing (Grade 2C).
2.2 Initiation of Anticoagulation in the Elderly or Other Populations
2.2.1. In elderly patients or patients who are debilitated, are malnourished, have congestive heart failure, have liver disease, have had recent major surgery, or are taking medications known to increase the sensitivity to warfarin (eg, amiodarone), we recommend the use of a starting dose of ≤ 5 mg (Grade 1C), with subsequent dosing based on the INR response.
2.3 Frequency of Monitoring
2.3.1. In patients beginning VKA therapy, we suggest that INR monitoring should be started after the initial two or three doses of oral anticoagulation therapy (Grade 2C).
2.3.2. For patients who are receiving a stable dose of oral anticoagulants, we suggest monitoring at an interval of no longer than every 4 weeks (Grade 2C).
2.4 Management of Nontherapeutic INRs
2.4.1. For patients with INRs above the therapeutic range, but < 5.0 and with no significant bleeding, we recommend lowering the dose or omitting a dose, monitoring more frequently, and resuming therapy at an appropriately adjusted dose when the INR is at a therapeutic level. If only minimally above therapeutic range, or associated with a transient causative factor, no dose reduction may be required (all Grade 1C).
2.4.2. For patients with INRs ≥ 5.0 but < 9.0 and no significant bleeding, we recommend omitting the next one or two doses, monitoring more frequently, and resuming therapy at an appropriately adjusted dose when the INR is at a therapeutic level (Grade 1C). Alternatively, we suggest omitting a dose and administering vitamin K (1 to 2.5 mg) orally, particularly if the patient is at increased risk of bleeding (Grade 2A). If more rapid reversal is required because the patient requires urgent surgery, we suggest vitamin K (≤ 5 mg) orally, with the expectation that a reduction of the INR will occur in 24 h. If the INR is still high, we suggest additional vitamin K (1 to 2 mg) orally (Grade 2C).
2.4.3. For patients with INRs of > 9.0 and no significant bleeding, we recommend holding warfarin therapy and administering a higher dose of vitamin K (2.5 to 5 mg) orally, with the expectation that the INR will be reduced substantially in 24 to 48 h (Grade 1B). Clinicians should monitor the INR more frequently, administer additional vitamin K if necessary, and resume therapy at an appropriately adjusted dose when the INR reaches the therapeutic range.
2.4.4. In patients with serious bleeding and elevated INR, regardless of the magnitude of the elevation, we recommend holding warfarin therapy and giving vitamin K (10 mg) by slow IV infusion supplemented with fresh frozen plasma, prothrombin complex concentrate, or recombinant factor VIIa, depending on the urgency of the situation. We recommend repeating vitamin K administration every 12 h for persistent INR elevation (all Grade 1C).
2.4.5. In patients with life-threatening bleeding (eg, intracranial hemorrhage) and elevated INR, regardless of the magnitude of the elevation, we recommend holding warfarin therapy and administering fresh frozen plasma, prothrombin complex concentrate, or recombinant factor VIIa supplemented with vitamin K, 10 mg by slow IV infusion, repeated, if necessary, depending on the INR (Grade 1C).
2.4.6. In patients with mild-to-moderately elevated INRs without major bleeding, we recommend that when vitamin K is to be given, it be administered orally rather than subcutaneously (Grade 1A).
2.5 Management of Variable INRs
2.5.1. For patients receiving long-term warfarin therapy with a variable INR response not attributable to any of the usual known causes for instability, we suggest a trial of daily low-dose oral vitamin K (100 to 200 µg) with close monitoring of the INR and warfarin dose adjustment to counter an initial lowering of the INR in response to vitamin K (Grade 2B).
2.7 Management of INRs in Antiphospholipid Syndrome
2.7.1. In patients who have a lupus inhibitor, who have no additional risk factors, and no lack of response to therapy, we recommend a therapeutic target INR of 2.5 (INR range, 2.0 to 3.0) [Grade 1A]. In patients who have recurrent thromboembolic events with a therapeutic INR or other additional risk factors for thromboembolic events, we suggest a target INR of 3.0 (INR range, 2.5 to 3.5) [Grade 2C].
4.1 Optimal Management of VKA Therapy
4.1.1. For health-care providers who manage oral anticoagulation therapy, we recommend that they do so in a systematic and coordinated fashion, incorporating patient education, systematic INR testing, tracking, follow-up, and good patient communication of results and dosing decisions as occurs in an anticoagulation management service (Grade 1B).
4.3 Patient Self-Testing and Patient Self-Management
4.3.1. Patient self-management is a choice made by patients and health-care providers that depends on many factors. In patients who are suitably selected and trained, patient self-testing and patient self-management is an effective alternative treatment model. We suggest that such therapeutic management be implemented where suitable (Grade 2B).

Perioperative Management of Antithrombotic Therapy

Treatment and Prevention of Heparin-Induced Thrombocytopenia
1.0 Recognition of Heparin-Induced Thrombocytopenia
1.1 Platelet Count Monitoring for HIT
1.1. For patients receiving heparin in whom the clinician considers the risk of heparin-induced thrombocytopenia (HIT) to be > 1.0%, we recommend platelet count monitoring over no platelet count monitoring (Grade 1C). For patients receiving heparin who have an estimated risk of HIT of 0.1 to 1.0%, we suggest platelet count monitoring over no platelet count monitoring (Grade 2C).

1.1.1 Platelet Count Monitoring of Patients Recently Treated With Heparin
1.1.1. For patients who are starting UFH or LMWH treatment and who have received UFH within the past 100 days, or those patients in whom exposure history is uncertain, we recommend obtaining a baseline platelet count and then a repeat platelet count within 24 h of starting heparin over not obtaining a repeat platelet count (Grade 1C).
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Prevention of VTE
1.0 General Recommendations
2.0 General, Vascular, Gynecologic, Urologic, Laparoscopic, Bariatric, Thoracic, and CABG Surgery
3.0 Orthopedic Surgery
4.0 Neurosurgery
5.0 Trauma, Spinal Cord Injury, Burns
6.0 Medical Conditions
7.0 Cancer Patients
8.0 Critical Care
8.1. For patients admitted to a critical care unit, we recommend routine assessment for VTE risk and routine thromboprophylaxis in most (Grade 1A).
8.2. For critical care patients who are at moderate risk for VTE (eg, medically ill or postoperative general surgery patients), we recommend using LMWH or LDUH thromboprophylaxis (Grade 1A).
8.3. For critical care patients who are at higher risk (eg, following major trauma or orthopedic surgery), we recommend LMWH thromboprophylaxis (Grade 1A).
8.4. For critical care patients who are at high risk for bleeding, we recommend the optimal use of mechanical thromboprophylaxis with GCS and/or IPC at least until the bleeding risk decreases (Grade 1A). When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis (Grade 1C).
9.0 Long-Distance Travel

Antithrombotic Therapy for Venous Thromboembolic Disease
1.1 Initial Anticoagulation of Acute DVT of the Leg
1.1.1. For patients with objectively confirmed DVT, we recommend short-term treatment with SC LMWH (Grade 1A), IV UFH (Grade 1A), monitored SC UFH (Grade 1A), fixed-dose SC UFH (Grade 1A), or SC fondaparinux (Grade 1A) rather than no such acute treatment.
1.1.2. For patients with a high clinical suspicion of DVT, we recommend treatment with anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C).
1.1.3. In patients with acute DVT, we recommend initial treatment with LMWH, UFH, or fondaparinux for at least 5 days and until the INR is ≥ 2.0 for 24 h (Grade 1C).
1.1.4. In patients with acute DVT, we recommend initiation of VKA together with LMWH, UFH, or fondaparinux on the first treatment day rather than delayed initiation of VKA (Grade 1A).
1.2 IV UFH for the Initial Treatment of DVT
1.2.1. In patients with acute DVT, if IV UFH is chosen, we recommend that, after an initial IV bolus (80 U/kg or 5,000 U) it be administered by continuous infusion (initially at a dose of 18 U/kg/h or 1,300 U/h) with dose adjustment to achieve and maintain an APTT prolongation that corresponds to plasma heparin levels of 0.3 to 0.7 IU/mL anti-Xa activity by the amidolytic assay rather than administration as IV boluses throughout treatment, or administration without coagulation monitoring (Grade 1C).
1.3 SC UFH Compared With IV Heparin for the Initial Treatment of DVT
1.3.1. In patients with acute DVT, if monitored SC UFH is chosen, we recommend an initial dose of 17,500 U, or a weight-adjusted dose of about 250 U/kg, bid, with dose adjustment to achieve and maintain an APTT prolongation that corresponds to plasma heparin levels of 0.3 to 0.7 IU/mL anti-Xa activity when measured 6 h after injection rather than starting with a smaller initial dose (Grade 1C) [see also Section 1.5].
1.3.2. In patients with acute DVT, if fixed-dose, unmonitored SC UFH is chosen, we recommend an initial dose of 333 U/kg followed by a twice-daily dose of 250 U/kg rather than nonweight-based dosing (Grade 1C) [see also Section 1.5].
1.4 LMWH for the Initial Treatment of DVT
1.4.1. In patients with acute DVT, we recommend initial treatment with LMWH SC once or twice daily, as an outpatient if possible (Grade 1C) or as an inpatient if necessary (Grade 1A), rather than treatment with IV UFH.

1.4.2. In patients with acute DVT treated with LMWH, we recommend against routine monitoring with anti-factor Xa level measurements (Grade 1A).

1.4.3. In patients with acute DVT and severe renal failure, we suggest UFH over LMWH (Grade 2C).

1.9 Catheter-Directed Thrombolysis for Acute DVT
1.9.1. In selected patients with extensive acute proximal DVT (eg, iliofemoral DVT, symptoms for < 14 days, good functional status, life expectancy of ≥ 1 year) who have a low risk of bleeding, we suggest that catheter-directed thrombolysis may be used to reduce acute symptoms and postthrombotic morbidity if appropriate expertise and resources are available (Grade 2B).

1.9.2. After successful catheter-directed thrombolysis in patients with acute DVT, we suggest correction of underlying venous lesions using balloon angioplasty and stents (Grade 2C).

1.9.3. We suggest pharmacomechanical thrombolysis (eg, with inclusion of thrombus fragmentation and/or aspiration) in preference to catheter-directed thrombolysis alone to shorten treatment time if appropriate expertise and resources are available (Grade 2C).

1.9.4. After successful catheter-directed thrombolysis in patients with acute DVT, we recommend the same intensity and duration of anticoagulant therapy as for comparable patients who do not undergo catheter-directed thrombolysis (Grade 1C).

1.10 Systemic Thrombolytic Therapy for Acute DVT
1.10.1. In selected patients with extensive proximal DVT (eg, symptoms for < 14 days, good functional status, life expectancy of ≥ 1 year) who have a low risk of bleeding, we suggest that systemic thrombolytic therapy may be used to reduce acute symptoms and postthrombotic morbidity if catheter-directed thrombolysis is not available (Grade 2C).

1.11 Percutaneous Venous Thrombectomy
1.11.1. In patients with acute DVT, we suggest that they should not be treated with percutaneous mechanical thrombectomy alone (Grade 2C).

1.12 Operative Venous Thrombectomy for Acute DVT
1.12.1. In selected patients with acute iliofemoral DVT (eg, symptoms for < 7 days, good functional status, and life expectancy of ≥ 1 year), we suggest that operative venous thrombectomy may be used to reduce acute symptoms and postthrombotic morbidity if appropriate expertise and resources are available (Grade 2B). If such patients do not have a high risk of bleeding, we suggest that catheter-directed thrombolysis is usually preferable to operative venous thrombectomy (Grade 2C).

1.12.2. In patients who undergo operative venous thrombectomy, we recommend the same intensity and duration of anticoagulant therapy afterwards as for comparable patients who do not undergo venous thrombectomy (Grade 1C).

1.13 Vena Caval Filters for the Initial Treatment of DVT
1.13.1. For patients with DVT, we recommend against the routine use of a vena cava filter in addition to anticoagulants (Grade 1A).

1.13.2. For patients with acute proximal DVT, if anticoagulant therapy is not possible because of the risk of bleeding, we recommend placement of an inferior vena cava filter (Grade 1C).

1.13.3. For patients with acute DVT who have an inferior vena cava filter inserted as an alternative to anticoagulation, we recommend that they should subsequently receive a conventional course of anticoagulant therapy if their risk of bleeding resolves (Grade 1C).

1.14 Immobilization for the Treatment of Acute DVT
1.14.1. In patients with acute DVT, we recommend early ambulation in preference to initial bed rest when this is feasible (Grade 1A).

2.1 Duration of Anticoagulant Therapy
2.1.1. For patients with DVT secondary to a transient (reversible) risk factor, we recommend treatment with a VKA for 3 months over treatment for shorter periods (Grade 1A).

2.1.2. For patients with unprovoked DVT, we recommend treatment with a VKA for at least 3 months (Grade 1A). We recommend that after 3 months of anticoagulant therapy, all patients with unprovoked DVT should be evaluated for the risk-benefit ratio of long-term therapy (Grade 1C). For patients with a first unprovoked VTE that is a proximal DVT, and in whom risk factors for bleeding are absent and for whom good anticoagulant monitoring is achievable, we recommend long-term treatment (Grade 1A).

Underlying values and preferences: This recommendation attaches a relatively high value to prevention of recurrent VTE and a lower value to the burden of long-term anticoagulant therapy. For patients with a second episode of unprovoked VTE, we recommend long-term treatment (Grade 1A). For patients with a first isolated distal DVT that is unprovoked, we suggest that 3 months of anticoagulant therapy is sufficient rather than indefinite therapy (Grade 2B).

2.1.3. For patients with DVT and cancer, we recommend LMWH for the first 3 to 6 months of long-term anticoagulant therapy (Grade 1A). For these patients, we recommend subsequent anticoagulant therapy with VKA or LMWH indefinitely or until the cancer is resolved (also, see Section 2.4) [Grade 1C].

2.1.4. In patients who receive long-term anticoagulant treatment, the risk-benefit ratio of continuing such treatment should be reassessed in the individual patient at periodic intervals (Grade 1C).

2.2 Intensity of Anticoagulant Effect
2.2.1. In patients with DVT, we recommend that the dose of VKA be adjusted to maintain a target INR of 2.5 (INR range, 2.0 to 3.0) for all treatment durations (Grade 1A). For patients with unprovoked DVT who have a strong preference for less frequent INR testing to monitor their therapy, after the first 3 months of conventional-intensity anticoagulation (INR range, 2.0 to 3.0), we recommend low-intensity therapy (INR range, 1.5 to 1.9) with less frequent INR monitoring over stopping treatment (Grade 1A). We recommend against high-intensity VKA therapy (INR range, 3.1 to 4.0) compared to an INR range of 2.0 to 3.0 (Grade 1A).

2.6 Treatment of Asymptomatic DVT of the Leg
2.6.1. In patients who are unexpectedly found to have asymptomatic DVT, we recommend the same initial and long-term anticoagulation as for comparable patients with symptomatic DVT (Grade 1C).

3.1 Elastic Stockings and Compression Bandages To Prevent Postthrombotic Syndrome
3.1.1. For a patient who has had a symptomatic proximal DVT, we recommend the use of an elastic compression stocking with an ankle pressure gradient of 30 to 40 mm Hg if feasible (Grade 1A). Compression therapy, which may include use of bandages acutely, should be started as soon as feasible after starting anticoagulant therapy and should be continued for a minimum of 2 years, and longer if patients have symptoms of the postthrombotic syndrome (PTS). (Note: feasibility, both short and long term, refers to ability of patients and their caregivers to apply and remove stockings.)

Underlying values and preferences: This recommendation attaches a relatively high value to long-term prevention of the postthrombotic syndrome (PTS) and a low value to the burden (eg, inconvenience or discomfort) associated with wearing stockings.

3.2 Physical Treatment of PTS Without Venous Leg Ulcers
3.2.1. For patients with severe edema of the leg due to PTS, we suggest a course of IPC (Grade 2B).

3.2.2. For patients with mild edema of the leg due to PTS, we suggest the use of elastic compression stockings (Grade 2C).

3.3 Physical Treatment of Venous Leg Ulcers
3.3.1. In patients with venous ulcers resistant to healing with wound care and compression, we suggest the addition of IPC (Grade 2B).

3.4 Hyperbaric Oxygen and the Management of Patients With Venous Ulcers
3.4.1. For patients with venous ulcers, we suggest that hyperbaric oxygen not be used (Grade 2B).

3.5.1 Pentoxifylline
3.5.1. In patients with venous leg ulcers, we suggest pentoxifylline, 400 mg po tid, in addition to local care and compression and/or IPC (Grade 2B).

3.5.2 Micronized Purified Flavonoid Fraction or Sulodexide for the Treatment of Venous Leg Ulcers
3.5.2. In patients with persistent venous ulcers, we suggest that rutosides, in the form of micronized purified flavonoid fraction given orally, or sulodexide administered intramuscularly and then orally, be added to local care and compression (Grade 2B).

4.1 IV or SC UFH, SC LMWH, SC Fondaparinux, and VKA for the Initial Treatment of Pulmonary Embolism
4.1.1. For patients with objectively confirmed pulmonary embolism (PE), we recommend short-term treatment with SC LMWH (Grade 1A), IV UFH (Grade 1A), monitored SC UFH (Grade 1A), fixed-dose SC UFH (Grade 1A), or SC fondaparinux (Grade 1A) rather than no such acute treatment. Patients with acute PE should also be routinely assessed for treatment with thrombolytic therapy (see Section 4.3 for related discussion and recommendations).

4.1.2. For patients in whom there is a high clinical suspicion of PE, we recommend treatment with anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C).

4.1.3. In patients with acute PE, we recommend initial treatment with LMWH, UFH, or fondaparinux for at least 5 days and until the INR is ≥ 2.0 for at least 24 h (Grade 1C).

4.1.4. In patients with acute PE, we recommend initiation of VKA together with LMWH, UFH, or fondaparinux on the first treatment day rather than delayed initiation of VKA (Grade 1A).

4.1.5. In patients with acute PE, if IV UFH is chosen, we recommend that after an initial IV bolus (80 U/kg or 5,000 U), it is administered by continuous infusion (initially at dose of 18 U/kg/h or 1,300 U/h) with dose adjustment to achieve and maintain an APTT prolongation that corresponds to plasma heparin levels of 0.3 to 0.7 IU/mL anti-Xa activity by the amidolytic assay rather than administration as IV boluses throughout treatment, or administration without coagulation monitoring (Grade 1C).

4.1.6. In patients with acute PE, if monitored SC UFH is chosen, we recommend an initial dose of 17,500 U, or a weight-adjusted dose of about 250 U/kg, bid, with dose adjustment to achieve and maintain an APTT prolongation that corresponds to plasma heparin levels of 0.3 to 0.7 IU/mL anti-Xa activity when measured 6 h after injection rather than starting with a smaller initial dose (Grade 1C).

4.1.7. In patients with acute PE, if fixed-dose, unmonitored SC UFH is chosen, we recommend an initial dose of 333 U/Kg followed by a twice-daily dose of 250 U/kg rather than non–weight-based dosing (Grade 1C).

4.1.8. In patients with acute nonmassive PE, we recommend initial treatment with LMWH over IV UFH (Grade 1A). In patients with massive PE, in other situations where there is concern about SC absorption, or in patients in whom thrombolytic therapy is being considered or planned, we suggest IV UFH over SC LMWH, SC fondaparinux, or SC UFH (Grade 2C).

4.1.9. In patients with acute PE treated with LMWH, we recommend against routine monitoring with anti-factor Xa level measurements (Grade 1A).

4.1.10. In patients with acute PE and severe renal failure, we suggest UFH over LMWH (Grade 2C).

4.3 Systemically and Locally Administered Thrombolytic Therapy for PE
4.3.1. All PE patients should undergo rapid risk stratification (Grade 1C). For patients with evidence of hemodynamic compromise, we recommend use of thrombolytic therapy unless there are major contraindications owing to bleeding risk (Grade 1B). Thrombolysis in these patients should not be delayed, because irreversible cardiogenic shock may ensue. In selected high-risk patients without hypotension who are judged to have a low risk of bleeding, we suggest administration of thrombolytic therapy (Grade 2B). The decision to use thrombolytic therapy depends on the clinician’s assessment of PE severity, prognosis, and risk of bleeding. For the majority of patients with PE, we recommend against using thrombolytic therapy (Grade 1B).

4.3.2. In patients with acute PE, when a thrombolytic agent is used, we recommend that treatment be administered via a peripheral vein rather than placing a pulmonary artery catheter to administer treatment (Grade 1B).

4.3.3. In patients with acute PE, with administration of thrombolytic therapy, we recommend use of regimens with short infusion times (eg, a 2-h infusion) over those with prolonged infusion times (eg, a 24-h infusion) [Grade 1B].

4.4 Catheter Extraction or Fragmentation for the Initial Treatment of PE
4.4.1. For most patients with PE, we recommend against use of interventional catheterization techniques (Grade 1C). In selected highly compromised patients who are unable to receive thrombolytic therapy because of bleeding risk, or whose critical status does not allow sufficient time for systemic thrombolytic therapy to be effective, we suggest use of interventional catheterization techniques if appropriate expertise is available (Grade 2C).

4.5 Pulmonary Embolectomy for the Initial Treatment of PE
4.5.1. In selected highly compromised patients who are unable to receive thrombolytic therapy because of bleeding risk, or whose critical status does not allow sufficient time for systemic thrombolytic therapy to be effective, we suggest that pulmonary embolectomy may be used if appropriate expertise is available (Grade 2C).

4.6 Vena Caval Filters for the Initial Treatment of PE
4.6.1. For most patients with PE, we recommend against the routine use of a vena caval filter in addition to anticoagulants (Grade 1A).

4.6.2. In patients with acute PE, if anticoagulant therapy is not possible because of risk of bleeding, we recommend placement of an inferior vena caval filter (Grade 1C).

4.6.3. For patients with acute PE who have an inferior vena caval filter inserted as an alternative to anticoagulation, we recommend that they should subsequently receive a conventional course of anticoagulant therapy if their risk of bleeding resolves (Grade 1C).

5.0 Long-term Treatment of Acute PE
5.1.1. For patients with PE secondary to a transient (reversible) risk factor, we recommend treatment with a VKA for 3 months over treatment for shorter periods (Grade 1A).

5.1.2. For patients with unprovoked PE, we recommend treatment with a VKA for at least 3 months (Grade 1A). We recommend that after 3 months of anticoagulant therapy, all patients with unprovoked PE should be evaluated for the risk-benefit ratio of long-term therapy (Grade 1C). For patients with a first unprovoked episode of VTE that is a PE, and in whom risk factors for bleeding are absent and for whom good anticoagulant monitoring is achievable, we recommend long-term treatment (Grade 1A).

Underlying values and preferences: This recommendation attaches a relatively high value to prevention of recurrent VTE and a lower value to the burden of long-term anticoagulant therapy.

For patients with a second episode of unprovoked VTE, we recommend long-term treatment (Grade 1A).

5.1.3. For patients with PE and cancer, we recommend LMWH for the first 3 to 6 months of long-term anticoagulant therapy (Grade 1A). For these patients, we recommend subsequent anticoagulant therapy with VKA or LMWH indefinitely or until the cancer is resolved (Grade 1C).

5.1.4. In patients who receive long-term anticoagulant treatment, the risk-benefit ratio of continuing such treatment should be reassessed in the individual patient at periodic intervals (Grade 1C).

5.1.5. In patients with PE, we recommend that the dose of VKA be adjusted to maintain a target INR of 2.5 (INR range, 2.0 to 3.0) for all treatment durations (Grade 1A). For patients with unprovoked PE who have a strong preference for less frequent INR testing to monitor their therapy, after the first 3 months of conventional-intensity anticoagulation (INR range, 2.0 to 3.0), we recommend low-intensity therapy (INR range, 1.5 to 1.9) with less frequent INR monitoring over stopping treatment (Grade 1A). We recommend against high-intensity VKA therapy (INR range, 3.1 to 4.0) compared with an INR range of 2.0 to 3.0 (Grade 1A).

5.1.6. In patients who are unexpectedly found to have asymptomatic PE, we recommend the same initial and long-term anticoagulation as for comparable patients with symptomatic PE (Grade 1C).

6.1 Pulmonary Thromboendarterectomy, VKA, and Vena Caval Filter for the Treatment of CTPH
6.1.1. In selected patients with chronic thromboembolic pulmonary hypertension (CTPH), such as those with central disease under the care of an experienced surgical/medical team, we recommend pulmonary thromboendarterectomy (Grade 1C).

6.1.2. For all patients with CTPH, we recommend life-long treatment with a VKA targeted to an INR of 2.0 to 3.0 (Grade 1C).

6.1.3. For patients with CTPH undergoing pulmonary thromboendarterectomy, we suggest the placement of a permanent vena caval filter before or at the time of the procedure (Grade 2C).

6.1.4. For patients with inoperable CTPH, we suggest referral to a center with expertise in pulmonary hypertension so that patients can be evaluated for alternative treatments, such as vasodilator therapy or balloon pulmonary angioplasty (Grade 2C).

7.1 Treatment of Infusion Thrombophlebitis
7.1.1. For patients with symptomatic infusion thrombophlebitis as a complication of IV infusion, we suggest oral diclofenac or another nonsteroidal antiinflammatory drug (Grade 2B), topical diclofenac gel (Grade 2B), or heparin gel (Grade 2B) until resolution of symptoms or for up to 2 weeks. We recommend against the use of systemic anticoagulation (Grade 1C).

7.2 Treatment of Superficial Vein Thrombosis
7.2.1. For patients with spontaneous superficial vein thrombosis, we suggest prophylactic or intermediate doses of LMWH (Grade 2B) or intermediate doses of UFH (Grade 2B) for at least 4 weeks. We suggest that as an alternative to 4 weeks of LMWH or UFH, VKA (target INR, 2.5; range, 2.0 to 3.0) can be overlapped with 5 days of UFH and LMWH and continued for 4 weeks (Grade 2C). We suggest that oral nonsteroidal antiinflammatory drugs should not be used in addition to anticoagulation (Grade 2B). We recommend medical treatment with anticoagulants over surgical treatment (Grade 1B).

Remark: It is likely that less extensive superficial vein thrombosis (ie, where the affected venous segment is short in length or further from the saphenofemoral junction) does not require treatment with anticoagulants. It is reasonable to use oral or topical nonsteroidal antiinflammatory drugs for symptom control in such cases.

8.1 IV UFH or LMWH for the Initial Treatment of UEDVT
8.1.1. For patients with acute upper-extremity DVT, we recommend initial treatment with therapeutic doses of LMWH, UFH, or fondaparinux as described for leg DVT (see Section 1) [Grade 1C].

8.2 Thrombolytic Therapy for the Initial Treatment of UEDVT
8.2.1. For most patients with acute upper-extremity DVT, we recommend against the routine use of systemic or catheter-directed thrombolytic therapy (Grade 1C).

8.2.2. In selected patients with acute upper-extremity DVT (eg, in those with a low risk of bleeding and severe symptoms of recent onset) we suggest a short course of catheter-directed thrombolytic therapy may be used for initial treatment if appropriate expertise and resources are available (Grade 2C).

8.3 Catheter Extraction, Surgical Thrombectomy, Transluminal Angioplasty, Stent Placement, Staged Approach of Lysis Followed by Interventional or Surgical Procedure, and Superior Vena Cava Filter Insertion, for the Initial Treatment of UEDVT
8.3.1. For most patients with acute upper-extremity DVT, we recommend against the routine use of catheter extraction, surgical thrombectomy, transluminal angioplasty, stent placement, staged approach of lysis followed by interventional or surgical procedure, or superior vena cava filter placement (Grade 1C).

8.3.2. In selected patients with acute upper-extremity DVT (eg, those with primary upper-extremity DVT and failure of anticoagulant or thrombolytic treatment who have severe persistent symptoms), we suggest that catheter extraction, surgical thrombectomy, transluminal angioplasty, or a staged approach of lysis followed by a vascular interventional or surgical procedure may be used, if appropriate expertise and resources are available (all Grade 2C).

8.3.3. In selected patients with acute upper-extremity DVT (eg, those in whom anticoagulant treatment is contraindicated and there is clear evidence of DVT progression or clinically significant PE), we suggest placement of a superior vena cava filter (Grade 2C).

8.4 Anticoagulants for the Long-term Treatment of UEDVT
8.4.1. For patients with acute upper-extremity DVT, we recommend treatment with a VKA for ≥ 3 months (Grade 1C).

Remark: A similar process as for lower-extremity DVT (see Section 2) should be used to determine the optimal duration of anticoagulation.

8.4.2. For most patients with upper-extremity DVT in association with an indwelling central venous catheter, we suggest that the catheter not be removed if it is functional and there is an ongoing need for the catheter (Grade 2C).

8.4.3. For patients who have upper-extremity DVT in association with an indwelling central venous catheter that is removed, we do not recommend that the duration of long-term anticoagulant treatment be shortened to < 3 months (Grade 2C).

8.5 Prevention of PTS of the Arm
8.5.1. For patients at risk for PTS after upper-extremity DVT, we do not suggest routine use of elastic compression or venoactive medications (Grade 2C).

8.6 Treatment of PTS of the Arm
8.6.1. In patients with upper-extremity DVT who have persistent edema and pain, we suggest elastic bandages or elastic compression sleeves to reduce symptoms of PTS of the upper extremity (Grade 2C).