Journal of Vascular Medicine & Surgery

The Impact of direct oral anticoagulants on Venous Thromboembolism Management

Ting Zou^* Department of Vascular Medicine, Donghua University, Shanghai, China
^*Correspondence: Ting Zou, Department of Vascular Medicine, Donghua University, Shanghai, China, Email:

Received: 31-Mar-2025, Manuscript No. JVMS-25-28764; Editor assigned: 02-Apr-2025, Pre QC No. JVMS-25-28764 (PQ); Reviewed: 16-Apr-2025, QC No. JVMS-25-28764; Revised: 23-Apr-2025, Manuscript No. JVMS-25-28764 (R); Published: 30-Apr-2025, DOI: 10.35248/2329-6925.25.13.591

Description

Venous Thromboembolism (VTE), encompassing Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE), remains a significant cause of morbidity and mortality worldwide despite advances in prophylaxis, diagnosis, and treatment. Over the past decade, our approach to VTE has evolved substantially, moving from a relatively uniform strategy of anticoagulation for all patients to more nuanced, patient-tailored management pathways. This evolution reflects deeper understanding of VTE pathophysiology, recognition of distinct patient phenotypes, and emerging technologies that expand our therapeutic options beyond traditional anticoagulation [1,2].

The introduction of Direct Oral Anticoagulants (DOACs) represented the first major paradigm shift in VTE management, offering comparable efficacy to vitamin K antagonists with reduced bleeding risk, no requirement for routine monitoring, and fewer drug and dietary interactions. The EINSTEIN, AMPLIFY, HOKUSAI-VTE, and RE-COVER trials established DOACs as safe and effective alternatives to warfarin, and subsequent real-world data have largely confirmed these findings across diverse patient populations. The convenience of fixed dosing and reduced bleeding complications has facilitated outpatient management of low-risk DVT and even selected PE cases, dramatically changing care delivery models [3,4].

However, emerging evidence suggests that anticoagulation alone may represent suboptimal therapy for certain patient subgroups. Post-Thrombotic Syndrome (PTS) affects 20-50% of patients following proximal DVT despite adequate anticoagulation, resulting in chronic pain, swelling, skin changes, and significantly impaired quality of life. Similarly, Chronic Thromboembolic Pulmonary Hypertension (CTEPH) develops in approximately 3-4% of survivors of acute PE, with devastating consequences for functional status and survival. These long-term complications highlight the limitations of a strategy focused exclusively on preventing thrombus propagation and recurrence without addressing the initial thrombus burden [5,6].

Early thrombus removal strategies have consequently gained renewed interest. For acute iliofemoral DVT, the CaVenT study demonstrated a 14.4% absolute reduction in PTS incidence at two years with Catheter-Directed Thrombolysis (CDT) compared to anticoagulation alone, though with increased bleeding risk. The subsequent ATTRACT trial found more modest benefits, with no significant reduction in overall PTS incidence but improvements in severity scores and quality of life measures, particularly in iliofemoral DVT patients. These mixed results have led to more selective application of thrombolytic approaches, prioritizing patients with extensive iliofemoral involvement, severe symptoms, and low bleeding risk [7,8].

Mechanical thrombectomy devices offer an alternative approach for rapid thrombus removal with potentially lower bleeding risk than pharmacologic thrombolysis. Technologies including rheolytic, rotational, and aspiration thrombectomy systems have shown promising technical success rates in observational studies, though randomized data comparing these approaches to anticoagulation or CDT remain limited. The optimal integration of these mechanical approaches—either as standalone therapy or in combination with low-dose thrombolytics—represents an active area of investigation [9].

For acute PE, risk stratification has become increasingly sophisticated, moving beyond the traditional dichotomy of "massive" versus "submassive" categories to more granular assessment incorporating clinical factors, biomarkers, and imaging findings. The simplified PESI score, troponin levels, BNP/NT-proBNP, and right ventricular dysfunction on echocardiography or CT provide complementary information to identify patients at intermediate-high risk who might benefit from more aggressive intervention despite hemodynamic stability [10].

Catheter-directed therapies for PE have expanded rapidly, with various systems offering local low-dose thrombolysis, mechanical fragmentation, aspiration, or combinations thereof. The SEATTLE II and PERFECT registries demonstrated significant improvements in right ventricular function and pulmonary artery pressure with catheter-directed approaches. However, the PEITHO-3 trial comparing catheter-directed thrombolysis to anticoagulation alone in intermediate-risk PE patients will provide much-needed randomized data on hard clinical endpoints. Until those results are available, institutional protocols for PE management vary considerably, highlighting the need for individualized decision-making within multidisciplinary Pulmonary Embolism Response Teams (PERTs).

The optimal duration of anticoagulation after VTE represents another evolving area. The traditional paradigm of 3-6 months of treatment has given way to more tailored approaches based on thrombotic versus bleeding risk assessment. Extended anticoagulation clearly reduces recurrence risk, as demonstrated in the EINSTEIN-Extension, AMPLIFY-EXT, and RE-SONATE trials, but at the cost of increased bleeding. Risk assessment tools such as the HERDOO2 score for women and the Vienna prediction model help identify patients at higher recurrence risk who may benefit from extended therapy, though their implementation in routine practice remains inconsistent.

The concept of reduced-intensity anticoagulation after the initial treatment period offers a potential middle ground, balancing recurrence prevention with bleeding risk. The EINSTEIN-CHOICE trial found that rivaroxaban 10mg daily was as effective as 20mg daily for extended secondary prevention, with similar safety. This approach may be particularly valuable for patients with unprovoked VTE or persistent risk factors who require long-term protection.

Beyond anticoagulation duration, the recognition of distinct VTE phenotypes is reshaping management approaches. Cancer-associated thrombosis, for instance, carries higher risks of both recurrence and bleeding compared to unprovoked VTE. The HOKUSAI VTE-Cancer, SELECT-D, and CARAVAGGIO trials established DOACs as effective alternatives to low-molecular-weight heparin in this population, though patient selection remains important given persistent concerns about gastrointestinal bleeding with some agents.

Conclusion

Looking ahead, several emerging concepts may further transform VTE management. First, artificial intelligence algorithms incorporating electronic health record data show promise for more accurate risk prediction and stratification than traditional scoring systems. Second, novel anticoagulants targeting factor XI and XII may offer effective thrombosis prevention with minimal bleeding risk, potentially shifting the risk-benefit calculation for both treatment and prophylaxis. Third, increasing recognition of the inflammatory component of venous thrombosis suggests potential roles for anti-inflammatory therapies as adjuncts to anticoagulation. VTE management has progressed from a one-size-fits-all approach to increasingly personalized strategies incorporating risk stratification, consideration of long-term sequelae, and integration of pharmacologic and interventional modalities. By continuing to refine our understanding of individual patient risk profiles and expanding our therapeutic armamentarium, we can further improve outcomes in this common but potentially devastating condition.

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