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cardio.dvt.distal.v1PRODUCTION
cardio.dvt.distal.v1

Distal DVT (isolated calf vein)

cardiologyacuteadult
Hard-required inputs
0 / 6
Care setting:

Encounter flow

10/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Distal (isolated calf) DVT — anticoagulation vs serial US surveillance is the central decision; lower extension/PE risk than proximal DVT but extension occurs in ~15% within 2 weeks

Inputs
1
Actions
0
Advance rule
Set
Advance when

distal location confirmed

Patient inputs (7)

Older patients higher recurrence + extension risk → favors AC over surveillance

Severe symptoms favor AC for symptom relief; mild symptoms allow surveillance

Whole-leg US confirms isolated distal location; serial US for surveillance strategy (Righini JTH 2009 PMID 38546285)

HAS-BLED determines tolerability of AC vs surveillance

Extension risk factors: positive D-dimer, extensive thrombus burden, persistent provoking factor, prior DVT, active cancer, hospitalization (ACCP 2021)

eGFR for DOAC dosing if AC chosen

Persistently elevated D-dimer is risk factor for extension → favors AC (CACTUS PMID 27836513 subgroup analyses)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningmajor_bleed_on_iddvt_AC
    Major bleed on AC for IDDVT (Hgb drop ≥2, transfusion, ICH, retroperitoneal) — particularly concerning given lower benefit threshold for IDDVT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereextension_distal_to_popliteal
    Extension of distal DVT to popliteal vein on serial US (during surveillance pathway or despite AC)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefailed_surveillance_with_extension
    Patient on surveillance pathway returns with worsening symptoms or extension on repeat US
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepersistent_d_dimer_elevation_post_treatment
    D-dimer remains elevated 1 month after completing AC for IDDVT — suggests ongoing thrombotic activity
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateiddvt_in_active_cancer
    IDDVT discovered in patient with active cancer — favors AC over surveillance regardless of symptoms (persistent provoking factor)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Isolated distal DVT — AC vs surveillance decision (ACCP 2021)
axis: distal_dvt_management_phenotype
Selected axis "Isolated distal DVT — AC vs surveillance decision (ACCP 2021)" by default fallback (first axis)
  • apixaban
    first line
    doac_factor_xa_direct
    10 mg BID × 7 d → 5 mg BID • PO • BID × 6-12 weeks
    triggers: iddvt_high_extension_risk, severe_symptoms, persistent_provoking_factor, no_active_bleed
    AMPLIFY (PMID 23808982) for full-dose efficacy; ACCP 2021 supports DOAC for IDDVT requiring AC
    rxcui 1364430
  • rivaroxaban
    first line
    doac_factor_xa_direct
    15 mg BID × 21 d → 20 mg daily • PO • BID then daily × 6-12 weeks
    triggers: iddvt_high_extension_risk, no_active_bleed, egfr_above_30
    EINSTEIN-DVT PMID 21128814 — non-inferior to standard care
    rxcui 1114195
  • enoxaparin
    comorbidity specific
    lmwh
    1 mg/kg SC BID • SC • BID
    triggers: pregnancy, active_cancer_doac_unsafe, severe_renal_impairment
    LMWH preferred in pregnancy and select cancer-VTE per CARAVAGGIO PMID 32223112
    rxcui 67108

outpatient playbook — drug actions (1)

  1. 1. no AC if completed treatment
    n/a • n/a • n/a
    trigger: Completed 6-12 weeks AC for provoked IDDVT
    ACCP 2021 Class 2B — extended AC not routinely indicated for IDDVT

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Isolated calf pain, swelling, tenderness without thigh involvement → suggests distal DVT; Compression US shows non-compressible distal vein (peroneal, posterior tibial, soleal) with patent popliteal/femoral → isolated distal DVT (IDDVT); Whole-leg compression US identifies isolated distal DVT not detected by proximal-only protocol (Bernardi 2008).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Distal DVT (isolated calf vein)** (cardio.dvt.distal.v1).
Scope: Distal (isolated calf) DVT — anticoagulation vs serial US surveillance is the central decision; lower extension/PE risk than proximal DVT but extension occurs in ~15% within 2 weeks

No severity triggers fired against current inputs.

Plan

Regimen axis: **Isolated distal DVT — AC vs surveillance decision (ACCP 2021)**.
1. apixaban 10 mg BID × 7 d → 5 mg BID PO BID × 6-12 weeks (doac_factor_xa_direct, first line) — AMPLIFY (PMID 23808982) for full-dose efficacy; ACCP 2021 supports DOAC for IDDVT requiring AC
2. rivaroxaban 15 mg BID × 21 d → 20 mg daily PO BID then daily × 6-12 weeks (doac_factor_xa_direct, first line) — EINSTEIN-DVT PMID 21128814 — non-inferior to standard care
3. enoxaparin 1 mg/kg SC BID SC BID (lmwh, comorbidity specific) — LMWH preferred in pregnancy and select cancer-VTE per CARAVAGGIO PMID 32223112

Setting playbook (outpatient) — Long-term IDDVT survivors (rarely require chronic AC); surveillance for recurrence; PTS surveillance (low rate vs proximal DVT)
4. no AC if completed treatment n/a n/a n/a — Completed 6-12 weeks AC for provoked IDDVT (ACCP 2021 Class 2B — extended AC not routinely indicated for IDDVT)

Non-pharmacologic actions:
- VTE risk reduction lifestyle (mobility, weight, hormones)
- Patient education on recurrence symptoms

AVOID / contraindication checks:
- Doac_avoid_active_bleeding (FDA labels)
- Apixaban_avoid_egfr_below_15 (FDA label)
- Warfarin_avoid_pregnancy_use_lmwh (ASH 2018)
- Decision:surveillance_only_low_extension_risk (ACCP 2021 Class 2C — CACTUS PMID 27836513 showed no benefit nadroparin in low risk IDDVT)

Monitoring

Regimen monitoring:
- serial compression us d5-7 and d10-14 if surveillance (ACCP 2021)
- cbc q week x first 4 weeks if AC (ASH 2020)
- creatinine at baseline and q3mo if AC (FDA labels)
- symptom review for extension or pe at each visit

Setting (outpatient) monitoring:
- Annual reassessment

Follow-up plan: AC pathway: stop at 6-12 weeks if provoked + transient risk; consider extended only if extension or unprovoked + high recurrence risk. Surveillance pathway: convert to proximal pathway if extension
- Close-out criterion: final disposition documented

Monitoring phase: AC pathway: bleed surveillance, weekly CBC × 4 weeks. Surveillance pathway: repeat US days 5-7 + 10-14 + symptoms

Disposition

Current setting: outpatient — Long-term IDDVT survivors (rarely require chronic AC); surveillance for recurrence; PTS surveillance (low rate vs proximal DVT)

Disposition criteria:
- Long-term annual surveillance

Escalation triggers (move to higher acuity):
- Recurrent VTE → re-evaluate per parent dossier
- New cancer dx → cancer-VTE evaluation

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Major bleed on AC for IDDVT (Hgb drop ≥2, transfusion, ICH, retroperitoneal) — particularly concerning given lower benefit threshold for IDDVT
- [SEVERE] Extension of distal DVT to popliteal vein on serial US (during surveillance pathway or despite AC)
- [SEVERE] Patient on surveillance pathway returns with worsening symptoms or extension on repeat US

Citations

- ACCP/CHEST 2021 Antithrombotic + ASH 2020 VTE Treatment [PMID:34352278](https://pubmed.ncbi.nlm.nih.gov/34352278/)
- Cited evidence (PMID 33007077) [PMID:33007077](https://pubmed.ncbi.nlm.nih.gov/33007077/)
- Cited evidence (PMID 27836513) [PMID:27836513](https://pubmed.ncbi.nlm.nih.gov/27836513/)
- Cited evidence (PMID 38546285) [PMID:38546285](https://pubmed.ncbi.nlm.nih.gov/38546285/)
- Cited evidence (PMID 18840838) [PMID:18840838](https://pubmed.ncbi.nlm.nih.gov/18840838/)

Last reconciled with current guidelines: 2026-05-14.
References