Practical insights

In May 2023, at the 9th Zeulenroda Phlebology Forum, experts from all over Germany convened to discuss thrombosis treatment and prevention. They had followed the invitation extended by the Thrombosis Action Group and this year’s Convention President, Dr. med. Christine Zollmann, from Jena. During the forum, selected case studies were presented and reviewed together, including the following:

Treatment of pelvic vein thrombosis

The case: A sports enthusiast born in 1981 came to the hospital suffering from acute pelvic vein thrombosis on the left without a relevant family history. His physician urged him to undergo surgery. This intervention ultimately failed despite several recanalization attempts using stents. The result was persistent pelvic vein obstruction with severe swelling of the leg, cyanotic discoloration and impaired exercise capacity, despite advanced compression therapy. Based on consistent physical activity, using a stationary bike, the patient achieved continuous improvement over the following months. However, pronounced collateral circulation networks are visible on the abdominal wall and leg, which are bothering the patient. The patient is receiving a DOAC for anticoagulation, currently in prophylactic doses, and undergoing compression therapy – both will probably continue indefinitely. It probably won’t be possible to perform another procedure on the pelvic veins for the rest of the patient’s life.

Recommendation: Despite the intervention failing in this case, Prof. Dr. Viola Hach-Wunderle, vascular expert with her own practice in Frankfurt am Main, would not necessarily advise against surgery, but preferably reserve it for patients with chronic post-thrombotic pelvic vein occlusion and venous claudication. Anticoagulation therapy, in combination with compression and mobilization, is still the standard treatment for acute pelvic vein thrombosis. For the future, she thinks that well-designed, randomized studies are needed to prove that surgical intervention is superior to conservative options when treating acute pelvic vein thrombosis.

Treatment of obese patients

The case: An obese patient in his mid-40s suffered from a long-stretch (20 cm), superficial thrombosis (thrombophlebitis) in the great saphenous vein at the level of the knee joint. The forum discussed anticoagulant treatment in cases of obesity.

Recommendation: In these cases, Prof. Dr. Viola Hach-Wunderle recommends treating the patient with anticoagulants until the superficial thrombosis has healed to prevent immediate recurrence. For high-risk patients, a higher initial dose administered for the first few days to weeks should be considered in addition. The standard treatment according to guidelines is fondaparinux (2.5 mg/day SC for 45 days). In cases of idiopathic thrombosis, an examination performed by a specialist in internal medicine is needed to exclude an underlying condition, such as malignancies, inflammation or possibly thrombophilia, and to assess the risk of recurrence. Her tip for obese patients: if the injection into the upper arm is too complicated because of corpulence, the injection can be given into the thigh for practical reasons, but not into the abdomen in cases of overhanging fat folds.

Dr. Jutta Schimmelpfennig added: In cases of deep vein thrombosis, obese patients (with a BMI greater than 30) or severely obese patients (with a BMI greater than 40) should be treated with a therapeutic, weight-adjusted dose of low-molecular-weight heparin. Doing away with dosage capping does not seems to have resulted in an accumulation or overdosing of LMWH.

Images: Andreas Wetzel