Direct oral anticoagulants for unusual-site venous thromboembolism

Abstract

Direct oral anticoagulants (DOACs) are currently the preferred oral anticoagulant treatment for most of the patients with deep vein thrombosis of the lower extremities and/or pulmonary embolism. DOACs have several advantages over vitamin K antagonists, such as availability of fixed dosages, fewer drug interactions, faster onset of action, shorter half-life, and lower risk of major and intracranial bleeding. Although the evidence on the use of DOACs in patients with unusual-site venous thromboembolism (VTE) is limited to a few, small randomized controlled trials, these drugs are increasingly used in clinical practice, and several observational cohort studies have been published recently. This narrative review will describe the latest evidence for the use of the DOACs in patients with thrombosis in atypical locations (splanchnic, cerebral, upper extremity, ovarian, and renal vein thrombosis) and will provide some practical advice for their use in patients with unusual-site VTE.

Keywords: Budd‐Chiari syndrome; cranial sinus thrombosis; direct‐acting oral anticoagulants; portal vein; upper extremity deep vein thrombosis; venous thromboembolism.

FIGURE 1

Use of the DOACs in specific patients with SVT. *The US Food and Drug Administration (FDA) removed this contraindication for apixaban in 2019, while as of November 2020 the European Medicine Agency (EMA) still considers apixaban not recommended in this population. The red color on the traffic light refers to situations in which DOACs are contraindicated; yellow refers to debated situations; green refers to situations in which DOACs can be considered. CHT, chemotherapy; CrCl, creatinine clearance; DOACs, direct oral anticoagulants; EBL, endoscopic band ligation; EGDS, esophagogastroduodenoscopy; GI, gastrointestinal; MVT, mesenteric vein thrombosis; SVT, splanchnic vein thrombosis

FIGURE 2

Use of the DOACs in specific CVT patients. The red color on the traffic light refers to situations in which DOACs are contraindicated; yellow refers to debated situations; green refers to situations in which DOACs can be considered. CNS, central nervous system; CVT, cerebral vein thrombosis; DOACs, direct oral anticoagulants; ICH, intracranial hemorrhage; LMWH, low‐molecular‐weight heparin; UFH, unfractionated heparin