Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
GREATER MANCHESTER GUIDELINE FOR:
THE DIAGNOSIS, INVESTIGATION AND
MANAGEMENT OF ABNORMALLY SWOLLEN
OR PAINFUL LEG(S)
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NHS England
Greater Manchester, Lancashire, South
Cumbria Strategic Clinical Network &
Senate
First published: July 2013
Prepared by:
Gareth Lord - Quality Improvement Manager – SCN
(Gareth.lord@nhs.net)
Derived from:
The ‘Greater Manchester guideline for the investigation and treatment
of suspected deep vein thrombosis consultation paper’ developed by
Mark Holland (MarkEdward.Holland@uhsm.nhs.uk) and the DVT
Steering Group, NICE Guidance (Venous thromboembolism:
Reducing the Risk - CG 92, Venous thromboembolic diseases: the
management of venous thromboembolic diseases and the role of
thrombophilia testing – CG 144, Quality standard for diagnosis and
management of venous thromboembolic diseases – QS 29) and the
National VTE Prevention Programme website
Version:
Date:
Intended Audience:
Variation from 1.2
Version 2
24th April 2014
DVT Steering Group, Heads of Commissioning, Operational
Managers, GP’s, Acute Physicians, Clinicians involved in
investigating, diagnosing or managing DVT, Other Interested
Stakeholders,
Extended pathway to include post hospital DVT guidance; Aligned
more to GP Guide which is also included in the appendix; Added
section on ‘Not DVT’; highlighted treatments that should be
considered as an option for first line; adjusted so easier to read.
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Contents
Introduction .................................................................................................................................3
Terms used in this guidance and note for GP’s ...........................................................................5
Pathway for the diagnosis, investigation and management of abnormally swollen or painful leg(s) ...........6
Patient presentation ....................................................................................................................7
Baseline tests ...........................................................................................................................10
Pursue further tests ...................................................................................................................11
Diagnosing DVT ........................................................................................................................13
Discharge..................................................................................................................................20
Patient information ....................................................................................................................20
Patient with signs and symptoms of both DVT and PE ..............................................................21
Appendix 1: Two-Level DVT Wells Score .................................................................................25
Appendix 2: GP referral form....................................................................................................26
Appendix 3: Algorithm for investigating a suspected DVT ........................................................28
Appendix 4: Discharge pro-forma .............................................................................................29
Appendix 5: Patient Information booklet ...................................................................................33
Appendix 6: Prescribing guideline ............................................................................................44
Appendix 7: Prescribing checklists for clinicians .......................................................................48
Appendix 8: GP guide ..............................................................................................................50
Introduction
Venous thromboembolism (VTE) is a clinically important condition. Left untreated, VTE is
potentially fatal. In clinical practice there are two main forms of VTE disease, deep vein
thrombosis (DVT) of the lower limbs or pelvis and pulmonary embolism (PE). Other forms of
venous thrombosis are less common, and include axillary and subclavian vein thrombosis
affecting the upper limbs, or cavernous and sagittal thrombosis affecting the brain.
Failure to diagnose and treat VTE correctly can result in fatal PE. However, diagnosis of
VTE is not always straight forward, pathways and tests can be inconsistent and there is in
most cases no clear responsible clinician or co-ordinator to manage the patient though the
pathway. As a consequence, quality of care can vary and conditions or underlying cause
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can remain undetermined. Many staff are trained only to reach the diagnosis of DVT and
subsequently discharge symptomatic patients without ever explaining the symptoms.
Commissioners do not have assurance that best practice is being followed by providers to
minimise the risk of a VTE, to diagnose VTE rapidly and treat appropriately. It was therefore,
necessary to evaluate current protocol and guidance and to develop a new guideline and
pathway to manage patients with suspected VTE (more specifically DVT) within Greater
Manchester.
This guideline has been developed by the Greater Manchester DVT Steering Group and
builds on existing NICE guidance to:
 To ensure the patients symptoms are diagnosed as opposed to just confirming or
excluding a DVT
 Provide ownership and consistency using clinical evidence
 Provide a step by step pathway and DVT algorithm
 Provide a better patient experience by seeking and treating the cause of the patient’s
symptoms
Key differences between this guideline and NICE guidance:
This guideline suggests the provider has a ‘Hospital DVT/VTE Service’ run by professionals
trained and experienced in VTE. These professionals will take responsibility of managing
the patient throughout the pathway.
The d-dimer in this guideline is taken with the baseline tests for all patients.
This guideline suggests performing a full leg length venous duplex ultrasound instead of a
proximal leg vein ultrasound.
This guideline uses an algorithm to risk stratify patients based on the changes to the
aforementioned diagnostics.
This guideline suggests an additional set of provocation factors are taken in to account when
considering provocation
To be used in conjunction with NICE guidance on Venous thromboembolism: Reducing the
Risk (NICE clinical guideline 92),
Rivaroxaban for the prevention of venous
thromboembolism after total hip or total knee replacement in adults and Dabigatran etexilate
for the prevention of venous thromboembolism after hip or knee replacement surgery in
adults.
It is important to note that this document acts as a guide for clinicians, investigating,
and diagnosing and managing patients first presenting with an abnormally swollen
and/or painful leg(s). In a small number of cases, it is accepted clinicians may feel it
necessary to deviate from this pathway based on their clinical knowledge, experience
and judgement.
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Terms used in this guidance
D-dimer test D-dimer is a product formed in the body when a blood clot (such as those
found in DVT or PE) is broken down. A laboratory or point-of-care test can be done to
assess the concentration of D-dimer in a person's blood. The threshold for a positive result
varies with the type of D-dimer test used and is determined locally. The result of the D-dimer
test can be used as part of probability assessment when DVT or PE is suspected.
International normalised ratio (INR) A standardised laboratory measure of blood
coagulation used to monitor the adequacy of anticoagulation in patients who are having
treatment with a vitamin K antagonist.
Provoked DVT or PE in a patient with an antecedent (within 3 months) and transient major
clinical risk factor for VTE – for example surgery, trauma, significant immobility (bedbound,
unable to walk unaided or likely to spend a substantial proportion of the day in bed or in a
chair), pregnancy or puerperium – or in a patient who is having hormonal therapy (oral
contraceptive or hormone replacement therapy).
Proximal DVT DVT in the popliteal vein or above. Proximal DVT is sometimes referred to as
'above-knee DVT'.
Renal impairment Reduced renal function that may be acute or chronic. An estimated
glomerular filtration rate of less than 90 ml/min/1.73 m2 indicates a degree of renal
impairment in chronic kidney disease. (For NICE guidance on the classification of chronic
kidney disease see Chronic kidney disease [NICE clinical guideline 73]).
Unprovoked DVT or PE in a patient with: no antecedent major clinical risk factor for VTE
(see 'Provoked deep vein thrombosis or pulmonary embolism' above) who is not having
hormonal therapy (oral contraceptive or hormone replacement therapy) or active cancer,
thrombophilia or a family history of VTE, because these are underlying risks that remain
constant in the patient.
Wells score Clinical prediction rule for estimating the probability of DVT and PE. There are
a number of versions of Wells scores available. This guideline recommends the two-level
DVT Wells score and the two-level PE Wells score.
GP’s
For a complete pathway guide from a GP perspective, refer to appendix 8.
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A&E (a2)
On hospital ward
(a3)
Pursue further tests
Hospital DVT/VTE Service (b)
Provide or pursue an alternative
diagnosis (c2)
Ultrasound (c1)
Diagnosis of DVT
Review post ultrasound scan (d)
Proven DVT (d1)
Discharge
DVT unexplained
(d1.1)
Pursue
Furtherfurther
tests totests
find to
reason
find reason
for DVT
for DVT
(e1)
(e1)
Not DVT (d2)
DVT explained
(d1.2)
Alternative diagnosis
(d2.1)
Return to GP or ward
(e2)
(d2.1)
Referral to continue to
pursue alternative diagnosis
(e3)
Review of treatment
where necessary (f1)
* Patient with abnormally swollen or painful leg(s)* identified as newly abnormal swollen or painful
leg(s) or newly noticeable/significant swelling or pain on already swollen or painful leg(s).
Community DVT service if one exists locally** - refers to a DVT service in a central location in the community that provide baseline tests and aim
to reduce hospital admissions. A1b is additional to this pathway.
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Responsibility of the Health Professional within the Hospital DVT/VTE
Service
Community
DVT service if
one exists
locally** (a1b)
Responsibility of
those referred to
GP (a1)
Responsibility
of the referrer
Patient with abnormally
swollen or painful leg(s)*
Baseline
tests
Patient
Presentation
Pathway for the diagnosis, investigation and management of abnormally
swollen or painful leg(s)
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Breakdown of the pathway
Patient presentation
This section is for the clinicians to whom patients present with signs or symptoms of
deep vein thrombosis (DVT), such as a swollen or painful leg(s). These include:
 GP’s
 A&E clinicians
 Outpatient clinicians
 Hospital ward clinicians
Patient with abnormally
swollen or painful leg(s)*
GP (a1)
Community
DVT service if
one exists
locally
A&E/OP Clinic
(a2)
On hospital ward
(a3)
Hospital DVT/VTE Service (b)
Ultrasound (c1)
GP (a1)
(a1) Patient presents to GP





Check symptoms
Physical examination to exclude other causes
Patients general medical history
Exclusion criteria
Two-level DVT Wells Score (appendix 1)
At this point a decision is made whether or not a patient should commence on a DVT
pathway. The distinction being: any patient with signs or symptoms in a lower limb
suggesting DVT as a potential diagnosis.
If a DVT is suspected but d-dimer cannot be provided locally – refer to community
DVT service (if one available) or hospital DVT service using the referral pro-forma
(appendix 2) as appropriate.
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Where d-dimer can be provided locally – refer to the remainder of the GP (a1) section.
(a1a) Providing d-dimer locally
Review baseline tests to determine if a patient should be sent for an ultrasound or an
alternative diagnosis should be sort:
Where DVT a possibility
High Risk
Wells score >=2
Low Risk
Wells score <2
plus
Where DVT unlikely
Wells Score <2
plus
Positive d-dimer
Negative d-dimer
For patients where DVT a possibility – (c1) refer for ultrasound
Patients where a DVT is a possibility should be sent for an ultrasound scan as soon as
possible. These patients should be offered an interim therapeutic dose of anticoagulation
therapy if diagnostic investigations are expected to take longer than 4 hours from the time of
first clinical suspicion. (NICE QS29:1)
Prescribing Low Molecular Weight Heparin’s (LMWH) - exclusions
There are some patients that may also have relative contraindications and therefore should
not routinely be prescribed LMWH. These patients include:






Already taking an anticoagulant – in such cases it would be unsafe to give further
anticoagulants until a DVT is proven. A proviso to this approach would be in a
patient taking an oral anticoagulant but where the INR is sub therapeutic (usually less
than 2).
Co-morbid diseases which preclude ambulatory management – in such cases a
suspected DVT might be present with one or more other active conditions. It is not
possible to define all possible scenarios and clinical assessment will be important, for
example patients unable to rest and elevate the affected leg at home.
Estimated GFR less than 30ml/min – the dose of LMWH will need to be adjusted,
however it might be safer to treat such patients as in-patients.
Leg Trauma – any history of leg trauma should alert the attending practitioner to the
possibility of a muscle tear. In such cases the administration of LMWH could have
disastrous consequences.
Cannot comply with ambulatory administration LMWH via a District Nurse, daily visit
to the Ambulatory Clinic or unable to self-administer.
Dual anti-platelet therapy of Aspirin AND Clopidogrel.
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
For all of the relative exclusion criteria the attending health professional ANP will
need to weigh-up the risk a DVT against the risk-benefit of LMWH, prior to a
Ultrasound scan.
Patients need to be informed heparins are of animal origin. If they are concerned about
using animal products, the health professional should consider using synthetic alternatives
based on clinical judgement and discussing their suitability, advantages and disadvantages.
People with suspected deep vein thrombosis have all diagnostic investigations
completed within 24 hours of first clinical suspicion (NICE QS29:2).
For patients where DVT unlikely – (c2) seek alternative diagnosis
Patients where the baseline tests reveal a DVT is unlikely should have arrangements made
where an alternative diagnosis is either given or pursued. The only situation which would
negate the need for an ultrasound scan is when there is an obvious alternative diagnosis.
For patients where a DVT unlikely: end this specific pathway
A&E/OP Clinic (a2)/ Hospital ward (a3)
Attending A&E Physician/Consultant/Nurse to:
 Check symptoms
 Physical examination to exclude other causes
 Patients general medical history
 Exclusion criteria
At this point a decision is made whether or not a patient should commence on a DVT
pathway. The distinction being: any patient with signs or symptoms in a lower limb
suggesting DVT as a potential diagnosis.
Patient referred to the Hospital DVT/VTE Service.
 Go to ‘Hospital DVT/VTE Service (b)’
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Baseline tests
Hospital DVT/VTE Service (b)
Provide or pursue an alternative
diagnosis (c2)
Ultrasound (c1)
Hospital DVT/VTE Service (b)
 Receives patients from A&E, GP or hospital ward
This section is for clinicians within the hospital DVT/VTE team only. From the
moment a patient is seen by one of the health professionals within the Hospital
DVT/VTE Service, the health professional is overall responsible for the care of the
patient through the pathway to the point of discharge from the pathway.
If DVT potential diagnosis, complete where not completed;
 Two-level DVT Wells Score
 Baseline blood tests including D-dimer, full blood count, clotting profile and Urea and
Electrolytes (U&E).
Review baseline tests to determine if a patient should be sent for an ultrasound or an
alternative diagnosis should be sort (see below or algorithm in appendix 3).
Where DVT a possibility
High Risk
Wells score >=2
Low Risk
Wells score <2
plus
Where DVT unlikely
Wells Score <2
plus
Positive d-dimer
Negative d-dimer
For patients where DVT a possibility
Patients where a DVT is a possibility should be sent for an ultrasound scan. These patients
should be offered an interim therapeutic dose of anticoagulation therapy if diagnostic
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investigations are expected to take longer than 4 hours from the time of first clinical
suspicion. (NICE QS29:1) Please refer to ‘Prescribing LMWH (exclusions)’ – pages 8 & 9
People with suspected deep vein thrombosis have all diagnostic investigations
completed within 24 hours of first clinical suspicion (NICE QS29:2).
For patients where DVT unlikely
Patients where the baseline tests reveal a DVT is unlikely should have arrangements made
where an alternative diagnosis is either given or pursued. The only situation which would
negate the need for an ultrasound scan is when there is an obvious alternative diagnosis.
Where an alternative diagnosis can be provided the patient should be discharged to the care
of their GP with a discharge summary (appendix 4) and the necessary patient information
unless the diagnosis suggests the patient should be referred to another health professional
specialist first.
Where an alternative diagnosis needs to be pursued, the patient should be referred to
another health professional with a discharge summary and the necessary information and a
letter is copied to the GP.
Pursue further tests
Waiting for Ultrasound more than 4 hours
Prescribing Low Molecular Weight Heparin’s (LMWH) - exclusions
If the ultrasound scan can be provided within 4 hours or baseline tests, there is no need to
prescribe LMWH prior to the ultrasound scan. If the patient is due to wait over 4 hours for an
ultrasound scan from the moment a scan is requested (this is considered the point of clinical
suspicion) LMWH are advised.
However, there are some patients that may also have relative contraindications and
therefore should not routinely be prescribed LMWH. These patients include:




Already taking an anticoagulant – in such cases it would be unsafe to give further
anticoagulants until a DVT is proven. A proviso to this approach would be in a
patient taking an oral anticoagulant but where the INR is sub therapeutic (usually less
than 2).
Co-morbid diseases which preclude ambulatory management – in such cases a
suspected DVT might be present with one or more other active conditions. It is not
possible to define all possible scenarios and clinical assessment will be important, for
example patients unable to rest and elevate the affected leg at home.
Estimated GFR less than 30ml/min – the dose of LMWH will need to be adjusted,
however it might be safer to treat such patients as in-patients.
Leg Trauma – any history of leg trauma should alert the attending practitioner to the
possibility of a muscle tear. In such cases the administration of LMWH could have
disastrous consequences.
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


Cannot comply with ambulatory administration LMWH via a District Nurse, daily visit
to the Ambulatory Clinic or unable to self-administer.
Dual anti-platelet therapy of Aspirin AND Clopidogrel.
For all of the relative exclusion criteria the attending health professional ANP will
need to weigh-up the risk a DVT against the risk-benefit of LMWH, prior to a
Ultrasound scan.
Patients need to be informed heparins are of animal origin. If they are concerned about
using animal products, the health professional should consider using synthetic alternatives
based on clinical judgement and discussing their suitability, advantages and disadvantages.
Ultrasound (c1)
 Perform full leg length scan with a venous duplex ultrasound. This should be
undertaken by a health professional trained in performing this scan.
People with suspected deep vein thrombosis have all diagnostic investigations
completed within 24 hours of first clinical suspicion (NICE QS29:2); ideally 4 hours
from request if possible.
During working hours, the aim should be to obtain a same day ultrasound scan, negating the
need for a dose of LMWH prior to the scan.
Provide or pursue an alternative diagnosis (c2)
If following the review of the baseline tests it is felt that a DVT is not likely, arrangements
should be made to provide or pursue an alternative diagnosis. It is the responsibility of the
Hospital DVT/VTE Service health professional seen by the patient to make arrangements
seeking an alternative diagnosis if one cannot be provided. This can be done by requesting
further tests, or referring /transferring a patient to another specialist service.
 For these patients, the DVT/VTE pathway ends.
Review Post ultrasound scan (d)
The post ultrasound scan should be carried out by a health professional trained in the care
of DVT patients.
Outcomes:
Wells Score
>=2
<2
>=2
>=2
<2
+
+
+
+
+
D-dimer
Positive
Positive
Negative
Negative
Positive
+
+
+
+
+
Ultrasound
Positive
Positive
Positive
Negative
Negative
Outcome
Proven DVT
Proven DVT
Proven DVT
Not DVT
Not DVT
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The aim of the post review is to provide a diagnosis or working diagnosis (if possible)
following the results.
If a proven DVT, the hospital DVT/VTE Service professional should determine why the
patient developed the DVT. If not a DVT, an alternative working diagnosis must be provided
or methods are sort to try and determine a working diagnosis.
Diagnosing a DVT
Review post ultrasound scan (d)
Proven DVT (d1)
DVT unexplained
(d1.1)
DVT explained
(d1.2)
Proven DVT (d1)
All patients with a proven DVT will require:
1. Anticoagulation (where eligible) or other treatment
2. Medical Review
3. Stockings
For patients with a proven DVT, it is important to determine if the DVT is either unexplained
(unprovoked) or explained (provoked) – see explaining the DVT section on pages 17 -18
Furthermore, the clinician needs to determine if the patient has an old thrombus (see below),
or if the DVT is recurrent (refer to page 19).
Old thrombus
 If the patient has an old thrombus responsible for the symptoms, the patient
needs to be referred to a haematologist to discuss their treatment and exit the
pathway even if the old thrombus was known about.
 If the patient has an old thrombus not responsible for the symptoms, and the
cause for the symptoms is still unknown, the patient needs to be referred to a
haematologist and exit the pathway and also needs to be referred to another
specialist for further investigation in order to diagnose the cause.
In both of the above cases, the patient needs to be given as much information as possible,
and provided with a copy of the discharge pro-forma, whilst the patient is referred.
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1. Anticoagulation (where eligible)
It is recommended healthcare professionals discuss the choice of anticoagulant therapies
with patients, taking in to account comorbidities and contraindications with the following
exceptions:



For patients with severe renal impairment or established renal failure (estimated
glomerular filtration rate [eGFR] <30 ml/min/1.73 m2) offer unfractionated heparin
(UFH) with dose adjustments based on the APTT (activated partial thromboplastin
time) or LMWH with dose adjustments based on an anti-Xa assay.
For patients with an increased risk of bleeding consider UFH.
For patients with PE and haemodynamic instability, offer UFH and consider
thrombolytic therapy (see recommendations 1.2.7 and 1.2.8 o pharmacological
systemic thrombolytic therapy in pulmonary embolism).
Anticoagulation therapy should be started as soon as possible (see prescribing guideline –
appendix 6 and refer to anticoagulation checklists in appendix 7 & 8).
For the purpose of this pathway - Rivaroxaban should be considered as an option for
treating DVT first line where felt clinically appropriate and if the patient agrees;
Warfarin should also be considered. The chosen medication should initially be
prescribed by the secondary care team.
It is important to note there are some inclusion and exclusion criteria for commencing oral
anticoagulation as an outpatient.
Inclusion criteria for outpatient oral anticoagulation
 Can safely comply with out-patient oral anticoagulation
 No clinical evidence or suspicion of pulmonary embolism
 Pain controlled
 Baseline INR less than 1.4
Exclusion Criteria for outpatient oral anticoagulation
 Excess alcohol consumption
 Previously unstable on oral anticoagulation
 IV drug abuser – frequently do not comply with follow-up
 Femoral or more proximal DVT with leg swelling (admit for observation at least 24
hours)
 Significantly deranged Liver Function Tests (add LFT to admission bloods)
 Baseline INR 1.4 or above
 Patients taking dual antiplatelet therapy e.g. Aspirin and Clopidogrel
 Thienopyridines e.g. Clopidogrel, Prasugrel, or newer anti-platelets e.g. Tirofiban
 Known bleeding tendency or coagulopathy
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It should also be noted that in the case of Rivaroxaban – secondary care will provide
the initial 21 day therapy at recommended dose and these patients should be
reviewed ideally between day 14 and 21.
Pregnancy
All pregnant patients with a proven DVT must be referred to the haematology clinic, not the
anticoagulation clinic. All pregnant patients should be treated with LMWH. The weight used
for dosing LMWH is the patient’s booking clinic weight. Pregnant women should not
administer LMWH into their abdominal wall, they should use their thigh.
Cancer (Also add in NICE guidance)
People with active cancer and confirmed proximal DVT should be offered anticoagulation
therapy (NICE QS29:7). All patients with a known cancer who are having active cancer
treatment should be treated with LMWH and continue for 6 months. The patient’s oncologist
will be informed if the diagnosis is not made by the oncology service. Arrangements will be
made for the platelet count to be monitored. At 6 months the risks and benefits of
anticoagulation should be assessed.
Treatment where anticoagulation not eligible
Patients with proximal DVT or PE should temporarily be offered inferior vena caval filters if
they cannot have anticoagulation treatment, and the inferior vena caval filter removed when
the patient becomes eligible for anticoagulation treatment.
For patients with recurrent proximal DVT or PE health professionals should consider inferior
vena caval filters despite adequate anticoagulation treatment only after deliberating
alternative treatments such as:


Increasing target INR to 3–4 for long-term high-intensity oral anticoagulant therapy or
Switching treatment to LMWH.
Health professionals should ensure that a strategy for removing the inferior vena caval filter
at the earliest possible opportunity is planned and documented when the filter is placed, and
that the strategy is reviewed regularly.
2. Medical review
Medical input will be needed to:
To review and plan investigations for patients with an unprovoked DVT.
 Review difficult cases where the diagnosis remains in doubt.
 Define the length of anticoagulation.
 Review patients where a DVT has been excluded but where an alternative diagnosis
remains in doubt.
 Plan thrombophilia screens where appropriate (see thrombophilia testing section
page 14).
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3. Stockings
All patients with a proven DVT must wear support stockings for a minimum of 2 years. All
below knee DVTs should have Class 2 below knee elastic stockings for 2 years. Above
knee DVTs with thigh swelling should have Class 2 full leg elastic stockings for 2 months in
the first instance, followed by Class 2 below knee elastic stockings. People with proximal
deep vein thrombosis are offered below-knee graduated compression stockings
within 3 weeks of diagnosis (NICE QS29:4). Secondary care should provide the initial
class 2 stocking with GP’s providing subsequent stockings.
Offer below-knee graduated compression stockings with an ankle pressure greater than 23
mmHg to patients with proximal DVT a week after diagnosis or when swelling is reduced
sufficiently and if there are no contraindications[3], and:
 Advise patients to continue wearing the stockings for at least 2 years
 Ensure that the stockings are replaced two or three times per year or according to
the manufacturers' instructions.
 Advise patients that the stockings need to be worn only on the affected leg or legs.
(NICE CG 144)
Thrombolysis
For patients with an extensive ileo-femoral DVT there is a risk of vascular compromise to the
leg. Such cases should be discussed a matter of urgency with a vascular surgeon.
Patients without cancer who receive anticoagulation therapy should have a review within 3
months of diagnosis of confirmed DVT to discuss the risks and benefits of continuing
anticoagulation therapy (NICE QS29:8).
Patients with cancer who receive anticoagulation therapy should have a review within 6
months of diagnosis of confirmed DVT to discuss the risks and benefits of continuing
anticoagulation therapy (NICE QS29:9).
Consider catheter-directed thrombolytic therapy for patients with symptomatic iliofemoral
DVT who have:
 symptoms of less than 14 days' duration and
 good functional status and
 a life expectancy of 1 year or more and
 a low risk of bleeding. (NICE CG144)
Thrombophilia testing
 Do not offer thrombophilia testing to patients who are continuing anticoagulation
treatment.
 Consider testing for antiphospholipid antibodies in patients who have had
unprovoked DVT or PE if it is planned to stop anticoagulation treatment.
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


Consider testing for hereditary thrombophilia in patients who have had unprovoked
DVT or PE and who have a first-degree relative who has had DVT or PE if it is
planned to stop anticoagulation treatment.
Do not offer thrombophilia testing to patients who have had provoked DVT or PE.
(NICE QS29:6)
Do not routinely offer thrombophilia testing to first-degree relatives of people with a
history of DVT or PE and thrombophilia.
Explaining the DVT
It is the responsibility of the Hospital DVT/VTE Service to try to determine the possible cause
of the patients DVT and to conclude if the DVT was provoked or unprovoked. The NICE
guidance definition of a provoked DVT or PE is a patient with an antecedent (within 3
months) and transient major clinical risk factor for VTE – for example surgery, trauma,
significant immobility (bedbound, unable to walk unaided or likely to spend a substantial
proportion of the day in bed or in a chair), pregnancy or puerperium – or in a patient who is
having hormonal therapy (oral contraceptive or hormone replacement therapy). Unprovoked
is defined as DVT in a person with no antecedent major clinical risk for VTE who is not
having hormonal therapy (oral contraceptive or hormone replacement therapy). It is
important to identify whether there are any reversible risk factors. The length of time that a
patient needs to take anticoagulation will depend whether such risk factors can be removed
regardless of whether they are in the time period that is defined as a provoked DVT or PE of
three months as defined by NICE. For example there is a fivefold risk of DVT even after five
years
on
an
oral
contraceptive
pill
(see
table
6
of
http://www.bmj.com/highwire/filestream/384759/field_highwire_article_pdf/0/bmj.b2921).
When such a risk factor is present, the patient needs only be on anticoagulation for a limited
time after the risk factor has been removed.
People with active cancer or a family history of VTE should also be considered as having an
unprovoked episode because these underlying risks will remain unchanged in the person.
However, people with active cancer are not included in this statement.
The following could be considered as provocation factors:









Oral contraceptive pill
Hormone replacement therapy
Recent travel on aero plane greater than 4 hours
Recent prolonged travel by coach or car
Previous PE
Known Thrombophilia
SLE or other connective tissue disease
Myeloproliferative disorder
Prothrombotic drugs
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Proven DVT (d1)
DVT unexplained
(d1.1)
Pursue further tests to
find reason for DVT
(e1)
DVT explained
(d1.2)
Return to GP or ward
(e2)
DVT unexplained (d1.1)
An unprovoked DVT is patient with unprovoked DVT who are not already known to
have cancer should be offered timely investigations for cancer (NICE QS29:5).
Investigations for cancer
In this context, investigations for cancer refer to investigations in people with unprovoked
DVT who are not already known to have cancer to determine if the VTE could be related to a
previously undetected cancer. In the context of this pathway, the specific investigations are:
 A physical examination (guided by the patients full history)
 Blood tests (full blood count, serum calcium and liver function tests)
 Urinalysis
NICE also suggest the health professional consider further investigations with an abdominopelvic CT scan (and a mammogram for women) in all patients aged over 40 years with a first
unprovoked DVT or PE who do not have signs or symptoms of cancer based on the initial
investigation (see above paragraph). (NICE CG144).
A highly suspected cancer should be urgently referred and seen by a specialist or in a
diagnostic clinic within 2 weeks from the date of decision to refer. Investigations should be
carried out within 2 weeks of being ordered.
 Once the patient has been referred for further testing, the patient ends this
pathway. The patient should receive any relevant information1 and a copy of the
discharge pro-forma – please refer to discharge section.
1
See appendix 5
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DVT explained (d1.2)
Patients with provoked DVT should NOT be offered testing for thrombophilia (NICE QS29:6).
Patients with a DVT that can be explained should receive all the necessary background and
information about their condition (see appendix 5), a treatment plan and anticoagulation
review where appropriate. The patients GP should also be informed using the discharge
pro-forma found in appendix 4 to help continue to manage the patient in primary care. The
patient can then be discharged from the pathway.
 Once the patient has had their DVT explained, received a treatment plan and all the
necessary information, the patient is discharged from this pathway – please refer
to discharge section.
Recurrent DVT
Treatment of recurrent DVT’s are based on clinical judgement and should take in to account
provocation, the choice of anticoagulant therapies with patients, and comorbidities and
contraindications.
Not DVT (d2)
Alternative diagnosis
(d2.1)
(d2.1)
GP or return to ward
(e2)
Referral to continue to
pursue alternative diagnosis
(e3)
Alternative diagnosis (d2.1)
The diagnostics may reveal another reason for the symptoms where no DVT is present.
NICE guidance stated the following proportion of cases for differential diagnosis for
suspected DVT:
Muscle Strain, Tear, Twisting Injury
Leg Swelling in a Paralysed Limb
Lymphangitis or Lymph Obstruction
Venous Insufficiency
40%
9%
7%
7%
Popliteal (Baker’s) Cyst
Cellulitis
Knee Abnormality
Unknown
5%
3%
25%
26%
If an alternative diagnosis can be provided to the patient, all the necessary information about
the condition and management of the condition must be provided to the patient.
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If an alternative diagnosis was not clearly identified, a likely cause for the symptoms must be
provided or the clinician must seek the cause through further tests.
Clinicians should not leave the patient with no diagnosis and no explanation for the
patient’s symptoms.
 Patients with no DVT present and referred to pursue alternative diagnosis end this
pathway.
 For patients with an alternative diagnosis and referred back to the GP, please refer
to discharge section and then ‘Return to GP (e2)’.
Discharge
When discharging the patient from the pathway at any point, the patient needs to have
been given all the necessary information about what is known about their condition,
who they are being referred to, their treatment plan and what the next steps are and
what to do if their symptoms change.
For those patients receiving anticoagulation therapy for DVT, review may vary
dependent on diagnosis but most patients should aim to have a review by at least 3
months (see Review Appointments).
Where the initial review of anticoagulation therapy is carried out should be agreed
locally. This could be in either anticoagulation clinics, community teams or by the
GP. GP’s and the patient should be notified who will carry this out.
Patient information (NICE Guidance CG144)
Give patients having anticoagulation treatment verbal and written information about:









How to use anticoagulants
Duration of anticoagulation treatment
Possible side effects of anticoagulant treatment and what to do if these occur
The effects of other medications, foods and alcohol on oral anticoagulation treatment
Monitoring their anticoagulant treatment
How anticoagulants may affect their dental treatment
Taking anticoagulants if they are planning pregnancy or become pregnant
How anticoagulants may affect activities such as sports and travel
When and how to seek medical help.
Provide patients who are having anticoagulation treatment with an 'anticoagulant information
booklet' and an 'anticoagulant alert card' and advise them to carry the 'anticoagulant alert
card' at all times. This includes an alert card for Rivaroxaban. Clinicians should ensure a
supply is available.
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Be aware that heparins are of animal origin and this may be of concern to some patients
(see Religion or belief: a practical guide for the NHS). For patients who have concerns about
using animal products, consider offering synthetic alternatives based on clinical judgment
after discussing their suitability, advantages and disadvantages with the patient. [This
recommendation is from ‘Venous thromboembolism: reducing the risk’ (NICE clinical
guideline 92]).
Advise patients about the correct application and use of below-knee graduated compression
stockings, how long they should be worn and when they should be replaced.
Presenting with signs and symptoms of both DVT and PE
If a patient presents with signs or symptoms of both DVT (for example a swollen and/or
painful leg) and PE (for example chest pain, shortness of breath or hemoptysis), carry out
initial diagnostic investigations for either DVT or PE, basing the choice of diagnostic
investigations on clinical judgment.
For the management of PE refer to NICE clinical guideline 144 ‘Venous thromboembolic
diseases: the management of venous thromboembolic diseases and the role of
thrombophilia testing’.
Review Appointments
For patients with a proven DVT a review is recommended within 3 months to look at;





Anticoagulation
Suspected Malignancy (though should suspicion occur at diagnosis referral for further
testing should happen immediately)
Provocation
Therapeutic Range and
Any adverse events
Review appointments could be carried out either at outpatient clinics or by GP’s. The
local service should determine this.
Patients with lower limb arterial ischemia
Patients with lower limb arterial ischemia should be referred to the nearest vascular clinic to
be seen by a vascular specialist.
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DVT unexplained
(d1.1)
DVT explained
(d1.2)
Pursue further tests to
find reason for DVT
(e1)
Alternative diagnosis
(d2.1)
Return to GP or ward
(e2)
Referral to continue to
(d2.1)
pursue alternative
diagnosis (e3)
Return to GP or ward (e2)
Ward clinicians
Patients returning to an inpatient ward should have a DVT discharge pro-forma
(appendix 4) that outlines diagnosis, medication/treatment, if any further
investigations are required and any additional information.
If the patient has a DVT and receiving medication, it is necessary for the ward
clinician overseeing the patients care establish who will review the
treatment/medication which could be determined by the length of time the
patient may remain in hospital; and when this should be. And to ensure the
clinician reviewing the patient has all the necessary information about the
patient’s condition.
GP’s
Patients discharged from Hospital DVT Team
GP’s should be sent a copy of the patients discharge pro-forma once seen and discharged
by the Hospital DVT Team. The patient should also have a copy.
Patients will then fall in to one of three categories:
No DVT
 No DVT – seek alternative (e3)
DVT


DVT explained
DVT unexplained
No DVT
No DVT – seek alternative diagnosis (e3)
Patients found not to have a DVT may have already been provided with an alternative
diagnosis and treatment plan. Where this is not the case, the GP should seek the reason for
the abnormally painful or swollen leg(s).
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
The pathway ends for patients with no DVT present
DVT
DVT explained
This group of patients will have had an explanation as to what most likely caused their DVT
by the Hospital DVT team. They will now require a review of their treatment.
DVT unexplained
Patients found to have a DVT but the reasons were unexplained. The Hospital DVT team
may have already referred the patient for further tests. If this has not happened, the GP may
wish to pursue further tests to find the reason for DVT. Patients will require review of their
treatment.
Pursue further tests to
find reason for DVT
(e1)
Return to GP or ward
(e2)
Referral to continue to
pursue alternative
diagnosis (e3)
Review of treatment
where necessary (f1)
Review of treatment where necessary (f1)
Patients who have a DVT investigated by the Hospital DVT Team should have received their
initial treatment and plan on discharge. This will include:






Anticoagulation therapy (either Rivaroxaban or Warfarin)
Class 2 stockings
Discharge pro-forma
Referrals where necessary to other specialists
Information about their condition
Advice and Information about their treatment (including alert cards)
Anticoagulation
Where the initial review of anticoagulation therapy is carried out should be agreed locally.
This could be in either anticoagulation clinics, community teams or by the GP. GP’s and the
patient should be notified who will carry this out. Rivaroxaban should be considered as
an option for treating DVT first line where felt clinically appropriate and if the patient
agrees; Warfarin should also be considered. Both should initially be prescribed by
the secondary care team. In the case of Rivaroxaban – secondary care will provide
the initial 21 day therapy at recommended dose.
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GP Responsibilities for patients continuing on anticoagulation









Monitoring the patient’s overall health and well-being and observing patient for
evidence of ADRs/abnormalities and raising with secondary care clinician if
necessary.
Clinical surveillance in line with anticoagulation practice throughout the treatment
period
Assessment of renal function at least once a year, or more frequently as clinical
circumstances dictate when it is suspected that renal function could decline or
deteriorate.
Annual review as appropriate to include:
History of any venous thromboembolic event in last year
Reassessment of bleeding risk
Prescription of drug after initiation by secondary care
Ensuring advice is sought from the secondary care clinician if there is any significant
change in the patient’s physical health status
Reducing/stopping treatment in line with secondary care clinician’s original request
Check patient continues to carry alert card after provision from hospital and supply
replacement where necessary.
Provide any information or advice where not previously provided
Please refer to prescribing guidelines on page 11
Class 2 Stockings
All patients with a proven DVT must wear support stockings for a minimum of 2 years. All
below knee DVTs should have Class 2 below knee elastic stockings for 2 years. Above
knee DVTs with thigh swelling should have Class 2 full leg elastic stockings for 2 months in
the first instance, followed by Class 2 below knee elastic stockings. People with proximal
deep vein thrombosis are offered below-knee graduated compression stockings
within 3 weeks of diagnosis (NICE QS29:4).
Offer below-knee graduated compression stockings with an ankle pressure greater than 23
mmHg to patients with proximal DVT a week after diagnosis or when swelling is reduced
sufficiently and if there are no contraindications[3], and:
 Advise patients to continue wearing the stockings for at least 2 years
 Ensure that the stockings are replaced two or three times per year or according to
the manufacturers' instructions.
 Advise patients that the stockings need to be worn only on the affected leg or legs.
(NICE CG 144) Secondary care should provide the initial class 2 stocking with
GP’s providing subsequent stockings.
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Appendix 1: Two-level DVT Wells Score
Clinical feature Points
Active cancer (treatment on-going, within 6 months, or palliative)
1
Paralysis, paresis or recent plaster immobilisation of the lower extremities
1
Recently bedridden for 3 days or more or major surgery within 12 weeks
requiring general or regional anaesthesia
Localised tenderness along the distribution of the deep venous system
1
Entire leg swollen
1
Calf swelling at least 3 cm larger than asymptomatic side
1
Pitting oedema confined to the symptomatic leg
1
Collateral superficial veins (non-varicose)
1
Previously documented DVT
1
An alternative diagnosis is at least as likely as DVT
-2
1
Clinical probability simplified score
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Appendix 2
Referral for the diagnosis, investigation and management of abnormally swollen or
painful leg(s)
Patient Details
NHS No:
Male / Female (Please Circle)
First Name:
Surname:
Title:
DOB:
Address:
Contact Number:
Referral Date:
GP Referrer
GP Name:
GP Surgery:
GP Contact Tel. No.:
Other Referrer (if not GP)
Name:
Organisation:
Contact Tel. No.:
Clinical Details
Clinical description:
Date of onset of Symptoms:
Other Symptoms as relevant:
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Two-level DVT Wells Score
Score
Please circle
where appropriate
Active Cancer (treatment ongoing, within 6 months, or palliative care)
Paralysis, paresis, or recent plaster immobilisation of the lower extremities
Recently bedridden ≥3 days or major surgery within 12 weeks requiring general or
regional anaesthesia
Localised tenderness along the distribution of the deep venous system
Entire leg swollen
Calf swelling 3 cm large than asymptomatic side
Pitting oedema confined to the symptomatic leg
Collateral superficial veins (non-varicose)
Previously documented DVT
Alternative diagnosis at least as likely as DVT
1
1
1
1
1
1
1
1
1
−2
Total score
D-Dimer
Has a D-dimer been carried out?
If Yes, What was the result?
Yes
Positive
No
Negative
Past Medical History:
Current Medication:
Drug Allergies:
Name of referrer:
Referrer Signature:
Please Fax Referral to Hospital DVT/VTE Service
AND telephone to confirm receipt of referral:
Hospital DVT/VTE Service
<Address of local service>
Fax No.: 0161 <fax>
Telephone No.: 0161 <phone>
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Appendix 3: ALGORITHM FOR INVESTIGATING A SUSPECTED DVT IN A SWOLLEN
AND/OR PAINFUL LEG
Patient with Swollen or Painful Leg
NO
DVT Considered as a Potential
Diagnosis
Alternative and
Appropriate Care
INITIAL CLINICAL ASSESSMENT
Well’s score >=2
Wells score <2
D-dimer +ve
D-dimer -ve
D-dimer -ve
Low Risk
High Risk
Interim Dose of
Anticoagulant if Wait
for Ultrasound Scan
Greater than 4 Hours
US
D-dimer +ve
Interim Dose of
Anticoagulant if Wait
for Ultrasound Scan
Greater than 4 Hours
US -ve
US -ve
+ve
Interim Dose of
Anticoagulant if Wait
for Ultrasound Scan
Greater than 4 Hours
US
+ve
NOT DVT
US -ve
Alternative and Appropriate Care
PROVEN DVT
Ap
Treat With Anticoagualnts
Assess for Cause of DVT
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Appendix 4:
DISCHARGE PROFORMA / LETTER
Diagnosis, investigation and management of abnormally swollen or painful leg(s)
Discharged by
Discharging clinician:
Title (Dr/ANP):
Name:
Hospital DVT Service
From:
<address>
Telephone:
Fax:
Email:
Discharge date:
Date of dictation:
Clinic date:
Discharged/Referred to
GP
Other Specialist within same organisation
Other provider team\specialist outside organisation
Name:
Address:
Post Code:
Patient details
Full Name:
NHS Number:
Date of birth:
Address:
Post Code:
Discharge destination:
Hospital Number:
Usual place of residence
Hospital ward/unit
Other hospital
Other
Other/Other hospital please state:
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GP details
GP Name:
Address:
Postcode:
Diagnosis, treatment and management
Presenting complaint:
Co-morbidities or
conditions:
Examinations carried
out (results to be sent to
GP):
Physical examination
Two level Wells score
Baseline blood tests
(including D-dimer, U&E,
full blood count and clotting profile)
Proximal leg ultrasound
CT Scan
Thrombophilia testing
Medical history
Other risk factors
Full leg length ultrasound
Calf vein ultrasound
Venogram
Other(s)
If ‘Other(s)’, please state:
Results:
Diagnosis:
DVT
Proven DVT
If DVT;
Above knee
Provoked
Recurrent
Not DVT
Below knee
Unprovoked
Old Clot
Reason Provoked:
Reason Unprovoked:
Was DVT the reason for symptoms? Yes
No
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Please note: If the patient has not been previously considered at high risk of cardio-vascular
disease, this diagnosis of a DVT should lead to a re-assessment.
Not DVT
Working diagnosis:
Definitive diagnosis:
Stockings provided?
Target INR:
Yes
No
Medication and
treatment plan
(including planned
duration):
Follow up or further
investigations required?
GP Action (as required)
/ additional
information:
Patient information sheet: (Please make sure this sheet contains info as to when to seek further
help and from whom) (Please Tick (√) to confirm this has been given)
Signed:
Referrals/copies sent:
(Please tick box to confirm copies of this discharge OR referrals have been sent to the following:
The patient (as detailed above)
Anticoagulation therapy service referral
Additional Information on page 4?
Other Additional Information to be completed on next page (page 4).
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Additional information
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Appendix 5: Patient Information
Deep Vein Thrombosis
What is a deep vein thrombosis?
A DVT is a blood clot that forms in a deep leg vein. Veins are blood vessels that take blood
towards the heart.
Deep leg veins are the larger veins that go through the muscles of the calf and thighs. (They
are not the veins that you can see just below the skin.) When you have a DVT the blood flow
in the vein is partially or completely blocked, depending on whether the blood clot partially or
completely fills the width of the vein.
A calf vein is the common site for a DVT. A thigh vein is less commonly affected. Rarely,
other deep veins in the body form blood clots.
Why do blood clots form in leg veins?
Blood normally flows quickly through veins, and does not usually clot. Blood flow in leg veins
is helped along by leg movements, because muscle action squeezes the veins. Sometimes
a DVT occurs for no apparent reason. However, the following increase your risk of having a
DVT:


Immobility which causes blood flow in the veins to be slow. Slow-flowing blood is
more likely to clot than normal-flowing blood.
o A surgical operation that lasts more than 30 minutes is the most common
cause of a DVT. The legs become still when you are under anaesthetic. Blood
flow in the leg veins can become very slow.
o Any illness or injury that causes immobility increases the risk.
o Long journeys by plane, train, etc may cause a slightly increased risk.
Damage to the inside lining of the vein increases the risk of a blood clot forming.
For example, a DVT may damage the lining of the vein. So, if you have a DVT, then
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







you have an increased risk of having another one in the future. Some conditions such
as vasculitis (inflammation of the vein wall) and some drugs (for example, some
chemotherapy drugs) can damage the vein and increase the risk of having a DVT.
Conditions that cause the blood to clot more easily than normal (thrombophilia)
can increase the risk. Some conditions can cause the blood to clot more easily than
usual. For example, nephrotic syndrome and antiphospholipid syndrome. Some rare
inherited conditions can also cause the blood to clot more easily than normal. For
example, factor V Leiden.
The contraceptive pill and hormone replacement therapy (HRT) that contain
oestrogen can cause the blood to clot slightly more easily. Women taking 'the pill' or
'HRT' have a small increased risk of DVT.
People with cancer or heart failure have an increased risk.
Older people are more likely to have a DVT, particularly if you have poor mobility or
have a serious illness such as cancer.
Pregnancy increases the risk. About 1 in 1,000 pregnant women have a DVT while
they are pregnant, or within about six months after they give birth.
Obesity also increases the risk.
Being male. Men tend to develop a DVT more often than women.
Intravenous drug abusers also have an increased risk, particularly if they inject
drugs into the veins in their leg or groin areas.
How common is a deep vein thrombosis?
It is estimated that about 1 in 1000 people have a DVT each year in the UK.
Is a deep vein thrombosis serious?
It can be. When a blood clot forms in a leg vein it usually remains stuck to the vein wall. The
symptoms tend to settle gradually. However, there are two main possible complications:


Pulmonary embolus (a blood clot that travels to the lung).
Post thrombotic syndrome (persistent calf symptoms).
Pulmonary embolus
In a small number of people who have a DVT, a part of the blood clot breaks off. This travels
in the bloodstream and is called an embolus. An embolus will travel in the bloodstream until
it becomes stuck. An embolus that comes from a clot in a leg vein will be carried up the
larger leg and body veins to the heart, through the large heart chambers, but will get stuck in
a blood vessel going to a lung. This is called a pulmonary embolus. DVT and pulmonary
embolisms
are
known
collectively
as
venous
thromboembolisms.
A small pulmonary embolus may not cause any symptoms. A medium sized pulmonary
embolus can cause breathing problems and chest pain. A large pulmonary embolus can
cause collapse and sudden death. It is estimated that about 1 in 10 people with an untreated
DVT develop a pulmonary embolus large enough to cause symptoms or death.
Post-thrombotic syndrome
Without treatment, up to 6 in 10 people who have a DVT develop long-term symptoms in the
calf. This is called 'post-thrombotic syndrome'. Symptoms occur because the increased flow
and pressure of the diverted blood into other veins can affect the tissues of the calf.
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Symptoms can range from mild to severe and include: calf pain, discomfort, swelling, and
rashes. An ulcer on the skin of the calf may develop in severe cases.
Post-thrombotic syndrome is more likely to occur if the DVT occurs in a thigh vein, or
extends up into a thigh vein from a calf vein. It is also more common in people who are
overweight, and in those who have had more than one DVT in the same leg.
What are the aims of treatment for a deep vein thrombosis?
The aims of treatment are:



To prevent the clot spreading up the vein and getting larger. This may prevent a large
embolus breaking off and travelling to the lungs (a pulmonary embolus).
To reduce the risk of post-thrombotic syndrome developing.
To reduce the risk of a further DVT in the future.
What are the treatments for a deep vein thrombosis?
Anticoagulation - preventing the clot from getting larger
Anticoagulation is often called 'thinning the blood'. However, it does not actually thin the
blood. It alters certain chemicals in the blood to stop clots forming so easily. This prevents a
DVT from getting larger, and prevents any new clots from forming. Rivaroxaban should be
considered where appropriate as a first line treatment for DVT; Warfarin is also a treatment.
However, it takes a few days for Warfarin tablets to work fully. Therefore, heparin injections
are used alongside Warfarin in the first few days for immediate effect. A serious embolus is
rare if you start anticoagulation treatment early after a DVT.
The aim is to get the dose just right so the blood will not clot easily, but not too much, which
may cause bleeding problems. You will need regular blood tests whilst you take Warfarin.
You need them quite often at first, but then less frequently once the correct dose is found. (If
you are pregnant, regular heparin injections rather than Warfarin tablets may be used.)
The length of time you will be advised to take anticoagulation depends on various factors.
For example, if you have a DVT during pregnancy or after an operation, then after the birth,
or when you are fit again, the increased risk is much reduced. So, anticoagulation may be
only for a few months. On the other hand, some people continue to have an increased risk of
having a DVT. In this case the anticoagulation may be long-term.
Note: you should not travel on any long journeys or travel by plane until at least two weeks
after starting anticoagulant treatment. Travel within two weeks of a DVT is not recommended
without seeking advice from a specialist.
Compression stockings
Most people who develop a DVT are advised to wear compression stockings. This treatment
has been shown to reduce the risk of a recurrent DVT, and can also reduce the risk of
developing post-thrombotic syndrome. You should wear the stocking each day, for at least
two years. If you do develop post-thrombotic syndrome, you may be advised to wear the
stockings for more than two years.
Note: a compression stocking used following a DVT should be fitted professionally after an
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assessment and accurate measurement. Do not just buy 'over the counter' support stockings
that may be the wrong class or size and which may potentially cause more damage. Your
stockings will also need changing every 3-6 months.
If you are advised to wear a compression stocking, you should put it on each day whilst lying
in bed before getting up. Wear it all day until you go to bed, or until you rest in the evening
with the leg raised. Take the stocking off before going to bed. The slight pressure from the
stocking helps to prevent fluid seeping into the calf tissues from the outer veins which carry
the extra diverted blood following a DVT. The stocking also reduces, and may prevent, calf
swelling. This in turn reduces discomfort and the risk of skin ulcers forming.
Walking regularly but raising your leg whilst resting



Unless your doctor advises against this, you should walk regularly. Walking is
thought to improve circulation in the affected leg and may help to reduce your risk of
further DVT.
When you are resting, as much as possible - raise your leg. This reduces the
pressure in the calf veins, and helps to prevent blood and fluid from 'pooling' in the
calves. 'Raised' means that your foot is higher than your hip so gravity helps with
blood flow returning from the calf. The easiest way to raise your leg is to recline on a
sofa with your leg up on a cushion.
Raise the foot of the bed a few inches if it is comfortable to sleep like this. This is so
your foot and calf are slightly higher than your hip when you are asleep.
Ways to reduce the risk of recurrent DVT after treatment has stopped.
Things that may help to prevent a recurrent DVT include the following:
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If possible, avoid long periods of immobility, such as sitting in a chair for many hours.
If you are able to, get up and walk around now and then. A daily brisk walk for 30-60
minutes is even better if you can do this. The aim is to stop the blood 'pooling', and to
get the circulation in the legs moving. Regular exercise of the calf muscles also
helps. You can do some calf exercises even when you are sitting.
Major operations are a risk for a DVT - particularly operations to the hip, lower
abdomen, and leg. You may be given an anticoagulant such as a heparin injection
just before an operation to help prevent a DVT. An inflatable sleeve connected to a
pump to compress the legs during a long operation may also be used. You may also
be given compression stockings to wear whilst you are in hospital. It is also common
practice to get you up and walking as soon as possible after an operation.
When you travel on long plane journeys, train journeys etc. you should have little
walks up and down the aisle every now and then. Also, exercise your calf muscles
every now and then whilst sitting in your seat. If you have had a previous DVT, you
should see your doctor for advice before you travel on a long journey or fly.
People who are overweight have an increased risk of DVT. Therefore, to reduce your
risk, you should try to lose weight.
In summary
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The main cause of DVT is immobility - especially during surgery.
The most serious complication of DVT is a pulmonary embolus where part of the
blood clot breaks off and travels to the lung.
Persistent calf symptoms may occur after a DVT.
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With treatment, the risk of the above two complications is much reduced.
Treatment includes anticoagulation, compression stockings, leg elevation, and
keeping active.
Prevention is important if you have an increased risk of DVT. For example, during
long operations or when you travel on long journeys.
References
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Deep vein thrombosis, Clinical Knowledge Summaries (April 2009)
Keeling DM, Mackie IJ, Moody A, et al; The diagnosis of deep vein thrombosis in
symptomatic outpatients and the potential for clinical assessment and D-dimer
assays to reduce the need for diagnostic imaging. Br J Haematol. 2004
Jan;124(1):15-25.
Venous thromboembolism: reducing the risk of venous thromboembolism
(deep vein thrombosis and pulmonary embolism) in inpatients undergoing
surgery, NICE Clinical Guideline (2007)
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Advice to patients about
POST-THROMBOTIC SYNDROME
What is Post-Thrombotic Syndrome?
Post-thrombotic syndrome (PTS) is the name used to describe the
long-term effects that can occur after you have had a venous
thrombosis of the deep veins of the leg (DVT). Generally, 1 out of 3
people who have had thrombosis in the legs will develop some
post-thrombotic symptoms within 5 years. Most symptoms of postthrombotic syndrome will occur within 2 years of the thrombosis.
People who have thrombosis more than once (recurrent
thrombosis) are at higher risk of developing post-thrombotic
syndrome. Thrombosis can go unnoticed, so it is sometimes
possible to have post-thrombotic syndrome without being
diagnosed with thrombosis first.
What is the problem?
When you have a DVT it interferes with the blood flow returning
from the leg back to the heart. This is why many people with a DVT
complain of pain and swelling of the lower leg at the time. The
blockage in the deep veins often disappears with anticoagulation
treatment and time but sometimes it remains. The DVT can also
damage the valves in the veins which normally stop blood flowing
backwards down the leg. Blocked veins and/or damaged valves
means that it is more difficult for blood to be pumped out of your
leg efficiently when you walk. The accumulation of blood at a
higher pressure than normal causes the symptoms of PTS.
How do I know if I have Post-Thrombotic Syndrome?
PTS can result in heaviness and swelling of the leg. This heaviness and swelling is usually
worse after prolonged sitting or standing and is helped by walking. However, sometimes the
symptoms are made worse by exercise if the obstruction to blood flow out of the leg is very
severe. PTS can also cause redness and pain of the skin around the ankle (inflammation)
and swelling due to leakage of fluid (oedema). If untreated, this skin damage can result in
ulceration.
How does PTS differ from a DVT?
Anyone who has had a DVT has an increased risk of another one. However, the degree of
this risk depends upon the cause of the original DVT and usually diminishes with time. It is
important to report any sudden changes in the affected leg so your doctor can exclude a new
DVT. This may be difficult to distinguish from PTS and an ultrasound of the leg is usually
necessary. This is a painless test that looks at the veins and the blood flow in your leg using
high frequency sound waves.
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What can I do about it?
Although PTS cannot be cured it is usually possible to control the
symptoms and reduce the risk of ulceration.
Compression Stockings
To help minimise development of PTS, it is best, unless contra
indicated, to wear a compression stocking as soon as a DVT is
diagnosed. It is only normally needed on the affected leg. These
stockings should be prescribed by your General Practitioner and
measured accurately by the Pharmacists so they fit correctly. You
should put on the stocking before you get out of bed and only remove
it before going to bed. Below knee stockings are usually sufficient
except when the venous damage is very extensive. Compression
stockings are available in 3 strengths: Class 1, 2 and 3.Your GP will
decide what strength you need but Class 2 is usually sufficient to
control the swelling. Open toe stockings can be worn under socks or
tights. Closed toe stockings can be worn by themselves like popsocks, and are cooler in hot weather. There are many different makes
of compression stocking – if one kind doesn’t suit you, try another.
You may also find it useful to buy an applicator specially designed to help you apply the
stockings. You will need a new supply of stockings every 4 – 6 months. Stockings should be
worn for a minimum of 2 years after a DVT.
Other things that help
There are other things which you can do to reduce the symptoms of PTS:
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Eat a healthy balanced diet with plenty of fresh fruit and vegetables.
Try to lose weight if you are overweight as increased weight puts more strain on the
veins.
Exercise regularly as this assists the calf muscle to pump blood up the veins. If you
are unable to walk, try moving your feet up and down while you are sitting or lying.
Consider an exercise bike or aqua aerobics at your local swimming pool.
When sitting, elevate your leg on another chair or on the end of the sofa.
Stop smoking as this reduces the amount of oxygen to your legs
Wear correctly fitting shoes with a low heel, and elevate you legs whenever possible.
Wash and cream your legs regularly to avoid dry skin which is more easily damaged.
Seek immediate medical or nursing advice if you damage your skin. Never try to
heal the wound yourself.
With thanks to the Sheffield Vascular Institute - Sheffield Teaching Hospitals NHS
Foundation Trust website (http://www.sth.nhs.uk )
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Rivaroxaban patient information
You have been prescribed rivaroxaban as you have been diagnosed with a deep vein
thrombosis (DVT).
Rivaroxaban works by preventing your blood from clotting as quickly or as effectively as
normal. It does this by blocking a substance in your blood which is involved in the
development of blood clots, called factor Xa.
Sometimes harmful blood clots can form in the veins of your legs and cause a blockage.
People who take rivaroxaban do not need to have regular blood tests.
Some medicines are not suitable for people with certain conditions, and sometimes a
medicine may only be used if extra care is taken. For these reasons, before you start taking
rivaroxaban it is important that your doctor or pharmacist knows:
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If you are pregnant or breast-feeding.
If you have had any surgery recently (other than hip or knee surgery).
If you have an ulcer in your stomach or intestines, or if you have recently recovered
from one.
If you have high blood pressure.
If you have any medical problems that may increase your risk of bleeding.
If you have a problem with the blood vessels in your eyes, known as vascular
retinopathy.
If you have any problems with your liver or kidneys.
If you are taking or using any other medicines. This includes any medicines you are
taking which are available to buy without a prescription, such as herbal and
complementary medicines.
If you have ever had an allergic reaction to any medicine.
How to take rivaroxaban
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Before you start this treatment, read the manufacturer's printed information leaflet
from inside your pack. The leaflet will give you more information about rivaroxaban, and
a full list of possible side-effects from taking it.
Take rivaroxaban exactly as your doctor has told you. The usual dose is 15mg twice
daily for 3 weeks then 20 mg daily for duration of therapy.
You should take rivaroxaban after a meal. This is because food may interfere with
the amount of rivaroxaban your body absorbs.
Try to take rivaroxaban at the same time each day, as this will help you to remember
to take it.
If you forget to take a dose, take it as soon as you remember. If you do not
remember until the following day, skip the missed dose. Do not take two doses together
to make up for a forgotten dose.
If you take any medicines that you have bought without a prescription, check with a
pharmacist that they are suitable to take with rivaroxaban. This is because some
medicines, such as some painkillers, may interfere with it.
If you are having an operation or dental treatment, tell the person carrying out the
treatment which medicines you are taking.
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Can rivaroxaban cause problems?
Along with their useful effects, most medicines can cause unwanted side-effects although
not everyone experiences them. These usually improve as your body adjusts to the new
medicine, but speak with your doctor f any of the following side-effects continue or become
troublesome.
Common rivaroxaban side-effects these affect less than 1 in 10 people
who take this medicine
What can I do if I experience this?
Feeling sick
If you are not already doing so, try taking your
doses after a meal
Bleeding (such as nosebleeds),
anaemia
if you experience any unusual bleeding, speak with
your doctor immediately or go to your local
accident and emergency department without
delay.
Feeling dizzy or faint
If this happens, do not drive or use tools or
machines until you feel well again
Changes in some blood tests, fever,
swollen feet or ankles, rash
If you are concerned about any of these, speak
with your doctor
Important:
If you experience any other symptoms which you think may be due to this medicine, speak
with your doctor or pharmacist.
How to store rivaroxaban
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Keep all medicines out of the reach and sight of children.
Store in a cool, dry place, away from direct heat and light.
Manufacturer's PIL, Xarelto® 15 mg & 20 mg film-coated tablets; Manufacturer's PIL,
Xarelto® 15 mg & 20 mg film-coated tablets, Bayer plc, The electronic Medicines
Compendium. Dated December 2011.
View this article online at www.patient.co.uk/medicine/Rivaroxaban-to-prevent-bloodclots.htm
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WARFARIN ANTICOAGULANT FACT SHEET
Most patients are prescribed Warfarin for anticoagulation. You will be given an
anticoagulant record book. The book tells you exactly how much Warfarin you need to take
and the date of your next appointment. An alert card is provided to put inside your purse or
wallet. It contains important information that other health professionals may need to know.
Why have I been prescribed Warfarin?
Warfarin is used to prevent blood clots forming or growing bigger. It is commonly prescribed
for patients when clots have already developed e.g. Deep vein thrombosis. It prevents the
clot growing bigger and reduces the risk of part of the clot breaking off and moving around
the blood stream to cause further problems. Warfarin interferes with the body’s normal
clotting system so that your blood takes longer to clot than usual thereby reducing the risk of
clots developing.
How do I take Warfarin?
Warfarin comes in 3 strengths
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1mgs Brown tablet
3mgs Blue tablet
5mgs Pink tablet
The prescribed dose should be taken every day, preferably in the evening If you go to bed
and forget – do not double your dose. Simply take your normal dose at the normal time next
day and make a note in your Yellow book of the date you missed your dose.
Why do I need to have blood tests?
Warfarin has an unpredictable individual response. Some patients need ½ mg daily while
others need up to 20mgs to get the same response. Levels need to be monitored on a
regular basis as Warfarin is affected by many internal and external influences e.g.
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Food and drink
Illness
Stress
Exercise
Medications (including herbal preparations)
Alcohol
The range is the level your blood clotting ideally should be stabilized at. It is usually 2-3. A
normal clotting time is 1.0. Below 2.0 and the risk of clot formation is higher; above 3.0 and
the risk of bleeding problems is higher
What are the side effects of Anticoagulant therapy?
Very few people experience side effects from oral anticoagulant drugs. The main risk is
bleeding. Possible bleeding signs are

Nosebleeds
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Red or dark urine
Unexplained bruising
Black or tarry bowel motion
Gums bleeding
Vaginal bleeding
Any unexpected bleeding should be reported immediately to your GP.
Other less common side effects are:
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Hypersensitivity
Rash
Hair loss
Purple toes
It is important that you contact your Anticoagulant clinic or GP if you think you may be
experiencing side effects from the Warfarin other than bleeding.
Are there any other things I need to know?
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Inform your Anticoagulant clinic immediately if other tablets change – particularly
antibiotics or painkillers.
Avoid Aspirin unless specifically prescribed by a Doctor. Note that Aspirin is found
in cold relief preparations so check with the chemist.
Many herbal preparations should not be taken with Warfarin. Let us know if you are
thinking of trying any such medications.
Warfarin is not usually recommended during pregnancy. If you miss a period you
must take a pregnancy test as soon as possible and let your Anticoagulant clinic
know.
It is safe to breastfeed on Warfarin.
After a blood test, injection or skin cut you need to apply pressure for a longer time
until any bleeding has stopped. Inform the person taking blood that you are on
anticoagulants.
Avoid contact sports.
Seek medical advice if you have a fall or head injury
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Appendix 6: Prescribing guideline for clinicians and patients choosing
rivaroxaban to treat DVT
The NICE single technology assessment reviewed and approved rivaroxaban for the
treatment of DVT. It is still unclear who will most benefit from rivaroxaban but the following is
a guide.
Rivaroxaban should be considered in:
 Patients with a new diagnosis of DVT who after discussion of the risks and benefits
opt for rivaroxaban
 Patients on long-term warfarin who have poor control (time in therapeutic range less
than 55%) which is not felt to be due to intentional non-adherence
 Patients with other medical conditions that require regular introductions of
medications which interfere with warfarin, e.g. COPD with antibiotics, and cause the
need for very frequent INR monitoring/dose changes.
 Patients who are currently managed on LMWH because of difficulty in INR
monitoring.
 Patients with poor mobility who find it difficult to attend outpatient clinics and/or
require home visits.
Rivaroxaban should be used with caution in patients with:
 Renal disease and impairment e.g. CKD stage 3 and 4 or eGFR <60mls/min
 Aged more than 75 years
 Patients who are planned to take anticoagulation indefinitely (more than 12 months)
because of the lack of long-term safety data for rivaroxaban.
Rivaroxaban should not be used in the following situations:
 Patients who are already on warfarin and well controlled, and who have not had
adverse events. This is due to the lack of long-term safety data in this indication.
 History of gastrointestinal bleed
 Pregnancy or lactation
 Patients with active or recent (<6/12) diagnosis of cancer
 Patients with known antiphospholipid syndrome
 Patients with a target INR more than 3.0
 Other indications for warfarin, except non-valvular atrial fibrillation * see separate
guide for use of NOACs in stroke or non-valvular AF.
 Patients with known poor compliance, as missing a single dose may leave a patient
under-anti-coagulated due to the short half-life of rivaroxaban
 Patients with eGFR < 30mls/min
Rivaroxaban is suggested as an option which should be discussed with the patient in:
 Patients who have a suspected DVT and are awaiting appropriate imaging.
 Patients who have had a provoked DVT or first unprovoked DVT in whom a finite
period of anticoagulation is required.
Full details are available from the SPC
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(http://www.medicines.org.uk/EMC/medicine/25586/SPC/Xarelto%2020mg%20filmcoated%20tablets/ )
Guide for new patients starting RIvaroxaban:
 Check FBC and coagulation screen, if low platelets or abnormal coagulation discuss
with haematology.
 Check U&E – suggest avoiding if GFR less than 30mls/min
 Start rivaroxaban at 15mg twice daily for 3 weeks then 20mg daily thereafter.
 Monitor U&E at least every year if baseline normal, every six months if baseline
abnormal. No requirement for coagulation monitoring.
Patients switching from warfarin to Rivaroxaban
 Check U&E – suggest avoiding if GFR less than 30mls/min
 Stop warfarin and monitor INR daily, start rivaroxaban, as above, when INR less than
2.5
 Monitor U&E at least every year if baseline normal, every six months if baseline
abnormal. No requirement for coagulation monitoring.
Patients switching from LMWH to Rivaroxaban
 Check U&E – suggest avoiding if GFR less than 30mls/min
 Stop LMWH and start rivaroxaban, as above, between 0-2 hours before next dose
would have been due.
 Monitor U&E at least every year if baseline normal, every six months if baseline
abnormal. No requirement for coagulation monitoring.
RIVAROXABAN WILL CAUSE PROLONGATION OF THE COAGULATION SCREEN
Management of patients having planned operative procedures
If at all possible elective procedures should be delayed for as long after the thrombosis as
possible.
Note the half-life of rivaroxaban is approximately 5-13 hours. The half-life is considerably
more in patients with kidney disease CKD 3/ or 4. A normal coagulation profile may indicate
that the anticoagulant effect of the drug is no longer significant.
Rivaroxaban can usually be restarted the following day when complete haemostasis has
been secured but if there is concern over bleeding then re-introduction should be delayed,
bridging therapy with LMWH may be required if there is a more than 24 hour delay.
An individual risk assessment should be carried out and discussion between the surgical and
haematology team and the patients GP.
Emergency surgery on rivaroxaban
Where patients require emergency surgery a full clotting screen with PT and APTT should
be checked.
Where results are normal, this suggests that the activity of rivaroxaban has ceased.
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For prolonged clotting times, delay the procedure for as long as is safe to allow clearance of
the drug.
Early discussion with a haematologist is recommended and a bleeding management plan
should be documented.
Dental procedures on rivaroxaban
Rivaroxaban at standard dose is approximately equitant to an INR of 2.5. Therefore dental
procedures that previously would have been safely performed whilst on warfarin can be
performed without interruption of rivaroxaban.
Where possible the dental surgery should be planned for as late in the day as possible to
ensure the lowed drug concentration. Patients should be advised to delay the following dose
for up to 4 hours.
Management of bleeding on rivaroxaban - see local Trust guidelines for management
plans
Prescribing Responsibilities
Rivaroxaban was reviewed by NICE under a technology appraisal (TA261) for the treatment
of DVT. The decision from NICE was to recommend rivaroxaban as an option for treating
deep vein thrombosis and preventing recurrent deep vein thrombosis and pulmonary
embolism after the diagnosis of acute DVT in adults.
The main advantage of rivaroxaban over combination therapy with low molecular weight
heparin followed by warfarin relates to the lack of monitoring required during treatment.
However, there are other factors that should be considered when deciding to treat DVTs with
rivaroxaban over warfarin.
Rivaroxaban (Xarelto®) is a specific inhibitor of activated factor Xa with high oral
bioavailability and a half-life of approximately nine hours.
Secondary Care Responsibilities
 Diagnosis of DVT
 Ensuring other treatment options have been explored
 Discussion of risks/ benefits, initiation of treatment
 Provide initial 21 day therapy at recommended dose
 Advising GP on monitoring adverse drug reactions (ADRs)
 Liaison with the general practitioner (GP for continuation of supply)
 Providing written information to the GP stating the date when therapy should be
reduced or stopped assuming no relapse in patient’s condition
 Responding to issues raised by GP after care of patient has been transferred
GP Responsibilities
 Monitoring the patient’s overall health and well-being and observing patient for
evidence of ADRs/abnormalities and raising with secondary care clinician if
necessary.
 Clinical surveillance in line with anticoagulation practice throughout the treatment
period
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Assessment of renal function at least once a year, or more frequently as clinical
circumstances dictate when it is suspected that renal function could decline or
deteriorate.
Annual review as appropriate to include:
History of any venous thromboembolic event in last year
Reassessment of bleeding risk
Prescription of drug after initiation by secondary care
Ensuring advice is sought from the secondary care clinician if there is any significant
change in the patient’s physical health status
Reducing/stopping treatment in line with secondary care clinician’s original request
Ensure patient has Yellow anticoagulant book for warfarin or Rivaroxaban alert card
if patient has not already had one supplied
Patient Responsibilities
 Report untoward effects to prescribing clinician
 Compliance with treatment
 Compliance with blood tests as detailed by prescribing clinician
 Informing other professionals as appropriate that they are receiving an anticoagulant
Prescribing & Clinical Information Summary
Summary of Product Characteristics (SPC) Xarelto (Rivaroxaban), Bayer. Available from eMC at http://emc.medicines.org.uk/
BNF prescribing information available at http://bnf.org/bnf/
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Appendix 7: Counselling checklist for Warfarin
 Introduce yourself.
 Explain the medical condition requiring Anticoagulation.
 Explain how the drug works .i.e. ‘longer to clot not thinner’.
 Show the patient the Yellow Anticoagulant booklet and alert card.
 Tell them to take the book or alert card with them if they leave the house.
 Explain what the range means and what their desired range is.
 Tell them the intended duration of therapy.
 Explain the importance of blood monitoring and about our clinics.
 Show them the different strengths of tablets.
 Test the patient on dose adjustments to check understanding of dose changes.
 Tell the patient when to take the tablets .i.e. roughly same time each evening.
 Explain what to do if the patient misses a dose; i.e. If a dose is missed, it can still be
taken on the day it was missed, otherwise continue the following day as per normal.
Do not double up on dose. Advise INR clinic of any missed doses at next
appointment. If an extra tablet is taken accidentally, patient to seek medical advice.
 Explain the signs of under / over dosage.
 Explain about local pressure after injection, laceration or venepuncture.
 Explain the risk of bleeding / bruising and what action to take in the event of bleeding,
fall or head injury. Seek medical attention if blood in urine, faeces, vomit or sputum,
vaginal bleeding (other than regular period), severe unusual headache
 Explain how to get repeat prescriptions.
 Tell the patient to inform other health care professionals .e.g. dentists that they are
on oral anticoagulants.
 Explain the risk of potential drug interactions particularly antibiotics and over the
counter drugs and to report medication changes to clinic staff immediately.
 Advise patient to inform us of changes to health lasting more than 4 days .e.g. pain,
D&V, flu.
 Explain about the risk of herbal drug interactions and tell the patient to check safety
with clinic staff before purchase.
 Explain that dietary changes may affect control.
 No Cranberry products or Aspirin unless agreed by medical staff.
 Inform the patient of safe alcohol intake limits.
 If the patient is female and could possibly become pregnant explain the risks and
actions to take if a period is missed.
 Discuss the risk of contact sports if applicable.
 Ask if the patient has any other questions.
I confirm that (counsellor) ________________________ has given me the above verbal
information, a fact sheet on oral Anticoagulant therapy and an initial supply of Warfarin.
Patient name
Signed (patient)
NHS No -
Date -
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Counselling checklist for Rivaroxaban
 Introduce yourself.
 Explain that Rivaroxaban is being prescribed to treat a DVT and reduce risk of
embolism.
 Explain how the drug works .i.e. ‘blood takes longer to clot not thinner’.
 Show the patient the information booklet and alert card.
 Advise the patient to put the alert card in a purse or wallet.
 Explain the initial intended duration of therapy and review arrangements.
 Explain the dose to take .i.e. 15mg TWICE daily for 3 weeks then 20mg ONCE daily
thereafter.
 Swallow whole and take with food.
 Advise the patient of what to do if misses a dose; i.e. If a dose is missed, it can still
be taken on the day it was missed, otherwise continue the following day as per
normal. Do not double up on dose. If an extra capsule is taken accidentally, advise
patient to seek medical advice
 Advise patient to apply local pressure after injection, laceration or venepuncture.
 Explain the risk of bleeding / bruising and what action to take in the event of
unexpected bleed, fall or head injury.
 No direct antidote but local procedures in place to deal with bleeding.
 Explain how to get repeat prescriptions.
 Advise the patient to inform any health care professionals .e.g. doctors / dentists that
they are on Rivaroxaban.
 Explain the risk of potential side effects / adverse events and to report concerns to
GP immediately. Seek medical attention if any blood in urine, faeces, vomit or
sputum, vaginal bleeding (other than regular period), severe unusual headache
 No Aspirin unless agreed by medical staff.
 If the patient is female and could possibly become pregnant explain the risks and
actions to take if a period is missed.
 Discuss the risk of contact sports if applicable.
 Ask if the patient has any other questions.
I confirm that (counsellor) ________________________ has given me verbal information, a
fact sheet and Patient Alert Card for Rivaroxaban. I have been given an initial supply of
Rivaroxaban.
Patient name
Signed (patient)
NHS No -
Date -
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Appendix 8:
GREATER MANCHESTER GUIDELINE FOR:
THE DIAGNOSIS, INVESTIGATION AND
MANAGEMENT OF ABNORMALLY SWOLLEN
OR PAINFUL LEG(S)
GP GUIDE
Version:
Date:
Intended Audience:
Authors:
Version 2.2
30th April 2014
GP Practices, DVT Steering Group
Members of the DVT Steering Group and Daniel Watts (derived
from full DVT guideline document)
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DVT Pathway at GP level
Stage 1 – First presentation (Front End)
(a1) Patient presents to GP with
abnormally swollen or painful leg(s)
 Symptoms
 Physical Examination
 Medical History
 Any exclusion criteria
 Wells score
Can GP Practice provide d-dimer testing?
Yes
(a1a) Perform d-dimer and see
baseline tests section
No
Is there a community DVT
service?
DVT possible?
No
(c2) Seek
alternative
diagnosis
(End of
pathway)
Yes
(c1) Refer
for
Ultrasound
and see
prescribing
LMWH and
exclusions
Yes
(a1b) Refer
as
appropriate
using local
guidance
(this
pathway
ends)
No
(b) Refer to
Hospital
DVT team
using
proforma
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Stage 2 – Treatment (back end of pathway)
DVT?
Yes
(e1/e2/f1)
Patients
discharged
from Hospital
DVT Team:
Review
treatment
(see review
treatment
section)
Patients
returning
from
ultrasound:
Refer to
locally agreed
guidelines
No
(e3) Seek alternative
diagnosis* (end of
pathway)
Patients
discharged
from
community
DVT service:
Refer to
locally agreed
guidelines
*Seek alternative diagnosis if not already provided.
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Breakdown of the pathway
Stage one: First presentation (front end of pathway)
Patient with signs or symptoms of deep vein thrombosis (DVT), such as a swollen or
painful leg(s)
(a1) Patient presents to GP





Check symptoms
Physical examination to exclude other causes
Patients general medical history
Exclusion criteria
Two-level DVT Wells Score (appendix 1)
At this point a decision is made whether or not a patient should commence on a DVT
pathway. The distinction being: any patient with signs or symptoms in a lower limb
suggesting DVT as a potential diagnosis.
If a DVT is suspected but d-dimer cannot be provided locally – refer to community
DVT service (if one available) or hospital DVT service using the referral pro-forma
(appendix 2) as appropriate.
Where d-dimer can be provided locally – refer to the rest of this section on pages 4
and 5.
(a1a) Providing d-dimer locally
Review baseline tests to determine if a patient should be sent for an ultrasound or an
alternative diagnosis should be sort:
Where DVT a possibility
High Risk
Wells score >=2
Low Risk
Wells score <2
plus
Where DVT unlikely
Wells Score <2
plus
Positive d-dimer
Negative d-dimer
For patients where DVT a possibility – (c1) refer for ultrasound
Patients where a DVT is a possibility should be sent for an ultrasound scan as soon as
possible. These patients should be offered an interim therapeutic dose of anticoagulation
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therapy if diagnostic investigations are expected to take longer than 4 hours from the time of
first clinical suspicion. (NICE QS29:1)
Prescribing Low Molecular Weight Heparin’s (LMWH) - exclusions
There are some patients that may also have relative contraindications and therefore should
not routinely be prescribed LMWH. These patients include:







Already taking an anticoagulant – in such cases it would be unsafe to give further
anticoagulants until a DVT is proven. A proviso to this approach would be in a
patient taking an oral anticoagulant but where the INR is sub therapeutic (usually less
than 2).
Co-morbid diseases which preclude ambulatory management – in such cases a
suspected DVT might be present with one or more other active conditions. It is not
possible to define all possible scenarios and clinical assessment will be important, for
example patients unable to rest and elevate the affected leg at home.
Estimated GFR less than 30ml/min – the dose of LMWH will need to be adjusted,
however it might be safer to treat such patients as in-patients.
Leg Trauma – any history of leg trauma should alert the attending practitioner to the
possibility of a muscle tear. In such cases the administration of LMWH could have
disastrous consequences.
Cannot comply with ambulatory administration LMWH via a District Nurse, daily visit
to the Ambulatory Clinic or unable to self-administer.
Dual anti-platelet therapy of Aspirin AND Clopidogrel.
For all of the relative exclusion criteria the attending health professional ANP will
need to weigh-up the risk a DVT against the risk-benefit of LMWH, prior to a
Ultrasound scan.
Patients need to be informed heparins are of animal origin. If they are concerned about
using animal products, the health professional should consider using synthetic alternatives
based on clinical judgement and discussing their suitability, advantages and disadvantages.
People with suspected deep vein thrombosis have all diagnostic investigations
completed within 24 hours of first clinical suspicion (NICE QS29:2).
For patients where DVT unlikely – (c2) seek alternative diagnosis
Patients where the baseline tests reveal a DVT is unlikely should have arrangements made
where an alternative diagnosis is either given or pursued. The only situation which would
negate the need for an ultrasound scan is when there is an obvious alternative diagnosis.
For patients where a DVT unlikely: end this specific pathway
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Stage 2: Treatment (back end of pathway)
This section refers to those patients returning from the hospital DVT service have had
diagnostics to conclude either DVT or no DVT.
Patients discharged from Hospital DVT Team (e1/e2/e3/f1)
GP’s should be sent a copy of the patients discharge pro-forma once seen and discharged
by the Hospital DVT Team. The patient should also have a copy.
Patients will then fall in to one of three categories:
No DVT
 No DVT – seek alternative (e3)
DVT


DVT explained
DVT unexplained
No DVT
No DVT – seek alternative diagnosis (e3)
Patients found not to have a DVT may have already been provided with an alternative
diagnosis and treatment plan. Where this is not the case, the GP should seek the reason for
the abnormally painful or swollen leg(s).
The pathway ends for these patients
DVT
DVT explained (d1.2/e2)
This group of patients will have had an explanation as to what most likely caused their DVT
by the Hospital DVT team. They will now require a review of their treatment.
DVT unexplained (d1.1/e1)
Patients found to have a DVT but the reasons were unexplained. The Hospital DVT team
may have already referred the patient for further tests. If this has not happened, the GP may
wish to pursue further tests to find the reason for DVT. Patients will require review of their
treatment.
Review of treatment where necessary (f1)
Patients who have a DVT investigated by the Hospital DVT Team should have received their
initial treatment and plan on discharge. This will include:
 Anticoagulation therapy (either Rivaroxaban or Warfarin)
 Class 2 stockings
 Discharge pro-forma
 Referrals where necessary to other specialists
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

Information about their condition
Advice and Information about their treatment (including alert cards)
Anticoagulation
Where the initial review of anticoagulation therapy is carried out should be agreed locally.
This could be in either anticoagulation clinics, community teams or by the GP. GP’s and the
patient should be notified who will carry this out. Rivaroxaban should be considered as an
option for treating DVT first line where felt clinically appropriate and if the patient agrees;
Warfarin should also be considered. Both should initially be prescribed by the secondary
care team. In the case of Rivaroxaban – secondary care will provide the initial 21 day
therapy at recommended dose.
GP Responsibilities for patients continuing on anticoagulation
 Monitoring the patient’s overall health and well-being and observing patient for
evidence of ADRs/abnormalities and raising with secondary care clinician if
necessary.
 Clinical surveillance in line with anticoagulation practice throughout the treatment
period
 Assessment of renal function at least once a year, or more frequently as clinical
circumstances dictate when it is suspected that renal function could decline or
deteriorate.
 Annual review as appropriate to include:
History of any venous thromboembolic event in last year
Reassessment of bleeding risk
 Prescription of drug after initiation by secondary care
 Ensuring advice is sought from the secondary care clinician if there is any significant
change in the patient’s physical health status
 Reducing/stopping treatment in line with secondary care clinician’s original request
 Check patient continues to carry alert card after provision from hospital and supply
replacement where necessary.
 Provide any information or advice where not previously provided
Please refer to prescribing guidelines on page 11
Class 2 Stockings
All patients with a proven DVT must wear support stockings for a minimum of 2 years. All
below knee DVTs should have Class 2 below knee elastic stockings for 2 years. Above
knee DVTs with thigh swelling should have Class 2 full leg elastic stockings for 2 months in
the first instance, followed by Class 2 below knee elastic stockings. People with proximal
deep vein thrombosis are offered below-knee graduated compression stockings
within 3 weeks of diagnosis (NICE QS29:4).
Offer below-knee graduated compression stockings with an ankle pressure greater than 23
mmHg to patients with proximal DVT a week after diagnosis or when swelling is reduced
sufficiently and if there are no contraindications[3], and:
 Advise patients to continue wearing the stockings for at least 2 years
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

Ensure that the stockings are replaced two or three times per year or according to
the manufacturers' instructions.
Advise patients that the stockings need to be worn only on the affected leg or legs.
(NICE CG 144) Secondary care should provide the initial class 2 stocking with
GP’s providing subsequent stockings.
Appendix 1: Two-level DVT Wells Score
Clinical feature Points
Active cancer (treatment on-going, within 6 months, or palliative)
1
Paralysis, paresis or recent plaster immobilisation of the lower
extremities
Recently bedridden for 3 days or more or major surgery within 12 weeks
requiring general or regional anaesthesia
Localised tenderness along the distribution of the deep venous system
1
Entire leg swollen
1
Calf swelling at least 3 cm larger than asymptomatic side
1
Pitting oedema confined to the symptomatic leg
1
Collateral superficial veins (non-varicose)
1
Previously documented DVT
1
An alternative diagnosis is at least as likely as DVT
-2
1
1
Clinical probability simplified score
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Appendix 2
Referral for the diagnosis, investigation and management of abnormally swollen or
painful leg(s)
Patient Details
NHS No:
Male / Female (Please Circle)
First Name:
Surname:
Title:
DOB:
Address:
Contact Number:
Referral Date:
GP Referrer
GP Name:
GP Surgery:
GP Contact Tel. No.:
Other Referrer (if not GP)
Name:
Organisation:
Contact Tel. No.:
Clinical Details
Clinical description:
Date of onset of Symptoms:
Other Symptoms as relevant:
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Two-level DVT Wells Score
Score
Please circle
where appropriate
Active Cancer (treatment ongoing, within 6 months, or palliative care)
Paralysis, paresis, or recent plaster immobilisation of the lower extremities
Recently bedridden ≥3 days or major surgery within 12 weeks requiring general or
regional anaesthesia
Localised tenderness along the distribution of the deep venous system
Entire leg swollen
Calf swelling 3 cm large than asymptomatic side
Pitting oedema confined to the symptomatic leg
Collateral superficial veins (non-varicose)
Previously documented DVT
Alternative diagnosis at least as likely as DVT
1
1
1
1
1
1
1
1
1
−2
Total score
D-Dimer
Has a D-dimer been carried out?
If Yes, What was the result?
Yes
Positive
No
Negative
Past Medical History:
Current Medication:
Drug Allergies:
Name of referrer:
Referrer Signature:
Please Fax Referral to Hospital DVT/VTE Service
AND telephone to confirm receipt of referral:
Hospital DVT/VTE Service
<Address of local service>
Fax No.: 0161 <fax>
Telephone No.: 0161 <phone>
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Appendix 3 Prescribing guideline for clinicians and patients choosing
rivaroxaban to treat DVT
The NICE single technology assessment reviewed and approved rivaroxaban for the
treatment of DVT. It is still unclear who will most benefit from rivaroxaban but the following is
a guide.
Rivaroxaban should be considered in:
 Patients with a new diagnosis of DVT who after discussion of the risks and benefits
opt for rivaroxaban
 Patients on long-term warfarin who have poor control (time in therapeutic range less
than 55%) which is not felt to be due to intentional non-adherence
 Patients with other medical conditions that require regular introductions of
medications which interfere with warfarin, e.g. COPD with antibiotics, and cause the
need for very frequent INR monitoring/dose changes.
 Patients who are currently managed on LMWH because of difficulty in INR
monitoring.
 Patients with poor mobility who find it difficult to attend outpatient clinics and/or
require home visits.
Rivaroxaban should be used with caution in patients with:
 Renal disease and impairment e.g. CKD stage 3 and 4 or eGFR <60mls/min
 Aged more than 75 years
 Patients who are planned to take anticoagulation indefinitely (more than 12 months)
because of the lack of long-term safety data for rivaroxaban.
Rivaroxaban should not be used in the following situations:
 Patients who are already on warfarin and well controlled, and who have not had
adverse events. This is due to the lack of long-term safety data in this indication.
 History of gastrointestinal bleed
 Pregnancy or lactation
 Patients with active or recent (<6/12) diagnosis of cancer
 Patients with known antiphospholipid syndrome
 Patients with a target INR more than 3.0
 Other indications for warfarin, except non-valvular atrial fibrillation * see separate
guide for use of NOACs in stroke or non-valvular AF.
 Patients with known poor compliance, as missing a single dose may leave a patient
under-anti-coagulated due to the short half-life of rivaroxaban
 Patients with eGFR < 30mls/min
Rivaroxaban is suggested as an option which should be discussed with the patient in:
 Patients who have a suspected DVT and are awaiting appropriate imaging.
 Patients who have had a provoked DVT or first unprovoked DVT in whom a finite
period of anticoagulation is required.
Full details are available from the SPC
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(http://www.medicines.org.uk/EMC/medicine/25586/SPC/Xarelto%2020mg%20filmcoated%20tablets/ )
Guide for new patients starting RIvaroxaban:
 Check FBC and coagulation screen, if low platelets or abnormal coagulation discuss
with haematology.
 Check U&E – suggest avoiding if GFR less than 30mls/min
 Start rivaroxaban at 15mg twice daily for 3 weeks then 20mg daily thereafter.
 Monitor U&E at least every year if baseline normal, every six months if baseline
abnormal. No requirement for coagulation monitoring.
Patients switching from warfarin to Rivaroxaban
 Check U&E – suggest avoiding if GFR less than 30mls/min
 Stop warfarin and monitor INR daily, start rivaroxaban, as above, when INR less than
2.5
 Monitor U&E at least every year if baseline normal, every six months if baseline
abnormal. No requirement for coagulation monitoring.
Patients switching from LMWH to Rivaroxaban
 Check U&E – suggest avoiding if GFR less than 30mls/min
 Stop LMWH and start rivaroxaban, as above, between 0-2 hours before next dose
would have been due.
 Monitor U&E at least every year if baseline normal, every six months if baseline
abnormal. No requirement for coagulation monitoring.
RIVAROXABAN WILL CAUSE PROLONGATION OF THE COAGULATION SCREEN
Management of patients having planned operative procedures
If at all possible elective procedures should be delayed for as long after the thrombosis as
possible.
Note the half-life of rivaroxaban is approximately 5-13 hours. The half-life is considerably
more in patients with kidney disease CKD 3/ or 4. A normal coagulation profile may indicate
that the anticoagulant effect of the drug is no longer significant.
Rivaroxaban can usually be restarted the following day when complete haemostasis has
been secured but if there is concern over bleeding then re-introduction should be delayed,
bridging therapy with LMWH may be required if there is a more than 24 hour delay.
An individual risk assessment should be carried out and discussion between the surgical and
haematology team and the patients GP.
Emergency surgery on rivaroxaban
Where patients require emergency surgery a full clotting screen with PT and APTT should
be checked.
Where results are normal, this suggests that the activity of rivaroxaban has ceased.
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For prolonged clotting times, delay the procedure for as long as is safe to allow clearance of
the drug.
Early discussion with a haematologist is recommended and a bleeding management plan
should be documented.
Dental procedures on rivaroxaban
Rivaroxaban at standard dose is approximately equitant to an INR of 2.5. Therefore dental
procedures that previously would have been safely performed whilst on warfarin can be
performed without interruption of rivaroxaban.
Where possible the dental surgery should be planned for as late in the day as possible to
ensure the lowed drug concentration. Patients should be advised to delay the following dose
for up to 4 hours.
Management of bleeding on rivaroxaban - see local Trust guidelines for management
plans
Prescribing Responsibilities
Rivaroxaban was reviewed by NICE under a technology appraisal (TA261) for the treatment
of DVT. The decision from NICE was to recommend rivaroxaban as an option for treating
deep vein thrombosis and preventing recurrent deep vein thrombosis and pulmonary
embolism after the diagnosis of acute DVT in adults.
The main advantage of rivaroxaban over combination therapy with low molecular weight
heparin followed by warfarin relates to the lack of monitoring required during treatment.
However, there are other factors that should be considered when deciding to treat DVTs with
rivaroxaban over warfarin.
Rivaroxaban (Xarelto®) is a specific inhibitor of activated factor Xa with high oral
bioavailability and a half-life of approximately nine hours.
Secondary Care Responsibilities
 Diagnosis of DVT
 Ensuring other treatment options have been explored
 Discussion of risks/ benefits, initiation of treatment
 Provide initial 21 day therapy at recommended dose
 Advising GP on monitoring adverse drug reactions (ADRs)
 Liaison with the general practitioner (GP for continuation of supply)
 Providing written information to the GP stating the date when therapy should be
reduced or stopped assuming no relapse in patient’s condition
 Responding to issues raised by GP after care of patient has been transferred
GP Responsibilities
 Monitoring the patient’s overall health and well-being and observing patient for
evidence of ADRs/abnormalities and raising with secondary care clinician if
necessary.
 Clinical surveillance in line with anticoagulation practice throughout the treatment
period
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





Assessment of renal function at least once a year, or more frequently as clinical
circumstances dictate when it is suspected that renal function could decline or
deteriorate.
Annual review as appropriate to include:
History of any venous thromboembolic event in last year
Reassessment of bleeding risk
Prescription of drug after initiation by secondary care
Ensuring advice is sought from the secondary care clinician if there is any significant
change in the patient’s physical health status
Reducing/stopping treatment in line with secondary care clinician’s original request
Ensure patient has Yellow anticoagulant book for warfarin or Rivaroxaban alert card
if patient has not already had one supplied
Patient Responsibilities
 Report untoward effects to prescribing clinician
 Compliance with treatment
 Compliance with blood tests as detailed by prescribing clinician
 Informing other professionals as appropriate that they are receiving an anticoagulant
Prescribing & Clinical Information Summary
Summary of Product Characteristics (SPC) Xarelto (Rivaroxaban), Bayer. Available from eMC at http://emc.medicines.org.uk/
BNF prescribing information available at http://bnf.org/bnf/
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Appendix 4: Counselling checklist for Warfarin
 Introduce yourself.
 Explain the medical condition requiring Anticoagulation.
 Explain how the drug works .i.e. ‘longer to clot not thinner’.
 Show the patient the Yellow Anticoagulant booklet and alert card.
 Tell them to take the book or alert card with them if they leave the house.
 Explain what the range means and what their desired range is.
 Tell them the intended duration of therapy.
 Explain the importance of blood monitoring and about our clinics.
 Show them the different strengths of tablets.
 Test the patient on dose adjustments to check understanding of dose changes.
 Tell the patient when to take the tablets .i.e. roughly same time each evening.
 Explain what to do if the patient misses a dose; i.e. If a dose is missed, it can still be
taken on the day it was missed, otherwise continue the following day as per normal.
Do not double up on dose. Advise INR clinic of any missed doses at next
appointment. If an extra tablet is taken accidentally, patient to seek medical advice.
 Explain the signs of under / over dosage.
 Explain about local pressure after injection, laceration or venepuncture.
 Explain the risk of bleeding / bruising and what action to take in the event of bleeding,
fall or head injury. Seek medical attention if blood in urine, faeces, vomit or sputum,
vaginal bleeding (other than regular period), severe unusual headache
 Explain how to get repeat prescriptions.
 Tell the patient to inform other health care professionals .e.g. dentists that they are
on oral anticoagulants.
 Explain the risk of potential drug interactions particularly antibiotics and over the
counter drugs and to report medication changes to clinic staff immediately.
 Advise patient to inform us of changes to health lasting more than 4 days .e.g. pain,
D&V, flu.
 Explain about the risk of herbal drug interactions and tell the patient to check safety
with clinic staff before purchase.
 Explain that dietary changes may affect control.
 No Cranberry products or Aspirin unless agreed by medical staff.
 Inform the patient of safe alcohol intake limits.
 If the patient is female and could possibly become pregnant explain the risks and
actions to take if a period is missed.
 Discuss the risk of contact sports if applicable.
 Ask if the patient has any other questions.
I confirm that (counsellor) ________________________ has given me the above verbal
information, a fact sheet on oral Anticoagulant therapy and an initial supply of Warfarin.
Patient name
Signed (patient)
NHS No -
Date -
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Appendix 5: Counselling checklist for Rivaroxaban
 Introduce yourself.
 Explain that Rivaroxaban is being prescribed to treat a DVT and reduce risk of
embolism.
 Explain how the drug works .i.e. ‘blood takes longer to clot not thinner’.
 Show the patient the information booklet and alert card.
 Advise the patient to put the alert card in a purse or wallet.
 Explain the initial intended duration of therapy and review arrangements.
 Explain the dose to take .i.e. 15mg TWICE daily for 3 weeks then 20mg ONCE daily
thereafter.
 Swallow whole and take with food.
 Advise the patient of what to do if misses a dose; i.e. If a dose is missed, it can still
be taken on the day it was missed, otherwise continue the following day as per
normal. Do not double up on dose. If an extra capsule is taken accidentally, advise
patient to seek medical advice
 Advise patient to apply local pressure after injection, laceration or venepuncture.
 Explain the risk of bleeding / bruising and what action to take in the event of
unexpected bleed, fall or head injury.
 No direct antidote but local procedures in place to deal with bleeding.
 Explain how to get repeat prescriptions.
 Advise the patient to inform any health care professionals .e.g. doctors / dentists that
they are on Rivaroxaban.
 Explain the risk of potential side effects / adverse events and to report concerns to
GP immediately. Seek medical attention if any blood in urine, faeces, vomit or
sputum, vaginal bleeding (other than regular period), severe unusual headache
 No Aspirin unless agreed by medical staff.
 If the patient is female and could possibly become pregnant explain the risks and
actions to take if a period is missed.
 Discuss the risk of contact sports if applicable.
 Ask if the patient has any other questions.
I confirm that (counsellor) ________________________ has given me verbal information, a
fact sheet and Patient Alert Card for Rivaroxaban. I have been given an initial supply of
Rivaroxaban.
Patient name
Signed (patient)
NHS No -
Date -
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Appendix 6: Full pathway for the diagnosis, investigation and management of
abnormally swollen or painful leg(s)
Patient with abnormally
swollen or painful leg(s)*
GP (a1)
Community
DVT service if
one exists
locally** (a1b)
A&E (a2)
On hospital ward
(a3)
Hospital DVT/VTE Service (b)
Provide or pursue an alternative
diagnosis (c2)
Ultrasound (c1)
Review post ultrasound scan (d)
Proven DVT (d1)
DVT unexplained
(d1.1)
Pursue further tests to
find reason for DVT
(e1)
Not DVT (d2)
DVT explained
(d1.2)
Alternative diagnosis
provided
(d2.1)
GP or return to ward
(e2)
Referral to continue to
(d2.1)
pursue alternative diagnosis
(e3)
Review of treatment
where necessary (f1)
* Patient with abnormally swollen or painful leg(s)* identified as newly abnormal swollen or painful
leg(s) or newly noticeable/significant swelling or pain on already swollen or painful leg(s).
Red text related to GP’s.
Community DVT service if one exists locally** - refers to a DVT service in a central location in the community that provide baseline tests and aim
to reduce hospital admissions. A1b is additional to this pathway
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DVT Steering Group (who developed this pathway)
Mark Holland
Gareth Lord
Charles McCollum
Peter Elton
Anita Sharma
Daniel Horner
Dhirendra Allen
Michelle Grundy
Wendy Morrison
Elizabeth Lamberton
Syed Zafar
Jurjees Hasan
Beatrice Fox
Vicky Hoskins
Sarah Jacobs
John Bright
David Thomson
Irene Lorenzelli
Suresh Chandran
Tariq Sharf
Arun Kallat
George Ajith
Allie Babak
Sarah Thackery
General Medical Consultant (UHSM)
Quality Improvement Manager (SCN)
Vascular Surgeon (UHSM)
Clinical Director (SCN)
GP and CCG Lead for Vascular (Oldham CCG)
Clinical Research Fellow (CMFT)
Consultant (THT)
AC Manager (RBH)
DVT Clinic Sister (RBH)
Pharmacist (SRFT)
Consultant (WWL)
Medical Oncologist (Christie)
Consultant Nurse (RBH)
Pharmacist (UHSM)
Senior Strategic Pharmacist (GMCSU)
Consultant (CMFT)
Consultant Physician (PAT)
Patient Participation Member (Oldham)
Consultant (PAT)
Programme Management Office Controller (Oldham CCG)
Consultant (RBH)
Consultant (CMFT)
Consultant (TGH)
Vascular Nurse (TGH)
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