Anticoagulation optimization and clinical impact of post-transplant deep vein thrombosis: clinical impact and a VV-ECMO subgroup analysis

Post-transplant deep vein thrombosis (DVT) is common after lung transplantation and may contribute to pulmonary embolism and other complications. Whether DVT adversely affects contemporary outcomes and how venovenous ECMO (VV-ECMO) bridging influences early DVT patterns remain unclear. We performed a retrospective single-center study of adult lung transplant recipients (2018–2025). DVT and clinical outcomes were ascertained. Primary analyses compared outcomes and overall survival between recipients with and without DVT in the overall cohort. Secondary analyses assessed DVT-free survival and early anatomic distribution among recipients bridged with preoperative VV-ECMO. Comparisons used Fisher’s exact/Mann–Whitney U tests; survival used Kaplan–Meier/log-rank tests. Among 502 recipients, 240 developed DVT. Compared with those without DVT, recipients with DVT had higher rates of pulmonary embolism (22.5% vs. 5.0%, p < 0.0001), acute kidney injury (52.9% vs. 41.2%, p = 0.009), PGD grade 3 (18.3% vs. 10.7%, p = 0.016), longer hospitalization (21 vs. 14 days, p < 0.001), and worse overall survival (HR 2.19, 95% CI 1.49–3.23; log-rank p < 0.001). Of 240 DVT cases, 31 (12.9%) were bridged with VV-ECMO. Within 14 days, upper-extremity DVT was more frequent with VV-ECMO (53.3% vs. 23.5%, p = 0.03), whereas lower-extremity and neck distributions were similar. In multivariable models, operative time was independently associated with DVT (OR 1.18 per hour, 95% CI 1.07–1.31, p < 0.001). Post-transplant DVT is frequent and portends worse outcomes. VV-ECMO bridging is associated with an upper-extremity–predominant DVT pattern but is not an independent DVT predictor after adjustment. Vigilant surveillance is warranted in this high-risk population.