Venous thromboembolism in China: epidemiology, management strategies, and future directions.

Introduction

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary thromboembolism/pulmonary embolism (PTE/PE), represents different manifestations of the same disease at different anatomical sites and stages. It is also one of the leading causes of unexpected death among hospitalized patients [ [1] , [2] , [3] ]. In recent years, against the background of population aging, lifestyle changes, a rising prevalence of cancer, an increasing number of complex surgical procedures and invasive interventions, and improved disease awareness, the demand for VTE diagnosis and treatment in China has increased substantially [ 4 ].

Strengthening quality control, improving the rate of standardized VTE prophylaxis, and implementing early intervention can effectively reduce the incidence and mortality of VTE. For several consecutive years, the National Health Commission of China has included ‘improving the rate of standardized prophylaxis for venous thromboembolism’ among the national goals for medical quality and patient safety improvement. This has promoted a shift from the traditional ‘single-disease diagnosis-and-treatment’ model to a hospital-based VTE prevention and management system encompassing risk assessment, prevention, diagnosis, treatment, follow-up, and quality control [ [1] , [2] , [3] , 5 ]. Representative Chinese national guidelines, expert consensus statements, and standards underpinning this system are summarized in Table 1 . The overall clinical management framework for VTE in China is shown in Figure 1 . Table 1 Major Chinese guidelines, expert consensuses, and standards underpinning the current management framework for VTE in China. Category Document Year Issuing body Main scope VTE guideline Chinese Guidelines for the Prevention and Treatment of Thrombotic Diseases 2018 Expert Committee on Chinese Guidelines for the Prevention and Treatment of Thrombotic Diseases in China Broad antithrombotic/thrombotic disease framework, including PTE, DVT, and VTE prevention PE guideline Chinese Guidelines for the Diagnosis, Treatment, Prophylaxis and Management of Pulmonary Thromboembolism (2025 Edition) 2025 Chinese Thoracic Society and related national expert groups Definition, epidemiology, risk factors, diagnostic strategies, risk stratification, comprehensive scenario-based acute-phase management strategies, management of special clinical conditions, long-term follow-up and preventive measures DVT guideline Guidelines for the Diagnosis and Treatment of Deep Venous Thrombosis (3rd Edition) 2017 Vascular Surgery Group, Society of Surgery, Chinese Medical Association DVT diagnosis, anticoagulation, thrombolysis, thrombectomy, stenting, filter use Hospital management Guideline for Quality Assessment and Management of Hospital-based Prevention and Treatment of Venous Thromboembolism (2022 Edition) 2022 Expert Committee of the National Capacity-Building Project for Prevention and Treatment of Pulmonary Embolism and Deep Vein Thrombosis Three core categories of indicators were established, covering VTE assessment quality, prevention quality, and outcome quality. The name, definition, calculation formula, clinical significance, data source, evaluation method, relevant interpretation, and recommendations for each quality indicator have been clearly specified Etiology/thrombophilia Chinese Guidelines for Diagnosis, Prevention and Treatment of Thrombophilia (2021) 2021 Thrombosis and Hemostasis Group, Chinese Society of Hematology, Chinese Medical Association Pathogenesis and etiological classification, diagnosis and etiological screening, treatment and long-term management of thrombophilia Laboratory diagnosis/standardization Chinese Expert Consensus on D-dimer Laboratory Testing and Clinical Application 2023 Chinese Society on Thrombosis and Hemostasis Laboratory methods, quality requirements, performance evaluation, result reporting, and clinical interpretation of D-dimer Pediatric patients Expert Consensus on Anticoagulant Therapy for Pediatric Venous Thromboembolism in Children (2025) 2025 Society of Pediatrics, Chinese Medical Association; Chinese Medical Doctor Association; Chinese Journal of Pediatrics Anticoagulant management of pediatric VTE in children aged >28 days, including treatment strategy and drug selection, treatment duration, monitoring and follow-up, perioperative management, and management of complications Pregnancy/puerperium Expert Consensus on the Prevention, Diagnosis and Management of Venous Thromboembolism During Pregnancy and the Puerperium 2021 Obstetrics Subgroup, Society of Obstetrics and Gynecology, Chinese Medical Association Risk assessment, prophylaxis, diagnosis, and treatment during pregnancy and puerperium Elderly patients Chinese Expert Consensus on the Prevention and Management of Venous Thromboembolism in Older Adults 2023 Peripheral Vascular Disease Management Branch, Chinese Geriatrics Society, and collaborating expert groups Prevention and management of VTE in the elderly Perioperative prevention Chinese Guidelines for Perioperative Thromboprophylaxis and Management in General Surgery 2016 Society of Surgery, Chinese Medical Association Perioperative VTE risk assessment, prophylaxis, and management in general surgery CAT Guidelines for the Prevention and Treatment of Cancer-associated Venous Thromboembolism (2019 Edition) 2019 Expert Committee on Oncology and Thrombosis, Chinese Society of Clinical Oncology Prevention, diagnosis, treatment, and bleeding management in CAT Selected representative national documents are shown rather than an exhaustive list. Titles of Chinese-language documents are presented in English. CAT, cancer-associated thrombosis; DVT, deep vein thrombosis; PE, pulmonary embolism; PTE, pulmonary thromboembolism; VTE, venous thromboembolism. Figure 1 Overview of VTE management in China. The upper panel outlines the main components of VTE management in China, including high-risk populations, prevention, diagnostic evaluation, treatment, and long-term management and follow-up. The lower panel summarizes the quality evaluation framework for in-hospital VTE prevention and treatment, including assessment, prevention, and outcome quality indicators. AI, artificial intelligence; CTPA, computed tomographic pulmonary angiography; CTV, computed tomographic venography; CUS, compression ultrasonography; MRV, magnetic resonance venography; VTE, venous thromboembolism.

Despite substantial progress, major challenges remain in VTE prevention and management in China. These include a large high-risk population, low prophylaxis rates, the lack of ideal biomarkers, insufficiently refined clinical risk assessment models, marked regional disparities, limited capacity in primary healthcare institutions, and an underdeveloped long-term management system [ 1 , 2 , 6 ]. Therefore, a systematic review of the epidemiology, in-hospital management models, diagnostic and treatment pathways, and future directions of VTE in China is of considerable importance for optimizing clinical practice and promoting international exchange. In this context, the present review summarizes the current management strategies for VTE in China, with a focus on epidemiology, in-hospital management models, prevention, diagnosis, treatment, and the management of special populations.

Epidemiology and Disease Burden of VTE in China

Over the past decade, the burden of VTE in China has continued to increase. A nationwide database study involving 90 hospitals showed that, from 2007 to 2016, the age- and sex-adjusted hospitalization rate for VTE in China rose from 3.2 to 17.5 per 100,000 population, whereas in-hospital mortality declined from 4.7% to 2.1%. These findings suggest that, despite a marked increase in the overall hospitalization burden, case recognition and in-hospital management have improved [ 7 ]. The 2021 National Report on Medical Services and Quality Safety issued by the National Health Commission of China further showed that, from 2016 to 2020, a total of 4.27 million patients with VTE were discharged nationwide, and the population prevalence increased from 3.26 per 10,000 population in 2016 to 8.53 per 10,000 population in 2020 [ 4 ]. In addition, a nationwide study of PE based on 5101 hospitals reported that, in 2021, the incidence and mortality of PE in China were 14.19 and 1.00 per 100,000 population, respectively, with a heavier burden observed in older adults, men, and certain geographic regions [ 8 ]. Although the absolute incidence currently reported in the Chinese population remains lower than that in Western countries, this gap appears to be narrowing [ 9 , 10 ].

Another key epidemiologic feature of VTE in China is its strong hospital association. An analysis of data from 5101 secondary and tertiary hospitals in the Hospital Quality Monitoring System showed that, from 2016 to 2020, a total of 291,700 cases of hospital-acquired VTE occurred in public hospitals. The incidence increased from 0.48‰ to 0.56‰, and the case fatality rate rose from 5.64% to 6.18%, markedly higher than the 2.79% case fatality rate for VTE overall [ 4 ]. More recent Hospital Quality Monitoring System data from the Annual Report on Cardiovascular Health and Diseases in China 2024 showed that 337,000 adult inpatient episodes with PE and 1.868 million adult inpatient episodes with DVT were recorded in China in 2023 [ 11 ]. These findings indicate clear deficiencies in in-hospital VTE prevention and control. The DissolVE-2 study showed that, among inpatients in 60 tertiary hospitals, 53.4% of surgical patients and 36.6% of medical patients were at high risk for VTE. However, only 14.3% received any form of prophylaxis, and only 10.3% received appropriate prophylaxis, far below the overall prophylaxis rate of approximately 40% to 60% reported internationally [ 12 ]. Risk assessment is the prerequisite for thromboprophylaxis. In the Chinese population, the risk factor profile remains dominated by acquired factors, including advanced age, pregnancy, surgery, trauma, infection, cancer, prolonged bed rest, and cardiopulmonary dysfunction. In contrast, the pattern of inherited thrombophilia differs from that in Western populations, in whom factor V (FV) Leiden and the prothrombin G20210A mutation are more common. In China, inherited thrombophilia is more often characterized by deficiencies of protein C, protein S, and antithrombin [ 6 , 13 , 14 ].

Therefore, the epidemiologic profile of VTE in China is defined not only by an incidence that remains lower than that reported in Western countries, but also by population aging, a locally distinctive risk factor spectrum, a large pool of high-risk hospitalized patients, steadily improving case recognition, and prophylaxis rates that still fall short of international standards. These features underscore the importance of in-hospital thromboprophylaxis and quality management in reducing the burden of VTE in China.

Hospital-based VTE Prevention and Management System in China

Strengthening quality control, improving the rate of standardized VTE prophylaxis, and enabling early intervention can effectively reduce the incidence and fatality of VTE. Given the increasing burden of hospital-associated VTE in China and the persistently insufficient rate of prophylaxis, the National Health Commission has included improvement of the standardized VTE prophylaxis rate in the National Goals for Medical Quality and Patient Safety Improvement for 6 consecutive years. This goal emphasizes that patients should undergo VTE risk assessment and bleeding risk assessment during hospitalization and after discharge. Standardized prophylactic measures should then be provided according to relevant clinical guidelines and the assessment results, including basic, pharmacologic, and mechanical prophylaxis [ 15 ]. The 2025 edition of the Tertiary Hospital Accreditation Standards also includes the incidence of postoperative DVT as a hospital safety monitoring indicator, further reinforcing this policy direction [ 16 ]. Together, these measures have promoted the transition of VTE prevention from a department-level clinical practice to a measurable hospital-wide quality management task.

Implementation has been mainly driven by the National Capacity-Building Project for the Prevention and Treatment of Pulmonary Embolism and DVT. Through standard dissemination, quality-control system development, bidirectional referral, and scientific research, this project aims to standardize the clinical management of in-hospital VTE in China, establish hospital-based VTE prevention and management systems at different levels, improve the overall capacity for in-hospital VTE prevention and treatment, and reduce fatal VTE events [ 17 ]. A nationwide cross-sectional survey further showed that many Chinese hospitals have established VTE prevention programs, including hospital-level steering committees and department-level working groups. However, system construction remains incomplete, and digital infrastructure still lags behind [ 18 ].

At the hospital level, the VTE prevention and management system mainly includes several core components: a hospital-level VTE prevention and management committee, a dedicated management office, department-level working groups, collaborative nursing participation, standardized VTE and bleeding risk assessment, risk-stratified prophylaxis and treatment pathways, professional training for medical staff, patient education, and routine monitoring of quality indicators [ 3 , 5 ]. The Expert Consensus on the Prevention and Treatment of Venous Thromboembolism in Zhejiang Province provides a highly representative provincial model for implementing this hospital-based prevention and management system. In addition to routine prevention measures and quality-control methods, the consensus identifies rapid emergency response teams, consultation and referral pathways, emergency response protocols, and feedback mechanisms as essential components of hospital-based VTE management [ 5 ]. A particularly distinctive component of this management system is the emergency green channel for patients with severe VTE or VTE requiring urgent treatment. This green channel is not an isolated emergency treatment protocol. Rather, it represents the acute-response module within the overall hospital-based VTE management system. It is mainly designed for confirmed or suspected high-risk PE and limb-threatening DVT. These conditions require rapid identification and assessment, multidisciplinary coordination, priority imaging, timely clinical intervention, and specialized inpatient care. Figure 2 illustrates the operating model of this emergency green channel. Figure 2 Emergency green-channel pathways as part of hospital-based VTE management in China. The figure summarizes emergency green-channel pathways within the hospital-based VTE prevention and management system in China. Panel A presents the pathway for confirmed acute PTE/PE before admission or suspected high-risk acute PTE/PE, including initial monitoring and stabilization, hemodynamic assessment, electronic green-channel activation, specialist consultation, priority assessment and treatment, thrombolysis or urgent interventional procedures when indicated, and specialized inpatient care. Panel B presents the pathway for limb-threatening DVT, including suspected phlegmasia cerulea dolens or phlegmasia alba dolens, with emphasis on immediate limb assessment, urgent venous and arterial imaging, exclusion of alternative causes, green-channel activation, VTE team or vascular surgery consultation, urgent interventional procedures when appropriate, and specialized inpatient care. The figure also shows the VTE rapid-response team, required institutional support, and information system-based closed-loop quality management needed to implement these pathways. CTPA, computed tomographic pulmonary angiography; CTV, computed tomography venography; DVT, deep vein thrombosis; ECG, electrocardiography; ICU, intensive care unit; MDT, multidisciplinary team; MRV, magnetic resonance venography; PE, pulmonary embolism; PERT, pulmonary embolism response team; PTE, pulmonary thromboembolism; VTE, venous thromboembolism.

Prevention of VTE in China

Risk factors and high-risk populations

VTE is a multifactorial disease driven by genetic factors, environmental exposures, and their interactions. Its risk factors can be broadly classified as acquired or inherited. In Chinese clinical practice, acquired factors remain the most important and most modifiable determinants of VTE risk [ 6 , 13 ]. The DissolVE-2 study showed that the most common risk factors among surgical inpatients were major surgery, bed rest, malignancy, and central venous access. In medical inpatients, the principal risk factors were acute infection or rheumatic disease, advanced age, heart failure or respiratory failure, reduced mobility, and active cancer [ 12 ]. In addition, studies of critically ill older adults, older patients with pneumonia, and older patients with PE consistently indicate that older adults constitute a high-risk population for VTE because of the age-related increase in thrombotic risk and the frequent coexistence of multiple comorbidities. This risk may be further amplified in the setting of infection or critical illness, underscoring the need to regard older patients as a key target population for early in-hospital screening, dynamic risk assessment, and standardized thromboprophylaxis [ [19] , [20] , [21] , [22] ]. Pregnancy and the puerperium are also associated with a markedly increased risk of VTE, mainly because of the hypercoagulable state, cesarean delivery, and peripartum bed rest [ 23 , 24 ]. In addition, studies from different specialties in China have shown that patients undergoing thoracic or hernia surgery, as well as those with rheumatic disease, stroke, or acute exacerbation of chronic obstructive pulmonary disease, are also at increased risk of VTE [ [25] , [26] , [27] , [28] , [29] , [30] ]. Overall, the main target populations for in-hospital VTE prevention in China include perioperative patients, patients hospitalized for acute medical illness, patients with cancer, older adults, and women during pregnancy and the puerperium.

Risk assessment models and their localization

Accurate and feasible risk assessment is the cornerstone of effective VTE prevention. In China, international risk assessment models remain the foundation of current practice. The Caprini score is the most commonly used tool in surgical patients, the Padua Prediction Score is widely applied in medical inpatients, and the IMPROVE score is used in selected settings. For patients with cancer, disease-specific tools such as the Khorana score may be used. During pregnancy, obstetric-specific risk assessment tools are emphasized [ 1 , 2 , 5 , 23 ]. The main challenge in China is not the lack of risk assessment models, but the relative complexity of international tools, their low implementation rate, and their suboptimal applicability in certain specialties. This has driven the development of simplified and localized models. The CHAT-1 study was the first to show that early perioperative VTE in Chinese adults undergoing inguinal hernia surgery has distinctive patterns and risk characteristics [ 31 ]. Subsequently, the CHAT-3 study proposed a simplified 3-factor model that required less time than the conventional Caprini score and improved the rate of pharmacologic prophylaxis [ 32 , 33 ]. More recently, Chinese investigators developed and externally validated a VTE risk assessment model for hospitalized patients in China, the SJT model. In multicenter medical cohorts, this model showed higher sensitivity and a higher Youden index than some conventional tools [ 34 , 35 ]. These findings suggest that China is gradually establishing a risk assessment framework in which international models serve as the basis and localized models act as complementary tools.

Beyond conventional scoring systems, artificial intelligence (AI)-assisted risk identification has also begun to complement VTE risk assessment in Chinese hospitals. A research team in Shanghai developed an AI-based clinical decision support system (AI-CDSS) integrated into the electronic medical record. Retrospective data showed that its use was associated with a 19.35% relative reduction in in-hospital VTE and a 14.57% increase in anticoagulant use, suggesting that the AI-CDSS improved hospital-associated VTE management processes and the standardization of anticoagulant use [ 36 ]. A subsequent prospective randomized study further showed that the AI-CDSS improved implementation of VTE screening and prophylaxis pathways in hospitalized patients, resulting in a 46% relative reduction in in-hospital VTE and a 24% increase in the use of mechanical prophylaxis [ 37 ]. These findings suggest that AI-assisted tools may help improve risk identification and the implementation of risk assessment-based prophylaxis in Chinese hospital settings. At the same time, population-specific genetic risk stratification is also emerging. In 2024, Liu et al. [ 38 ] developed and optimized a polygenic risk score (PRS) model for first VTE events in the Chinese population. The PRS-53 model showed good discriminative performance, suggesting that, in the setting of primary prevention, genetic information may ultimately complement conventional clinical risk models in identifying individuals at high inherited risk.

Risk-stratified prophylactic strategies

The decision-making principles for VTE prophylaxis in China are generally well defined. Low-risk patients should receive basic preventive measures. For patients at intermediate or high risk, mechanical prophylaxis, pharmacologic prophylaxis, or a combination of both should be selected based on bleeding risk. For patients with high bleeding risk or contraindications to anticoagulation, mechanical prophylaxis should be prioritized [ [1] , [2] , [3] ]. Basic prevention includes early mobilization, avoidance of dehydration, minimization of unnecessary bed rest, and patient education. Mechanical prophylaxis mainly includes graduated compression stockings, intermittent pneumatic compression, and venous foot pumps [ 5 ]. The effectiveness of mechanical prophylaxis depends not just on whether it is used, but also on device selection, duration of daily use, and patient adherence [ 39 , 40 ]. A multicenter prospective orthopedic study from China showed that the duration of venous foot pump use should be optimized based on the specific clinical setting, not simply prolonged [ 39 ]. For high-risk patients with an acceptable bleeding risk, pharmacologic prophylaxis remains the core strategy. Low molecular weight heparin (LMWH) is still the most commonly used agent in Chinese clinical practice, especially in perioperative and intensive care settings. For patients with severe renal impairment, unfractionated heparin (UFH) may be considered or the regimen adjusted [ 19 , 30 ].

Quality improvement and digital implementation of thromboprophylaxis

VTE prevention in China has been incorporated into hospital quality management systems. The 2022 in-hospital quality guideline proposed that quality evaluation of VTE prevention and treatment should cover 3 domains: assessment quality, prophylaxis quality, and outcome quality. Assessment indicators include the rate of VTE risk assessment, the proportion of patients with intermediate to high VTE risk, the rate of bleeding risk assessment, and the proportion of patients with high bleeding risk. Prophylaxis indicators include the rates of pharmacologic prophylaxis, mechanical prophylaxis, and combined prophylaxis. Outcome indicators include the in-hospital detection rate of VTE, rate of standardized treatment, incidence of bleeding events, and mortality [ 3 ]. As described above, these indicators should be embedded within hospital-level governance structures and closed-loop information systems. At the same time, digital support is evolving from an auxiliary tool into a core component of infrastructure. In addition to electronic risk assessment forms, standardized prophylaxis order sets, screening pathways, and disease-specific registries, AI-CDSSs have shown potential in real-world Chinese studies to enhance risk identification, optimize in-hospital workflow, and improve pathway implementation [ 36 , 37 ]. More broadly, recent advances in medical AI support the integration of heterogeneous data sources, including electronic medical records, imaging, physiological signals, and omics data, into clinical decision support systems. In VTE care, this supports the future development of digital platforms that move beyond simple electronic reminders toward multimodal risk prediction, workflow optimization, outcome monitoring, and personalized management [ 41 ].

The practical value of China’s VTE management model lies in translating guidelines and consensus statements into routine hospital workflows supported by information systems that make ‘assessment–stratification–prevention–monitoring–feedback’ traceable, controllable, and continuously improvable.

Diagnostic Approach to VTE

Clinical diagnostic pathways

The evaluation of suspected VTE in China generally follows the same stepwise approach used internationally, combining clinical probability assessment, D-dimer testing, and imaging confirmation [ 1 , 2 , 42 ]. For suspected acute PTE, the 2025 Chinese guideline recommends an initial assessment of pretest probability based on clinical judgment or validated tools, including the simplified Wells score, the revised Geneva score, and the YEARS algorithm. In patients with a low clinical probability, a negative high-sensitivity D-dimer result is usually sufficient to exclude acute PTE, whereas patients with a high clinical probability should proceed directly to imaging [ 1 ]. For DVT, Chinese guidelines similarly recommend a diagnostic pathway that combines the Wells score, D-dimer testing, and compression ultrasonography (CUS). In patients with a low clinical probability and a negative D-dimer result, DVT can be ruled out, whereas those with an intermediate or high clinical probability should undergo immediate ultrasonography, with repeat scanning or additional computed tomography venography (CTV)/magnetic resonance venography (MRV) if necessary [ 2 , 42 ].

The role of D-dimer in VTE diagnosis

In China, the principal role of D-dimer remains to exclude, rather than confirm, VTE, and its interpretation should always be integrated with clinical pretest probability rather than considered in isolation. In patients with a low clinical probability, a negative D-dimer result is usually sufficient to exclude acute VTE. In individuals aged 50 years or older, the use of an age-adjusted cutoff (age × 10 μg/L for assays reported in fibrinogen-equivalent units) can reduce false-positive results and improve diagnostic efficiency [ 43 ]. However, D-dimer levels may also be elevated in the settings of surgery, trauma, infection, malignancy, and pregnancy. Particularly in pregnancy and the postpartum period, D-dimer concentration physiologically increases, making its conventional cutoff value unreliable for exclusion. In these cases, clinical probability assessment and CUS play a more decisive role. Therefore, a positive result must be interpreted in conjunction with the clinical context and imaging findings [ 23 , 43 ]. Recent Chinese studies in high-risk hospitalized populations suggest that, in perioperative and critical care settings, D-dimer is more useful as a dynamic monitoring marker or as part of a combined model. For example, postoperative elevation of D-dimer after surgery for spinal metastases may indicate early DVT. In older patients with hip fractures, age-adjusted D-dimer combined with platelet distribution width, albumin, or thromboelastography (TEG) parameters may improve the identification of newly developed DVT. In patients with major burns or acute brain injury, the D-dimer level on days 5 to 7 after injury or surgery, as well as its dynamic increase, shows moderate or greater predictive value and a high negative predictive value for DVT occurrence or progression, and may help identify patients at high risk of DVT [ [44] , [45] , [46] , [47] , [48] ]. The diagnostic performance of D-dimer is also highly dependent on assay sensitivity. Although high-sensitivity assays allow clinicians to safely rule out VTE in low-probability patients, moderate-sensitivity assays may require stricter adherence to pretest probability assessment to avoid false reassurance [ 43 ]. Therefore, in Chinese clinical practice, D-dimer is best positioned as a standardized tool for ruling out VTE and, in selected settings, as a dynamic marker of thrombotic risk.

Imaging modalities and emerging diagnostic approaches

With regard to imaging, CUS for DVT and computed tomographic pulmonary angiography (CTPA) for PTE remain the first-line modalities for VTE diagnosis in China [ 1 , 2 , 42 ]. Color Doppler ultrasonography is noninvasive, convenient, and suitable for bedside use and is therefore the preferred test for lower-extremity DVT. However, its sensitivity is lower for calf muscle vein and iliac vein thromboses. Accordingly, if the result is negative but clinical suspicion remains high, repeat examination or additional imaging, such as MRV or CTV, is still required. CTV is used mainly for thrombosis in the major veins of the lower extremities or the inferior vena cava, and the combination of CTV and CTPA may increase the diagnostic yield for VTE. MRV does not require contrast administration and is particularly suitable for pregnant women. Although venography remains the historical gold standard for lower-extremity DVT, its invasive nature, the risk of contrast allergy, nephrotoxicity, and potential injury to the vessel wall have led to its gradual replacement by ultrasonography in routine practice [ 42 ].

Chinese studies have also explored the use of additional imaging modalities. Cardiovascular magnetic resonance black-blood thrombus imaging has shown high reliability for the diagnosis of acute DVT, with excellent sensitivity and specificity [ 49 ]. A recent meta-analysis further suggested that magnetic resonance black-blood thrombus imaging may have greater diagnostic value for cerebral venous thrombosis than contrast-enhanced magnetic resonance imaging and noncontrast MRV [ 50 ]. High-resolution noncontrast 3-dimensional CUBE T1-weighted magnetic resonance imaging can accurately diagnose acute lower-extremity DVT and may be more sensitive than ultrasonography for detecting nonocclusive mural thrombi, suggesting potential value as a baseline imaging modality before discontinuation of anticoagulation [ 51 ]. In addition, hemodynamic parameters derived from conventional ultrasonography have also been investigated. One study linked ultrasonographically measured inferior vena cava blood volume to the severity of lower-extremity DVT, suggesting that this parameter may have a role in the assessment of venous stasis and thrombotic risk [ 52 ].

Beyond D-dimer and conventional imaging, recent Chinese studies have increasingly focused on the combined use of novel biomarkers and whole-blood viscoelastic testing. A 2024 Chinese study showed that TEG combined with conventional coagulation indices improved the identification of newly developed lower-extremity DVT in older patients with hip fractures [ 45 ]. Another 2024 cohort study found that postoperative hypercoagulability detected by TEG was associated with an increased risk of lower-extremity DVT in patients with femoral and pelvic fractures [ 53 ]. Chinese investigators have also explored the early identification of PE using combinations of blood cell parameters and inflammatory markers [ 54 ]. Overall, however, these emerging approaches remain adjunctive or investigational and cannot replace the established diagnostic pathway based on clinical probability assessment and standard imaging.

Laboratory standardization

In the field of VTE diagnosis, China places strong emphasis on laboratory standardization and external quality assessment. The 2023 Chinese expert consensus on D-dimer laboratory testing noted that, as of May 2023, more than 500 D-dimer assay kits and calibrators had been registered in China. Results across different testing systems remain poorly comparable because of the lack of a unified traceability system, differences in antibody recognition, and inconsistency in reporting units and cutoff values. Accordingly, the consensus recommends that the same assay method be used whenever possible for serial testing. When D-dimer is used to exclude VTE, the between-day coefficient of variation near the cutoff should be ≤7.5%, sensitivity at the cutoff should be ≥97%, and the negative predictive value should be ≥98%. Laboratory reports should also clearly state whether results are expressed in fibrinogen equivalent units or D-dimer units, specify the measurement unit, and provide the locally validated cutoff for VTE exclusion [ 43 ]. National standards further emphasize that the package insert of any quantitative D-dimer assay intended for VTE exclusion should explicitly state this indication and the corresponding threshold [ 55 ]. Data from the China National External Quality Assessment Scheme have shown that different quantitative D-dimer methods perform differently in the diagnosis of PE and DVT, indicating that external quality assessment directly affects threshold interpretation and diagnostic consistency in clinical practice [ 56 ].

Thrombophilia testing

Identification of the etiology of VTE is crucial for guiding subsequent management and is an indispensable part of diagnostic evaluation. Etiologic assessment should not only consider common provoking factors, such as prolonged bed rest, surgery, trauma, fracture, and acute medical illness, but also actively evaluate potential acquired and inherited thrombophilia [ 1 ]. Currently, the clinical utility of thrombophilia testing and related genetic research remains controversial. A major concern is that genetic findings often do not alter the core acute anticoagulation strategy for VTE. Accordingly, the 2023 American Society of Hematology guideline recommends a selective testing strategy, limiting thrombophilia testing to clinical scenarios in which the results may influence management decisions [ 57 ]. However, a recent practical guideline for major hereditary thrombophilia argues that the value of genetic testing should not be assessed solely by its impact on anticoagulation duration. Identification of specific hereditary thrombophilia may inform anticoagulant selection, refine inpatient VTE risk assessment, improve awareness of preventive measures, and identify patients at risk for heparin resistance or warfarin-induced skin necrosis [ 58 ]. Because the hereditary thrombophilia spectrum in China is characterized more often by antithrombin, protein C, and protein S deficiencies, with factor V Leiden and the prothrombin G20210A mutation being rare, thrombophilia testing should be regarded as a targeted etiologic and management tool for selected patients rather than a universal screening approach for all patients with VTE. In China, the general principle is that routine thrombophilia screening should not be performed in all patients with VTE but should be reserved for those with appropriate clinical indications [ 13 , 59 ]. Recommended candidates for screening include patients with VTE who are younger than age 50 or have early-onset arterial thrombosis in the absence of atherosclerotic risk factors; patients with unprovoked VTE; patients with a definite family history of VTE; patients with recurrent VTE; patients with VTE at unusual sites, including the splenic vein, intracranial veins, portal vein, mesenteric veins, hepatic vein, renal vein, and upper-extremity deep veins, or with multifocal or extensive thrombosis; patients who develop skin necrosis, thrombus progression, or recurrent thrombosis during standard antithrombotic therapy; neonates with purpura fulminans; women with recurrent unexplained adverse pregnancy outcomes, including recurrent miscarriage, fetal growth restriction, stillbirth, preeclampsia, and placental abruption; and individuals with a personal or family history of VTE who are planning major surgery, pregnancy, use of hormonal agents, or frequent long-haul air travel [ 13 ]. With respect to laboratory evaluation for thrombophilia, in addition to routine blood cell counts, coagulation testing, immunologic testing, urinalysis, and liver and renal function tests, the updated Chinese guideline also recommends high-throughput sequencing-based genetic testing. The timing of testing should be selected with careful consideration of the effects of ongoing anticoagulant therapy on laboratory parameters [ 13 , 59 ].

Treatment of VTE

Risk-stratified therapeutic decision making

In China, treatment strategies for confirmed VTE are primarily based on risk stratification principles. For PTE, patients are first classified into high-risk or non-high-risk groups based on their hemodynamic status; hemodynamically stable patients are further subdivided into intermediate-high-risk, intermediate-low-risk, and low-risk groups based on the presence of right ventricular dysfunction and cardiac biomarkers. This framework helps assess short-term prognosis while also informing treatment selection, monitoring intensity, and the need for escalation to reperfusion therapy. For patients with suspected or confirmed high-risk PTE, as well as some moderate-to-high-risk PTE patients at risk of clinical deterioration, immediate multidisciplinary evaluation is recommended; if conditions permit, the Pulmonary Embolism Response Team should be activated as early as possible [ 1 ].

Treatment decisions for DVT depend on the location of the thrombus, the severity of symptoms, the risk of thrombus extension, the risk of bleeding, and the persistence of precipitating factors. Anticoagulation remains the standard treatment strategy for most patients. Catheter-directed thrombolysis, percutaneous mechanical thrombectomy, surgical thrombectomy, or venous stenting should be reserved for specific patients who meet the following criteria: acute iliofemoral or mixed DVT, severe symptoms, good functional status, long life expectancy, and low risk of bleeding [ 2 , 42 ]. Inferior vena cava filters should not be used routinely and are generally limited to patients with acute proximal DVT or PE who have a clear contraindication to anticoagulation [ 60 ]. The overall framework for treatment and long-term management of VTE in China is summarized in Figure 3 . Figure 3 Overview of treatment and long-term management of VTE in China. The figure outlines the treatment pathway for confirmed VTE in China, including acute-phase treatment, anticoagulant selection, treatment duration, follow-up, and long-term management. It also highlights special populations, together with China-specific management features such as structured in-hospital pathways, quality control, multidisciplinary collaboration, and digital support tools. DOAC, direct oral anticoagulant; DVT, deep vein thrombosis; INR, international normalized ratio; LMWH, low-molecular-weight heparin; PE, pulmonary embolism; VKA, vitamin K antagonist; VTE, venous thromboembolism.

Acute-phase management

Anticoagulation is the main treatment for acute VTE. Chinese guidelines recommend starting anticoagulation as soon as acute VTE is confirmed unless contraindications are present. In patients with a high clinical probability of PE or DVT and no major bleeding risk, parenteral anticoagulation may be started before imaging confirmation [ 1 , 2 , 42 ]. Common parenteral agents include UFH, LMWH, and fondaparinux. In daily practice, LMWH is often preferred for hemodynamically stable patients. It is convenient to use and has predictable pharmacokinetics. UFH is more suitable for patients with hemodynamic instability, those who may need thrombolysis or invasive treatment, patients with severe renal impairment, and patients who may require rapid reversal of anticoagulation [ 1 , 2 , 42 ]. Oral anticoagulants include direct oral anticoagulants (DOACs) and vitamin K antagonists, mainly warfarin. DOACs are now widely used for VTE treatment. Warfarin remains useful in patients with mechanical heart valves, antiphospholipid syndrome, selected patients with severe renal impairment, and those for whom treatment cost is an important concern. Among DOACs, rivaroxaban and apixaban can be used directly in the initial treatment phase. Dabigatran and edoxaban require a short course of parenteral anticoagulation before oral maintenance treatment. When warfarin is used, it should overlap with parenteral anticoagulation for at least 5 days. The overlap should continue until the international normalized ratio reaches and remains within the therapeutic range [ 1 , 42 ]. A multicenter randomized study from China showed that genotype-guided warfarin dosing improved dose attainment. This supports more individualized use of vitamin K antagonists in Chinese clinical practice [ 61 ].

For acute PTE, supportive care is also important in the early stage. Oxygen therapy should be given to patients with hypoxemia. If mechanical ventilation is needed, low-tidal-volume ventilation is preferred. Patients with shock or hypotension require close monitoring and timely hemodynamic support. This may include cautious fluid resuscitation and, when needed, vasopressors or inotropic agents [ 1 ]. The use of reperfusion therapy should be based on risk stratification. Systemic thrombolysis is recommended for acute high-risk PTE when no contraindications exist. It is not routinely recommended for non-high-risk PTE. Patients with intermediate-high-risk PTE should receive anticoagulation and close observation. Rescue thrombolysis may be used if clinical deterioration occurs. In patients with contraindications to thrombolysis, high bleeding risk, or failure of thrombolysis or intensive medical treatment, catheter-directed intervention or surgical embolectomy may be considered in experienced centers. In catastrophic PTE with refractory respiratory or circulatory failure, early extracorporeal membrane oxygenation may be considered where available [ 1 ].

For DVT, anticoagulation is likewise the foundation of acute-phase treatment. Once DVT is confirmed, anticoagulation should be started promptly unless contraindicated [ 2 , 42 ]. The management of isolated distal DVT should be determined by clinical assessment. Patients with severe symptoms or risk factors for thrombus extension should receive anticoagulation. In contrast, patients without severe symptoms or extension risk may undergo serial imaging during the first 2 weeks, with anticoagulation initiated only if thrombus extension occurs [ 2 ]. Early ambulation is recommended once adequate anticoagulation has been established. In patients with limb-threatening manifestations, such as phlegmasia, or in selected patients with acute iliofemoral DVT, thrombus removal strategies may be considered. If clinically significant iliac venous stenosis persists after clot removal, balloon angioplasty and stent placement may be used to restore venous outflow [ 2 , 42 ].

Long-term and extended anticoagulation: current treatment patterns

Chinese guidelines recommend at least 3 months of anticoagulation for all patients with acute PTE. After the initial treatment phase, the duration of anticoagulation should be individualized. Decisions should consider recurrence risk, bleeding risk, and patient preference. Anticoagulation may be stopped after 3 months in patients with PTE caused by a major transient risk factor, provided that the provoking factor has resolved and there is no clear risk of progression to chronic thromboembolic pulmonary disease. Extended treatment is recommended for patients with persistent risk factors, minor transient risk factors and low bleeding risk, a first unprovoked PTE with low bleeding risk, or recurrent unprovoked PTE. For patients with recurrent unprovoked PTE, long-term anticoagulation is usually advised [ 1 ]. During the extended phase, DOACs are preferred for most patients. However, the balance between recurrent thrombosis and bleeding should be reassessed regularly [ 1 , 2 ]. In China, LMWH, warfarin, and DOACs are all used in clinical practice. Real-world data suggest that rivaroxaban is feasible in older and very elderly patients. Even so, dose selection, renal function, bleeding risk, and cost should still be carefully considered [ [62] , [63] , [64] ].

The treatment principles for DVT are generally similar. However, management should also consider thrombus location and chronic venous complications. Provoked DVT is usually treated for 3 months. Unprovoked proximal DVT, recurrent VTE, and cancer-associated thrombosis (CAT) often require extended anticoagulation if the bleeding risk is acceptable [ 2 , 42 ]. Long-term care should involve more than deciding whether anticoagulation should continue. In patients with PTE, follow-up should monitor recurrence, bleeding, post-PE syndrome, newly diagnosed malignancy, and progression to chronic thromboembolic pulmonary disease or chronic thromboembolic pulmonary hypertension [ 1 ]. In patients with DVT, prevention and management of postthrombotic syndrome remain important. Compression therapy and symptom-directed conservative treatment are standard approaches. Selected patients with chronic iliac or iliofemoral venous obstruction, severe symptoms, or venous ulceration may benefit from endovascular reconstruction [ 2 , 42 ]. Overall, VTE treatment in China has moved beyond simple control of the acute event. Current practice increasingly emphasizes a whole-course strategy. This strategy combines acute rescue, individualized anticoagulation, structured follow-up, and management of chronic complications.

Management of VTE in Special Populations

Pregnancy and the postpartum period

Pregnancy and the puerperium are classic hypercoagulable states, and the risk of VTE is substantially higher than that in nonpregnant women. Management therefore focuses on dynamic risk assessment throughout pregnancy, risk-stratified prophylaxis, and multidisciplinary collaboration [ 23 ]. Chinese expert consensus recommends health education and risk screening for all pregnant women, with mechanical or pharmacologic prophylaxis for those with a history of VTE, obesity, advanced maternal age, multifetal pregnancy, cesarean delivery, pregnancy complications, or prolonged immobilization. When prophylaxis is indicated, LMWH is the preferred agent [ 23 ]. However, obstetric thromboprophylaxis should also account for bleeding risk. A recent Chinese multicenter cohort study showed a U-shaped association between third-trimester serum uric acid concentration and postpartum hemorrhage, partly mediated by hemoglobin, fibrinogen, and D-dimer, highlighting the need to interpret coagulation-related markers in the broader peripartum context when considering VTE prophylaxis [ 65 ]. Chinese surveys have also shown that many opportunities for prophylaxis are still missed during pregnancy and the postpartum period, highlighting the need for further standardization of obstetric VTE prevention [ 24 , 66 ]. For diagnosis, CUS is the first-line test when DVT is suspected, whereas ventilation-perfusion scanning or CTPA may be used for suspected PE after appropriate counseling [ 23 ]. Recent Chinese studies suggest that diagnostic and preventive strategies for obstetric VTE are shifting from empirical management toward more refined risk stratification. In postpartum women with suspected PE, a postpartum-adapted YEARS algorithm avoided 52.63% to 60.0% of CTPA examinations while maintaining a negative predictive value of 100%, with an overall specificity of 65% [ 67 ]. In women after cesarean delivery, early bilateral CUS combined with dynamic D-dimer monitoring may help identify those at high risk of VTE. In that study, no VTE occurred during follow-up among women with normal ultrasonography findings on the first postpartum day and a D-dimer level <3 mg/L; the negative predictive value of the relevant indicators approached 100%, and the strategy also helped reduce unnecessary LMWH use [ 68 ].

Children and adolescents

The overall incidence of VTE in children is lower than that in adults, but detection rates in hospitalized children have increased with the more frequent use of central venous catheters and advances in imaging [ 69 , 70 ]. Most pediatric VTE is secondary. The 2025 Chinese expert consensus on anticoagulant therapy for pediatric VTE states that treatment aims to reduce thrombotic harm, recurrence, and complications and that anticoagulation remains the standard of care. The choice of medication should take into account the patient’s age, underlying medical conditions, inherited or acquired thrombotic disorders, bleeding risk, history of recent surgery or trauma, and treatment adherence [ 69 ]. In the acute phase, UFH and LMWH remain the primary anticoagulants, while DOACs are increasingly being used in older children and adolescents. Clinical data from pediatric and adolescent orthopedic trauma patients in China indicate that rivaroxaban-based anticoagulation therapy, administered both during hospitalization and after discharge, significantly reduces the thrombotic burden within 3 months without leading to VTE recurrence or major bleeding [ 70 , 71 ].

Older adults

Older adults account for a significant proportion of patients with VTE in China. According to relevant expert consensus in China, the incidence of VTE rises sharply with age, with the incidence being particularly high among people aged 80 and older. Clinical management of this population is often complex, as most patients have multiple comorbidities, reduced renal function, a high risk of falls, and are taking multiple medications simultaneously. Therefore, clinicians must balance the risk of thromboembolic recurrence against the risk of bleeding throughout the treatment process [ 72 ]. D-dimer levels also tend to increase with age. For this reason, age-adjusted diagnostic strategies, noninvasive imaging, and dynamic follow-up are particularly important in older patients [ 43 , 72 ]. Anticoagulation therapy remains the primary treatment approach. When prescribing DOACs, careful assessment of the patient’s renal function, body weight, and potential drug interactions is warranted. For patients with severe renal impairment, UFH remains an important treatment option [ 72 ].

Perioperative patients

The management of perioperative VTE is not limited to the treatment of confirmed thrombotic events. It should be viewed as a process-based strategy that spans the entire surgical process. This strategy includes risk assessment, prevention, early diagnosis, and anticoagulation management. The ‘2025 Chinese Expert Consensus on the Prevention and Pharmaceutical Care of Perioperative Venous Thromboembolism’ emphasizes dynamic VTE risk assessment at key time points. These time points include admission, the postoperative period, patient transport, changes in clinical status, and discharge. Management should also be individually tailored based on bleeding risk and contraindications to mechanical prophylaxis [ 30 ]. This approach is particularly important in general surgery, gynecology, and orthopedics. In the field of general surgery, the Chinese Nursing Consensus emphasizes dynamic perioperative assessment and preventive measures based on clinical pathways [ 73 ]. In gynecologic surgery, consensus documents recommend that enhanced preventive measures should be taken for patients with malignant tumors, those undergoing lengthy procedures, or those requiring prolonged bed rest and that these preventive measures should be continued after discharge [ 74 ]. For major orthopedic surgeries, the Chinese expert consensus recommends a combination of basic, mechanical, and pharmacologic preventive measures for intermediate- to high-risk patients with low bleeding risk. For patients at high risk of bleeding, basic and mechanical measures should be implemented first until pharmacologic prevention becomes safer [ 75 ]. Evidence reviews and network meta-analyses also show that prophylaxis after major orthopedic surgery requires careful selection of agents, timing, and duration [ [76] , [77] , [78] ]. Therefore, perioperative VTE management should not focus only on the choice of anticoagulant; it also requires dynamic risk assessment, specialty-specific pathways, and postdischarge continuation to be integrated into a continuous care process.

Patients with cancer

CAT represents a specific form of VTE closely related to the biological and clinical features of malignancy. Its development is affected by multiple factors, such as patient characteristics, tumor type, tumor site, disease stage, comorbidities, and specific anticancer therapies [ 79 ]. The risk of thrombosis may persist after active cancer treatment and continue into the survivorship period. In a recent systematic review and meta-analysis of 160 population-based cohort studies involving 49,395,865 participants, cancer survivors had a higher overall risk of cardiovascular disease than noncancer controls. Among 17 cardiovascular subtypes, venous embolism, thrombosis, or thrombophlebitis showed the strongest association [ 80 ]. These findings emphasize the importance of long-term thrombotic risk management in cancer survivors. Therefore, CAT management requires integrated consideration of tumor-related factors, anticancer treatment, risk of thrombotic recurrence, bleeding risk, patient preference, and survivorship care and differs from VTE management in the general population. For ambulatory patients receiving chemotherapy, Chinese reviews and guidelines recommend risk stratification using models such as the Khorana score, with primary thromboprophylaxis considered for high-risk patients [ 79 , 81 ]. For hospitalized patients with cancer, several tools, including the Khorana, Vienna CATS, COMPASS-CAT, and Padua scores, may be used for risk assessment; however, the optimal model remains uncertain and should be selected according to the clinical context. For hospitalized surgical patients with cancer, the Caprini score or modified Caprini score may be used for risk stratification [ 79 ]. In addition, certain cancer types with disease-specific treatment patterns and thrombotic risk profiles may require more tailored assessment tools. For example, the Chinese expert consensus on the prevention and treatment of multiple myeloma-associated VTE recommends the Chinese VTE risk stratification system for patients with multiple myeloma [ 82 ]. Prophylactic strategies should be selected according to the care setting, type of surgery, and contraindications to anticoagulation and may include pharmacologic prophylaxis alone or in combination with mechanical prophylaxis [ 79 , 81 ].

Once CAT occurs, anticoagulation remains the cornerstone of treatment. LMWH has long been the mainstay of therapy, whereas DOACs such as rivaroxaban, apixaban, and edoxaban have increasingly become commonly used first-line options in clinical practice [ 79 , 81 ]. A population-based cohort study using the Hong Kong electronic health database, which included 4356 patients with CAT, further showed that switching from initial LMWH therapy to DOACs was associated with lower rates of VTE-related hospitalization and all-cause mortality than continued LMWH use, without an increased risk of major bleeding within 6 months [ 83 ]. These findings support the clinical feasibility of switching from LMWH to DOACs in appropriately selected patients. However, anticoagulant selection should remain cautious in patients with gastrointestinal malignancies, genitourinary cancers with a high bleeding risk, or active mucosal lesions and should be individualized according to bleeding risk, drug–drug interactions, and treatment adherence [ 79 , 81 ].

Conclusions and Future Perspectives

Overall, the VTE management model in China has gradually evolved into a closed-loop pathway that begins with in-hospital risk assessment, is centered on standardized prophylaxis and risk-stratified diagnosis, extends to individualized anticoagulation and the management of special populations, and is supported by quality control and follow-up management [ 5 ]. Representative ongoing multicenter studies relevant to VTE management in China are summarized in Table 2 . Rather than focusing solely on DVT or PE as single-disease entities, recent practice in China emphasizes incorporation of VTE into hospital quality management systems and uses national guidelines, expert consensuses, and quality indicators to promote pathway standardization. Table 2 Representative ongoing multicenter studies relevant to VTE management in China. Registry ID Category Study name Study design Population/focus Current status Key source NCT02943343 Epidemiology/management patterns China Pulmonary Thromboembolism Registry Study (CURES) Nationwide prospective multicenter registry Acute symptomatic PE; epidemiology, management patterns, and chronological trends in China Ongoing ClinicalTrials.gov NCT04211181 Prevention/hospital management/quality improvement CHIPs-VTE in inpatient (Effect on Thromboprophylaxis Among Hospitalized Patients Using a System-wide Multifaceted Quality Improvement Intervention) Multicenter cluster randomized clinical trial Hospitalized patients at risk of hospital-acquired VTE; system-wide multifaceted quality-improvement intervention Recruiting ClinicalTrials.gov ChiCTR2400079931 Prevention The effectiveness of VTE prophylaxis in hospitalized patients: A Multicenter Prospective Study Multicenter prospective study Effectiveness of VTE prophylaxis in hospitalized patients Recruiting ChiCTR ChiCTR2400082194 Real-world management/prevention and treatment The prevention and treatment of inpatients with venous thromboembolism, a real-world, multicenter, observational study Real-world multicenter observational study Inpatients with VTE; prevention and treatment patterns Recruiting ChiCTR ChiCTR2500103822 Treatment/special populations Prospective Multicenter Clinical Study of Edoxaban in Multiple Myeloma Patients with Venous Thromboembolism Prospective multicenter clinical study Multiple myeloma patients with VTE; edoxaban-based treatment Recruiting ChiCTR NCT06382038 Long-term management SmaPE (Smart Technology Facilitated Patient-centered Care for Patients With Pulmonary Thromboembolism) Multicenter randomized controlled trial Patients with pulmonary thromboembolism; mobile VTE application-based patient-centered management Not yet recruiting ClinicalTrials.gov NCT06950697 Prognosis/risk prediction/special populations Development and Application of a Thrombosis Risk Prediction Model in Lung Cancer Patients Treated With Immune Checkpoint Inhibitors Multicenter observational study Lung cancer patients receiving immune checkpoint inhibitors; VTE/ATE incidence, risk factors, prognosis, and model development Recruiting ClinicalTrials.gov NCT06727669 Prognosis/longitudinal cohort Longitudinal Cohort of Thrombosis and Hemostasis Diseases Multicenter prospective longitudinal observational cohort Chinese patients with thrombosis and hemostasis diseases, including DVT and PE Recruiting ClinicalTrials.gov Selected representative ongoing multicenter studies identified in ClinicalTrials.gov and the ChiCTR are shown rather than an exhaustive list. Because of space limitations, completed landmark studies are discussed in the main text rather than included in this table. Study status was current at the time of search and may change over time. ATE, arterial thromboembolism; ChiCTR, Chinese Clinical Trial Registry; DVT, deep vein thrombosis; PE, pulmonary embolism; VTE, venous thromboembolism.

Nevertheless, several important challenges remain. First, inadequate prophylaxis is still the most practical and persistent weakness. Marked differences remain across regions, hospital tiers, and specialties in the use of risk assessment tools, implementation of prophylactic measures, and continuity of care after discharge. Second, although disease-specific consensus statements have been developed for some high-risk populations, specialty-based, risk-stratified, and operationally feasible clinical pathways are still uneven. Surveys from hematology and intensive care settings also indicate persistent gaps in awareness of specialty-specific VTE risk and in adherence to standardized prophylaxis in routine practice [ 84 , 85 ]. In addition, the specificity and applicability of current risk assessment and screening tools remain limited in certain populations. This suggests that VTE management in China has established an overall framework but still requires stronger capacity for refined implementation.

Future development of VTE management in China should continue to move toward precision risk stratification. Available evidence suggests that Chinese population-specific PRSs, microRNAs, and multidimensional prediction models may help shift VTE management from empirical stratification to more refined individualized prediction [ 38 , 86 ]. In addition, environmental and epigenetic factors may become important components of future risk models. An epigenome-wide association study in the CARDIA cohort showed that particulate matter with a diameter of < 2.5 μm was associated with DNA methylation changes, and pathway enrichment analyses implicated platelet activation, signaling, and aggregation, as well as disease networks related to PE and venous thrombosis [ 87 ]. Although this study was not designed to evaluate VTE risk directly, it suggests that integrating environmental exposure, epigenetic regulation, and clinical factors may provide new directions for mechanistic research and precision prevention in VTE [ 87 ]. Emerging biotechnological platforms, including nanomaterial-mediated targeted delivery and vascular endothelial cell-targeted mRNA therapy, also indicate that China is not only adopting international evidence but also actively developing next-generation antithrombotic therapies [ 88 , 89 ]. On the treatment side, an important future direction is the development of agents that preserve antithrombotic efficacy while reducing bleeding risk. Candidate drugs targeting the FXI/FXIa pathway are representative of this trend. International studies have shown that after total knee arthroplasty, abelacimab was more effective than enoxaparin for preventing postoperative VTE and was associated with a lower bleeding risk, whereas oral milvexian reduced postoperative VTE in a dose-dependent manner without a significant increase in bleeding [ 90 , 91 ]. At the same time, the first-in-human study of SHR-2004, an FXI monoclonal antibody developed in China, demonstrated dose-dependent pharmacokinetic and pharmacodynamic effects without major bleeding signals, suggesting that China has entered the early clinical development stage of this drug class [ 92 ]. However, current evidence for FXI/FXIa-targeted therapy is still derived mainly from orthopedic thromboprophylaxis and early-phase studies. Its role in established VTE, especially in complex settings such as CAT, remains to be clarified by ongoing phase 3 trials [ 93 ].

At present, the key future challenge in VTE care lies not only in technological innovation itself, but also in translating these emerging data into executable clinical pathways. To achieve continuous improvement in the diagnosis and treatment of VTE, China should continue to update national clinical guidelines, strengthen the development of specialized in-hospital VTE treatment teams and multidisciplinary collaborative care models, improve training systems for primary care and specialist medical staff, expand digital and intelligent diagnostic and treatment support systems, and establish a comprehensive, continuous management pathway spanning from inpatient care to postdischarge follow-up. Consequently, the next phase of VTE prevention and treatment in China should move toward more precise, comprehensive, and end-to-end care.

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Funding

This study is supported by the 10.13039/501100001809 National Natural Science Foundation of China ( 82470134 , 82103827 , 82470135 ), the Young Elite Scientists Sponsorship Program by CAST ( 2023QNRC001 ), and Program of National Key Research and Development Project of China (2022YFC2304600).

Author contributions

Y.H. and L.V.T. designed and supervised this study. All the authors contributed to the methodology and literature search. W.Z. drafted the manuscript. Q.L. reviewed and edited the manuscript. Z.C. contributed to the methodology and literature search and approved the final version of the manuscript. All authors read the manuscript and gave final approval for the version to be published.

Relationship disclosure

There are no competing interests to disclose.

Handling Editor: Professor Michael Makris

Wenqing Zhai and Qian Li contributed equally to this study.

Liang V Tang and Yu Hu contributed equally to this study.