Isolated distal deep vein thrombosis (DVT) represents up to 50% of all lower limb DVT in ultrasound-based studies and is a frequent medical condition, which management is not well established. Data arising from registries and nonrandomized studies suggest that most distal DVTs do not extend to the proximal veins and have an uneventful follow-up when left untreated. These data had some impact on international recommendations like the American College of Chest Physicians, whose last releases in 2016 and 2021, stated that ultrasound surveillance might be an option for selected low-risk patients. However, robust data arising from randomized studies are limited resulting in a significant variability in the care of isolated distal DVT. In this "Journal of Thrombosis and Haemostasis in Clinic" article, we present a case-based approach on how to differentiate patients who may be candidate for ultrasound surveillance with those who might benefit from a course of anticoagulant treatment and the duration of such a treatment.