Research on interventional treatment strategies for lower extremity deep venous thrombosis based on real-world data

Objective To evaluate diagnostic value of plasma D-dimer (D-D),fibrinogen (Fg) and Ddimer/fibrinogen (D/F) ratio in acute lower extremity deep vein thrombosis (DVT) after artificial joint replacement.Methods From August 2009 to December 2011,273 patients who had undergone total hip arthroplasty (THA) or total knee arthroplasty (TKA) underwent venography of lower extremity deep vein at 35 days postoperatively.According to results of angiography,all patients were divided into DVT group including 66 patients (15 males and 51 females,median age 66 years) and non-DVT group including 207 patients (70 males and 137 females,median age 63 years).Plasma levels of D-D and Fg were measured by immunoturbidimetry and solidification methods respectively preoperatively and at 3-5 days postoperatively.The differences of plasma levels of D-D and Fg and D/F ratio between the two groups were analyzed with statistical method.Furthermore,diagnostic value of postoperative plasma D-D and D/F ratio in acute DVT was assessed using a receiver operating characteristic (ROC) curve.Results There was no statistical significance in preoperative plasma levels of D-D and Fg,and postoperative plasma levels of Fg between two groups.However,the postoperative plasma levels of D-D and D/F ratio were higher in the DVT group than those in the nonDVT group,and there was significant difference between two groups.In addition,the ROC curve analysis showed that the area under curve of postoperative plasma D-D and D/F ratio was 0.688 and 0.684,respectively,but this difference did not reach statistical significance.Conclusion Plasma Fg may be meaningless for the diagnosis of acute DVT after artificial joint replacement.Although plasma D-D and D/F ratio may be useful for diagnosing acute DVT,the diagnostic accuracy is low. Key words: Fibrinogen; Venous thrombosis; Arthroplasty,replacement

Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal

Thrombosis in the healthy pediatric population is a rare occurrence. Little is known about the optimal treatment or outcomes of children with unprovoked acute lower extremity (LE) deep vein thrombosis (DVT) associated with atresia of the inferior vena cava (IVC). We retrospectively analyzed the records of patients with acute LE DVT subsequently found to have IVC atresia who presented to two tertiary pediatric institutions between 2008 and 2016. Data were reviewed for thrombophilia risk factors, treatment, and outcomes. Eighteen patients, aged 13-18 years (median: 16 years), presenting with acute LE DVT were found to have IVC atresia. Three patients also presented with pulmonary embolism. Fourteen patients underwent site-directed thrombolysis in addition to anticoagulation. Five patients (28%) had confirmed or suspected recurrent thrombosis. Thirteen patients (72%) had no identified provocation for DVT. Ten patients (56%) had post-thrombotic syndrome, and 17 of 18 patients remain on indefinite anticoagulation. This study suggests that IVC atresia is a risk factor for LE DVT and pulmonary embolism in otherwise healthy children and highlights the importance of dedicated imaging of the IVC in young patients with unprovoked LE DVT. Indefinite anticoagulation may be considered in pediatric patients presenting with unprovoked thrombosis secondary to an atretic IVC.

Acute lower extremity deep vein thrombosis (DVT) is a common disorder with significant associated morbidity, including pain and swelling, as well as the risk of pulmonary embolism (PE), recurrent venous thromboembolism (VTE) and chronic debilitating post-thrombotic syndrome (PTS). Anticoagulation is standard of care for DVT treatment. It assists in reducing thrombus progression and the occurrence of PE, but incomplete DVT resolution increases the risk of recurrent VTE, valvular insufficiency, and PTS. Endovascular DVT interventions, such as catheter-directed thrombolysis, pharmacomechanical thrombectomy, and large-bore mechanical thrombectomy offer an alternative therapeutic strategy for DVT management. This paper will discuss technical factors and current issues when performing lower extremity DVT interventions including patient selection, anticoagulation, choice of device for endovascular thrombus removal, adjunctive techniques, and venous stent management.Level of Evidence: No level of evidence for: review articles, basic science, laboratory investigations, and experimental study articles.

Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal

Wells Clinical Probability and D-dimer Testing: Risk Stratification for Acute Lower Extremity Deep Vein Thrombosis

Defining the role of risk stratification and duplex ultrasound in the diagnosis of acute lower extremity deep vein thrombosis

Patients With Right Lower Extremity Deep Vein Thrombosis Have a Higher Risk of Symptomatic Pulmonary Embolism: A Retrospective Study of 1585 Patients

ABSTRACTObjectives: To evaluate case series studies that quantitatively assess the effects of catheter-directed thrombolysis (CDT) and compare the efficacy of CDT and anticoagulation in patients with acute lower extremity deep vein thrombosis (DVT). Methods: Relevant databases, including PubMed, Embase, Cochrane, Ovid MEDLINE and Scopus, were searched through January 2017. The inclusion criteria were applied to select patients with acute lower extremity DVT treated with CDT or with anticoagulation. In the case series studies, the pooled estimates of efficacy outcomes for patency rate, complete lysis, rethrombosis and post-thrombotic syndrome (PTS) were calculated across the studies. In studies comparing CDT with anticoagulation, summary odds ratios (ORs) were calculated. Results: Twenty-five articles (six comparing CDT with anticoagulation and 19 case series) including 2254 patients met the eligibility criteria. In the case series studies, the pooled results were a patency rate of 0.87 (95% CI: 0.85-0.89), complete lysis 0.58 (95% CI: 0.40-0.75), rethrombosis 0.11 (95% CI: 0.06-0.17) and PTS 0.10 (95% CI: 0.08-0.12). Six studies comparing the efficacy outcomes of CDT and anticoagulation showed that CDT was associated with a reduction of PTS (OR 0.38, 95%CI 0.26-0.55, p<0.0001) and a higher patency rate (OR 4.76, 95%CI 2.14-10.56, p<0.0001). Conclusion: Acute lower extremity DVT patients receiving CDT were found to have a lower incidence of PTS and a higher incidence of patency rate. In our meta-analysis, CDT is shown to be an effective treatment for acute lower extremity DVT patients.

Soluble P-Selectin for the Diagnosis of Deep Vein Thrombosis (DVT) in Cancer Patients

4:18 PM Abstract No. 167 - Balloon-assisted catheter-directed thrombolysis for acute lower extremity deep vein thrombosis

Presence and degree of residual venous obstruction on serial duplex imaging is associated with increased risk of recurrence and progression of infrainguinal lower extremity deep venous thrombosis

Combining clinical risk with D-dimer testing to rule out deep vein thrombosis

Acute lower extremity deep vein thrombosis (DVT) occurs due to obstruction of large veins by thrombus and its clinical findings are pain and swelling. If not treated, it can cause morbidity and mortality. Oral warfarin or low molecular weight heparin are applied in traditional treatment. However, recently, endovascular procedures have gained increasing popularity in deep vein thrombosis. In this study we aimed to compare our early results of pharmacomechanical thrombectomy (PMT) versus oral anticoagulation for acute deep vein thrombosis. We comprised 50 patients presented with acute DVT between January 2013 and June 2014, who received either adjusted subcutaneous low molecular weight heparin (LMWH) or PMT followed by intravenous unfractionated heparin (UFH) for 5 days. Warfarin was administered to PMT patients for 3 months and at least 6 months for the control group. Median follow-up was 14 months (6-18 months). Recanalization within 6 months was found in 84.0%, femoral venous insufficiency was found in 36.0%, and postthrombotic syndrome (PTS) was found in 28.0% of the patients who received PMT treatment. The mean duration of symptoms was 11.0 days (range, 3-20 days). The mean duration of the procedure was 78.1 minutes (range, 55-100 min). In contrast to medical therapy in the treatment of deep vein thrombosis, usage of catheter-directed thrombolysis experienced early recanalization with higher thrombus resolution. PMT with adjunctive thrombolytic therapy is an effective treatment modality in patients with significant DVT. Also, early thrombus removal in patients with acute DVT prevents development of postthrombotic morbidity. We believe that the efficacy and usage will increase with the experience of surgeons in the future.

Objective To investigate the efficacy and safety of balloon-assisted catheter directed thrombolysis (CDT) for acute lower extremity deep vein thrombosis (DVT).Methods From September 2008 to February 2011,94 patients with acute lower extremity DVT were admitted.The cases in early stage were treated by CDT (Group A,n =50),and the cases in late stage were treated by balloon-assisted CDT ( Group B,n =44).The clinical data of these patients were retrospectively analyzed.The circumference difference between normal and affected limbs,scores of venous patency,and rates of venous patency were recorded for judging the efficacy.The total dose of urokinase and retention time of infusion catheter was compared between the two groups.The incidence of pulmonary embolism and bleeding were used to judge the safety of treatment.The venous patency was followed up by ultrasound or/and venography.Measurement data with normal distribution was described by mean + standard,and was analyzed using T test.Measurement data with non-normal distribution was described by M ( QL,QU ),QL =P25,QU =P75,and was analyzed using Wilcoxon' s test.Categorical variable data was analyzed using Chi-Square test Results The prior treatment circunfference difference between normal and affected limbs were (5.37 ±1.97) cm (thigh) & (4.14 ± 1.57) cm (calf) in Group A and (5.41±2.22) cm (thigh) & (4.05 ±1.61) cm (calf) in Group B ; and the difference between the groups was insignificant ( thigh:t =- 0.113,P=0.910; calf:t =0.288,P =0.774).The post treatment correspondences were:(2.96 ± 1.10) cm (thigh) & ( 1.93 ± 0.84 ) cm (calf) in Group A and ( 1.78 ± 1.40) cm ( thigh ) & ( 1.41± 1.17 ) cm (calf) in Group B; the difference between the groups was significant (thigh:t =4.66,P ＜0.0001; calf:t =2.548,P =0.012 ).The prior treatment score of venous patency was 9 (8,10) in Group A and 8.3(7,10) in Group B without significant difference (Z =- 1.5172,P =0.1292).The post treatment score of venous patency was 3.5 ( 2,5 ) in Group A and 0 ( 0,1) in Group B with significant difference ( Z =-5.7702,P ＜0.01).The rate of venous patency after the treatment was 55.0％ (42.3％,72.4％ ) in Group A and 100％ (88.5％,100％ ) in Group B,with significant difference ( Z =4.9148,P ＜ 0.01).The total dose of urokinase used in the treatment was 5.950 ( 5.525,7.225 ) × 106U in Group A and 4.100 (3.600,5.050) × 106U in Group B with significant difference (Z =-6.0133,P ＜ 0.01).The retention time of perfusion catheter was 10 (9,12) d in Group A and 6 (5,7) d in Group B with significant difference ( Z =- 8.0358,P ＜ 0.01).No symptomatic pulmonary embolism occurred in both groups during the treatment and follow-up period.The rate of bleeding complication was 38.0％ (19/50) in Group A and 22.3％ (10/44) in Group B,without significant difference (x2 =2.5590,P =0.1097 ).The removal rate of optional filter was 88.37％ (38/43) in Group A and 100％ (39/39) in Group B,with significant difference ( x2 =4.829,P =0.028 ).The rate of venous patency at the last follow-up point was 50.0％ (44.4％,59.2％ ) in Group A,and 95.4％ (83.6％,100％ ) in Group B,with significant difference (Z =- 3.2721,P =0.0011).Conclusions Balloon-assisted CDT was a promising treatment for acute lower-extremity DVT.It improved the effect of thrombolysis and reduced the dosage of urokinase,and did not increase the risk of pulmonary embolism. Key words: Venous thrombosis; Lower extremity; Thrombolytic therapy; Vena cava filters; Angioplasty, balloon