Clinical Signs Of Deep Venous Thrombosis Research Articles

Perioperative prevalence of deep vein thrombosis in patients with percutaneous kyphoplasty: A retrospective study with routine ultrasonography.

In recent years, deep venous thrombosis (DVT) after spine surgery has received extensive attention, but perioperative prevalence of DVT in patients undergoing percutaneous kyphoplasty (PKP) is lacking.To assess the perioperative prevalence of deep vein thrombosis (DVT) in patients undergoing PKP with routinely applied ultrasonography.We reviewed 1113 consecutive patients undergoing PKP from January 2014 to August 2017. The surgical procedure was bilateral PKP. All patients were routinely examined with ultrasonography when admitted to the hospital and on the first post-operative day. Clinical signs of DVT were checked and recorded before examination.Forty (3.6%) out of 1113 patients were diagnosed with DVT by ultrasonography. Of the 40 detected cases of DVT, only six (0.54%) patients presented with clinical signs of DVT, demonstrating that there were 34 (3.05%) asymptomatic cases. No patient presenting with clinically suspected pulmonary embolism (PE) was observed. Gender, body mass index (BMI), operative time, hypertension, diabetes, heart disease, and lower limb fracture were not significant risk factors for DVT (P > .05). In contrast, patient age, oncologic conditions, DVT history, and paraplegia appeared to be significant risk factors for DVT (P < .01). There was no significant difference in the incidence of DVT found between the three PKP surgical levels (P > .05).The total incidence of perioperative DVT diagnosed with ultrasonography in patients undergoing PKP was 3.6%, of which only 0.54% was symptomatic cases. It is necessary to assess DVT using ultrasonography during the perioperative procedure of PKP, especially for high-risk patients.Level of evidence: Level IV.

Mandatory adherence to diagnostic protocol increases the yield of CTPA for pulmonary embolism.

ObjectivesTo determine if mandatory adherence to a diagnostic protocol increases the rate of computed tomography pulmonary angiographies (CTPAs) positive for pulmonary embolism (PE)—the so-called diagnostic yield. Further, we aim to identify factors associated with this diagnostic yield.MethodsWe included all patients with suspected PE requiring CTPA from 9 January 2014 t0 3 June 2014. The requesting physicians were forced to follow diagnostic workup for PE by calculating a Wells score and, if necessary, determining D-dimer level. The percentage of positive CTPA scans was calculated and compared with our previous cohort (Walen et al. Insights Imaging 2014;5(2):231–236). Odds ratios were calculated as a measure of association between dichotomous variables and CTPA findings.ResultsOf 250 scans, 74 were positive (29.6 % [95 % CI, 24.3-35.5 %]) and 175 were negative (70 %). The percentage positive scans increased with 6.6 % and the percentage negative scans decreased with 3.1 %. This change was statistically significant (p = 0.001). Independent clinical predictors of diagnostic yield were previous deep venous thrombosis (DVT) (OR, 3.22; p = 0.013) and clinical signs of DVT (OR, 2.71; p = 0.012). Chronic obstructive pulmonary disease (COPD) was negatively associated with PE (OR, 0.33; p = 0.045).ConclusionsThis study shows that mandatory adherence to a diagnostic protocol increases the yield of CTPA for PE in our centre.Main Messages• Mandatory adherence to diagnostic protocol increases the yield of CTPA for PE• Previous DVT and signs of DVT were associated with a higher yield• No patients with a low Wells score and a low D-dimer had PE

Incidence of Symptomatic and Asymptomatic Venous Thromboembolism After Elective Knee Arthroscopic Surgery: A Retrospective Study With Routinely Applied Venography

The purpose of this study was to assess the incidence of total venous thromboembolism (VTE) after knee arthroscopy with routinely applied venography. We reviewed 537 consecutive patients undergoing arthroscopic knee surgery from March 2012 to July 2013. The surgical procedure was categorized as simple anterior cruciate ligament reconstruction (ACLR), posterior cruciate ligament reconstruction (PCLR), or reconstruction of both cruciate ligaments. All patients having arthroscopy in our institution were routinely examined with venography on the third postoperative day. Clinical signs of DVT were checked and recorded before venography. Eighty (14.9%) of 537 patients were diagnosed with VTE by venography. Of the 80 detected cases of VTE, only 20 (3.7%) patients presented with clinical signs of DVT, indicating that there were 60 (11.2%) asymptomatic cases. No patient died or presented with a clinically suspected pulmonary embolism (PE). Sex, body mass index (BMI), operative time, and duration of tourniquet application were not significant risk factors for DVT. Patient age (P < .0001) is a strongly significant risk factor for deep venous thrombosis (DVT). Compared with patients who underwent simple arthroscopic procedures, complex procedures-the reconstruction of 1 (P < .005) or both knee cruciate ligaments (P < .0005)-led to a significantly higher postoperative incidence of DVT. The total incidence of VTE diagnosed with venography after arthroscopic knee surgery was 14.9%, of which only 3.7% of cases were symptomatic, indicating 11.2% cases of silent VTE. Advanced age and complex arthroscopic surgery are strongly associated with VTE. Level IV, prognostic case series.

Clinical prediction of pulmonary embolism in respiratory emergencies

Introduction The initial management of suspected pulmonary embolism (PE) is commonly done in respiratory departments, but is based on clinical prediction rules developed in other settings. Objective To determine the accuracy of established prediction rules for PE in patients with respiratory emergencies. Design A prospective study Materials and Methods Patients presenting to respiratory emergency department with acute symptoms and signs suggestive of PE ( n = 183) and subsequently admitted to hospital were prospectively enrolled. Wells’ rule, original and revised Geneva scores, their components separately, and other common clinical parameters were recorded during admission. PE was diagnosed by perfusion lung scanning, computed tomographic pulmonary angiography, lower limb venous ultrasonography, magnetic resonance pulmonary angiography, and/or pulmonary angiography. Results PE was confirmed in 52 and ruled out in 131 patients. Tachycardia, atelectasis, elevated hemidiaphragm, clinical signs of deep-venous thrombosis, physician perception that PE is the likeliest diagnosis, previous thromboembolism, chest pain, and absence of chronic obstructive pulmonary disease or cough were associated with the presence of PE. These significant parameters could be combined for accurate pre-test PE prediction, with a newly devised combinatorial tool exhibiting the highest area under curve [0.92 (95% CI: 0.87-0.97)], followed by Wells’ rule [0.86 (95% CI 0.79-0.92)], the revised Geneva score [0.83 (95% CI 0.77-0.90)], and the original Geneva score [0.75 (95% CI 0.68-0.83)]. Conclusion Wells’ rule and the revised Geneva score are more useful in diagnosing PE in respiratory emergencies. A newly devised prediction tool can be of even greater accuracy in this patient population.

Venous thromboembolism after spine surgery: changes of the fibrin monomer complex and D-dimer level during the perioperative period

The goal of this study was to determine the incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) after spine surgery. Another purpose was to clarify the rapid changes of the fibrin monomer complex (FMC) and D-dimer levels during the perioperative period of spine surgery for early diagnosis of venous thromboembolism (VTE). The participants were 72 patients who underwent spine surgery between September 2007 and March 2008. The FMC and D-dimer levels were measured 6 times: 1) at induction of general anesthesia; 2) just after implantation or during surgery; 3) immediately following surgery; 4) 1 day after surgery; 5) 3 days postsurgery; and 6) 7 days after surgery. All patients received mechanical prophylaxis, including compression stockings and intermittent pneumatic compression devices, and all were examined with duplex ultrasonography assessments of both lower extremities and with lung perfusion scintigraphy 7-10 days after surgery. If DVT or PE was suspected, the patient underwent multidetector CT venography. There were no patients with clinical signs of DVT and PE, but 6 (8.3%) showed VTE, among whom 5 had DVT and 3 had PE. Patients with VTE had significantly higher FMC levels 1 day after surgery, compared with those without VTE (55.9 ± 17.2 μg/ml vs 11.1 ± 2.89 μg/ml; p < 0.01). Patients with VTE had significantly higher D-dimer levels 7 days postsurgery, compared with those without VTE (12.5 ± 2.95 μg/ml vs 4.3 ± 0.39 μg/ml; p < 0.01). Receiver operating characteristic analysis showed that the FMC result was more useful than the D-dimer assay for diagnosis of VTE. When the cutoff value was set to 20.8 μg/ml for FMC, sensitivity was 100% and specificity was 86.3%. In this study the prevalence of VTE after spine surgery was 8.3%. The FMC measured 1 day after spine surgery is considered to be useful as an indicator of VTE.

Noncontrast CT in Deep Cerebral Venous Thrombosis and Sinus Thrombosis: Comparison of its Diagnostic Value for Both Entities

With its highly variable clinical presentation, the diagnosis of cerebral venous sinus thrombosis (SVT), and especially of deep venous thrombosis (DVT), as rare but important causes of stroke is challenging. Because noncontrast cranial CT (NCCT) is still the imaging technique of choice in most emergency departments, we aimed to investigate its value in the diagnosis of SVT and DVT. Screening our patient data base, we identified 8 patients with DVT and 25 patients with SVT. We also included a control group of 36 patients who had presented with clinical signs of DVT or SVT but in whom thrombosis was subsequently excluded. MR imaging, multidetector row CT angiography (MDCTA), and/or digital subtraction angiography (DSA) were used as the reference standard. Three independent readers assessed the NCCTs for the presence of direct and indirect signs of DVT or SVT. Direct signs included the presence of hyperattenuated sinuses (ie, cord sign) or veins (ie, attenuated vein sign), whereas parenchymal edema and hemorrhage were indirect signs. The sensitivity and specificity of the attenuated vein sign for the diagnosis of DVT were 100%, and 99.4%, respectively, whereas the sensitivity and specificity of the cord sign for SVT were 64.6% and 97.2%, respectively. The sensitivity and specificity values of NCCT were 93.7% and 98% for intracerebral edema and 94.8% and 98.7% for intracerebral hemorrhages, respectively. Although NCCT is insufficient to exclude a SVT, its value in the emergency diagnosis of DVT seems to be very high.

Relationship between the extent of deep venous thrombosis and the extent of acute pulmonary embolism as assessed by CT angiography

The aim of our study is to investigate prospectively the quantitative relationship between deep venous thrombosis (DVT) and acute pulmonary embolism (PE). 110 patients clinically suspected of having venous thromboembolic disease underwent combined CT pulmonary angiography (CTPA) and venography of lower limb veins. 44 patients presented with clinical signs of DVT and positive ultrasonography or ascending venography, but no clinical sign of PE (Group 1). 66 patients presented with clinical signs of PE and positive CTPA (Group 2). Clot load in lower limb veins and pulmonary arteries were scored by two independent readers, each using two separate systems for DVT and two for PE. 27 (61%) patients in Group 1 also had PE, and 55 (83%) patients in Group 2 also had DVT. Correlations between PE and DVT scores were weak but statistically significant in Group 2 (r(s) ranging from 0.470-0.520; p< or =0.001), but only some were significant in Group 1 (r(s) ranging from 0.253-0.318; p-values ranging from 0.035-0.097). In conclusion, although PE occurs in a majority of patients with DVT, and vice versa, the amount/burden of clot load in one condition does not necessarily indicate - or indicates only weakly - the degree of burden in the other condition.

Poster 173: Deep venous thrombosis in patients with Guillain-Barré syndrome undergoing inpatient rehabilitation.

Objectives: To determine (1) the incidence of deep venous thrombosis (DVT) in patients with Guillain-Barré syndrome (GBS) who are undergoing inpatient rehabilitation and (2) the percentage of these patients who are on anticoagulant prophylaxis and are imaged for DVT while they are on the rehabilitation service. Design: Retrospective chart review. Setting: Inpatient rehabilitation service in an academic hospital. Participants: 36 patients newly diagnosed with GBS admitted for inpatient rehabilitation. Interventions: Not applicable. Main Outcome Measures: Percentage of patients diagnosed with DVT, started and maintained on anticoagulation for DVT prophylaxis, and imaged with duplex ultrasound to diagnose DVT. Results: 4 patients (11.1%) were diagnosed with DVT. A patient had a clot in a proximal vein (femoral) and 3 patients had clots in distal veins (1 peroneal, 1 posterior tibial, 1 peroneal and soleal). 3 of these 4 patients had clinical signs of DVT (calf tenderness and/or unilateral swelling). 20 patients (55.6%) were on DVT prophylaxis (unfractionated heparin, aspirin, coumadin) on admission to the rehabilitation service, and 28 patients (77.9%) were on DVT prophylaxis (unfractionated heparin, low molecular weight heparin, aspirin, coumadin) during their inpatient rehabilitation stay. 11 patients (30.6%) were imaged by duplex ultrasound to rule out DVT. Conclusions: DVT was an infrequent complication in these rehabilitation inpatients with GBS, possibly because most were on anticoagulant prophylaxis while on the rehabilitation service. A prospective study on this issue is suggested.

Clinical features of acute pulmonary thromboembolism in younger patients.

The incidence of acute pulmonary thromboembolism (APTE) in younger patients is extremely low compared with older patients, so the clinical features of these younger patients with APTE is unknown. In the present study, 8 patients with APTE who were less than 40 years old (YG) were compared with 40 patients who were more than 41 years of age (OG). All YG patients had coagulopathy compared with 3 patients in the OG (p<0.01). Deep venous thrombosis (DVT) occurred in all 8 patients in the YG compared with 19 patients in the OG (p<0.01). A higher incidence of patients whose symptoms occurred gradually was noted in the YG (p<0.05). There were no significant differences in clinical characteristics, initial symptoms, past history or other predisposing factors for venous thromboembolism between the 2 groups. Residual pulmonary hypertension was not noted in the YG. However, 1 patient in the YG had recurrent APTE, despite good warfarin control. This study demonstrated the frequency of gradual onset, coagulopathy and clinical signs of DVT in the YG and therefore more careful and long-term observation is necessary in such patients.

Local venous thrombosis after cardiac catheterization.

Pulmonary embolism is a rare but life-threatening complication of cardiac catheterization. Underlying deep venous thrombosis (DVT) is often not detectable clinically. To determine the true incidence of DVT the authors prospectively studied 450 consecutive patients (29% women, 71% men, mean age: fifty-eight years) undergoing a diagnostic cardiac catheterization. Patients were examined clinically and by duplex sonography with a high-resolution (5 or 7.5 MHz) transducer before and twenty-four hours after catheterization before mobilization. Duplex sonography excluded complete proximal DVT in all patients. Only partial occluding thrombi (pDVT) were detected in 11 (2.4%) patients. The thrombi were always localized at the puncture site. In 2 patients a difference was found in the circumferences of the legs, but no other clinical signs of DVT were seen. With use of continuous wave (cw) Doppler sonography, only 3 of these 11 patients (27%) showed a spontaneous (s) sound. Phlebography was performed in 4/11 patients (36%). In 2 patients the diagnosis was confirmed; in 1 patient extravenous compression was assumed, and the other demonstrated a normal-appearing phlebography at the time of investigation. Logistic regression analysis yielded a 3.5 times higher risk for developing a pDVT if a venous puncture was performed in addition to arterial puncture. Furthermore a 9.8 times higher risk was found if more than one venous puncture was necessary. During the follow-up no patient developed clinical signs of pulmonary embolism. The results of this study demonstrate that DVT is a rare complication of cardiac catheterization (0/450 patients), but pDVT occurred in 2.4%. Risk factors for pDVT are the venous puncture itself and multiple puncture attempts. Clinical relevance of pDVT remains to be determined.