Complication Of Deep Venous Thrombosis Research Articles

Effect of Implementing Nursing Guidelines on Occurrence of Deep Venous Thrombosis for Critically Ill Patients

B ackground: Deep venous thrombosis (DVT) is a major health problem that results in significant morbidity and mortality for the critically ill patients in the critical care units. It was documented that occurs in about two million Americans each year, whereas pulmonary embolism (PE) as a complication of causes approximately 50.000 to 60.000 deaths. Moreover, it was revealed by a study done in Assuit University Hospital that out of 220 surgical patients, 12 (5%) died with pulmonary embolism as a complication of DVT. Other research done at Alexandria University in El-Hadra Hospital on 50 orthopedic patients revealed that seven patients were detected with DVT. The critical care nurses are the key players in the prevention of and its complications. They are in the ideal position to asses' patient risk factors early and ask for prophylaxis. Objective : the current study was carried out to evaluate the effect of implementing nursing guidelines on the occurrence of for critically ill patients. Methods : Four critical care unites were used to collect the data for this study at Assuit University Hospital, sixty critically ill patients were included in this study, they were divided into two groups G1 (control group) and G2 (interventional group) 30 patients each. Two tools were used to collect the data of this study. Tool one: Patient’s assessment for DVT, and Tool two : the DVT evaluation sheet. Results and conclusion: Findings of the current study revealed low incidence of for the global sample, only two patients experienced in the control group, and none of the interventional group experienced DVT. Moreover, it was observed that the preventive measures of done by the critical care nurses for the control group using non-pharmacological and mechanical methods were not adequately performed. In addition, it was found that all the studied patients of control group did not wear the elastic stocking, while small proportion of this group performed leg exercises, changed their position, did deep breathing, and coughing exercises, and transfer on the chair. It was observed that most of the studied patients experienced low percent of manifestations with no statistical significant difference between the both groups. The present study revealed also that nearly half of the studied patients were in moderate & high risk grades for in the both groups. Recommendations: based on the current study findings it can be recommended that this research should be repeated on a large sample size and in multi centers for generalization. Moreover, training programs should be established to update critical care nurses' knowledge and skills about preventive measures, and how to use the technical skills to assess the occurrence of using the evidence base nursing and medicine.

Acute venous disease: Venous thrombosis and venous trauma

Acute venous disorders include deep venous thrombosis, superficial venous thrombophlebitis, and venous trauma. Deep venous thrombosis (DVT) most often arises from the convergence of multiple genetic and acquired risk factors, with a variable estimated incidence of 56 to 160 cases per 100,000 population per year. Acute thrombosis is followed by an inflammatory response in the thrombus and vein wall leading to thrombus amplification, organization, and recanalization. Clinically, there is an exponential decrease in thrombus load over the first 6 months, with most recanalization occurring over the first 6 weeks after thrombosis. Pulmonary embolism (PE) and the post-thrombotic syndrome (PTS) are the most important acute and chronic complications of DVT. Despite the effectiveness of thromboembolism prophylaxis, appropriate measures are utilized in as few as one-third of at-risk patients. Once established, the treatment of venous thromboembolism (VTE) has been defined by randomized clinical trials, with appropriate anticoagulation constituting the mainstay of management. Despite its effectiveness in preventing recurrent VTE, anticoagulation alone imperfectly protects against PTS. Although randomized trials are currently lacking, at least some data suggests that catheter-directed thrombolysis or combined pharmaco-mechanical thrombectomy can reduce post-thrombotic symptoms and improve quality of life after acute ileofemoral DVT. Inferior vena caval filters continue to have a role among patients with contra-indications to, complications of, or failure of anticoagulation. However, an expanded role for retrievable filters for relative indications has yet to be clearly established. The incidence of superficial venous thrombophlebitis is likely under-reported, but it occurs in approximately 125,000 patients per year in the United States. Although the appropriate treatment remains controversial, recent investigations suggest that anticoagulation may be more effective than ligation in preventing DVT and PE. Venous injuries are similarly under-reported and the true incidence is unknown. Current recommendations include repair of injuries to the major proximal veins. If repair not safe or possible, ligation should be performed.

Effectiveness of compression stockings to prevent the post-thrombotic syndrome (The SOX Trial and Bio-SOX biomarker substudy): a randomized controlled trial

BackgroundPost thrombotic syndrome (PTS) is a burdensome and costly complication of deep venous thrombosis (DVT) that develops in 20–40% of patients within 1–2 years after symptomatic DVT. Affected patients have chronic leg pain and swelling and may develop ulcers. Venous valve disruption from the thrombus itself or thrombus-associated mediators of inflammation is considered to be a key initiating event for the development of venous hypertension that often underlies PTS. As existing treatments for PTS are extremely limited, strategies that focus on preventing the development of PTS in patients with DVT are more likely to be effective and cost-effective in reducing its burden. Elastic compression stockings (ECS) could be helpful in preventing PTS; however, data on their effectiveness are scarce and conflicting.Methods/DesignThe SOX Trial is a randomized, allocation concealed, double-blind multicenter clinical trial. The objective of the study is to evaluate ECS to prevent PTS. A total of 800 patients with proximal DVT will be randomized to one of 2 treatment groups: ECS or placebo (inactive) stockings worn on the DVT-affected leg daily for 2 years. The primary outcome is the incidence of PTS during follow-up. Secondary outcomes are severity of PTS, venous thromboembolism (VTE) recurrence, death from VTE, quality of life and cost-effectiveness. Outcomes will be evaluated during 6 clinic visits and 2 telephone follow ups. At baseline, 1 and 6 months, blood samples will be obtained to evaluate the role of inflammatory mediators and genetic markers of thrombophilia in the development of PTS (Bio-SOX substudy).DiscussionThe SOX Trial will be the largest study and the first with a placebo control to evaluate the effectiveness of ECS to prevent PTS. It is designed to provide definitive data on the effects of ECS on the occurrence and severity of PTS, as well as DVT recurrence, cost-effectiveness and quality of life. This study will also prospectively evaluate the predictive role of biomarkers that are reflective of putative underlying pathophysiological mechanisms in the development of clinical PTS. As such, our results will impact directly on the care of patients with DVT.Trial RegistrationNCT00143598 and ISRCTN71334751

A PHARMACY-ORIENTED INITIATIVE INCREASES DEEP VENOUS THROMBOSIS PROPHYLAXIS RATES.

Purpose Venous thromboembolism (VTE) is a disease that includes both deep venous thrombosis (DVT) and pulmonary embolism (PE). VTE accounts for more than 250,000 hospitalizations annually in the United States and may be the most common preventable cause of death in hospitalized patients (Kim, 2001). PE is a complication of DVT, and approximately 25 to 30% of untreated patients with proximal DVT will develop symptomatic PE (Geerts, 2004). In hospitalized medical patients, up to 1 in 20 patients will suffer a fatal PE (Baglin, 1997). Based on the infrequent use of thromboprophylaxis, some authors have speculated that physician awareness and recognition of patient risk factors for VTE could be improved. Experimental Design and Methods All patients admitted to the general internal medicine inpatient service over a 12-week period from Sunday 7 am to Friday 7 am were included in the study. Four inpatient medicine teams rotate every 24 hours for admissions. Two teams were designated as “interventional” and two teams as “control.” For the patients admitted to the two teams assigned to the intervention group, electronic medical records were queried by the pharmacy staff the morning after admission and the history and physical examination note identified. The admission history and physical examination note was then used and to determine the patient9s risk for DVT. The medium- to high-risk patients were then pointed out to the physician. The physician was then left to decide whether or not to institute DVT prophylaxis. IfIf pharmacologic prophylaxis was an option, they were left to decide which evidence-based therapy would be administered. TThe primary goal of the study was the appropriate administration of DVT prophylaxis within 30 hours of the patient9s hospital admission. Summary of Results The study is currently in its last stage and has 149 patients in the interventional group and 161 in the control group. Interim analysis of randomly selected subject records showed that appropriate DVT prophylaxis rates in the control group were 8 of 15 or 53% and 13 of 15 or 86% in the interventional group. Conclusions Preliminary data suggest that the pharmacy-driven DVT prophylaxis initiative, as outlined in the study, is an effective and feasible tool for increasing DVT prophylaxis rates among general internal medicine inpatients. This may be an effective tool that can increase compliance with JCAHO standards for an effective DVT prophylaxis inpatient program.

Outcome of Laparoscopic Live Donor Nephrectomy in 2005: National Survey of Japanese Transplantation Centers

The increased acceptance of laparoscopic nephrectomy (LN) has been a driving force for live donor kidney transplantation. However, the outcomes of LN in live donors has not yet been clarified in Japan. In this study, we surveyed 125 Japanese kidney transplantation centers to investigate the current status of live donor LN. Of 125 centers, the 98 that responded had performed 695 live donor nephrectomies. Among these centers, 43 had performed LN. Among the 695 nephrectomies, 441 donors had undergone LN and 254, open nephrectomies. In 43 centers, 16 were performed as hand-assisted (HA) LN; 20, non-HA; 3, both HA and non-HA; and 5 laparoscope-assisted. Ten centers used a peritoneal approach; 30, a retroperitoneal; and 3, both. In 441 LN donors, 1 had a life-threatening complication of deep venous thrombosis and survived. Blood transfusions were performed in 7 donors. Open conversions from LN were necessary in 24. Minor complications not requiring prolonged hospital stay were reported in 52. The mortality of LN was zero. In contrast, among the 441 recipients, 1 case was reported as primary nonfunction after venous misadventure in the operation and 30 recipients needed hemodialysis after transplantation because of delayed graft function. Urinary tract complications were noted in 11 recipients. This survey presented the current status of the procedure, providing a base for informed consent from potential donors.

Is Perioperative Blood Transfusion a Risk Factor for Mortality or Infection After Hip Fracture?

To assess whether allogeneic blood transfusion in the perioperative period is associated with changes in mortality or complication rates in patients undergoing surgical treatment for hip fracture (proximal femoral fracture). Retrospective case-control series, all patients followed up for 1 year or until death. District General Hospital in Peterborough, UK. PATIENTS PARTICIPANTS: Three thousand six hundred twenty-five consecutive patients admitted and operated for hip fracture (proximal femoral fracture) during July 1989 to January 2002 (151 months); 1068 (29.9%) received a perioperative allogeneic blood transfusion. Thirty- 120-, and 365-day mortality, deep and superficial wound infection rates. Overall mortality for all patients at 1 year post fracture was 28.2% (1007 patients). Transfusion was associated with a statistically significant increase in mortality from 120 days onward after hip fracture. However, when this was adjusted with a statistical regression model for baseline characteristics and confounding variables, this difference became statistically insignificant (P = 0.17). Infection rates in the transfusion group were 2.0% for superficial infection and 0.9% for deep infection compared with 1.9% and 0.6%, respectively, in the nontransfusion group. These figures were not statistically significantly different. Other complications of deep venous thrombosis, chest infection, and congestive cardiac failure showed no statistically significant increase in those patients who received transfusion. Our data suggest that transfusion is not associated with a change in mortality or infection rates in the hip-fracture patient.

Frequency and determinants of the postthrombotic syndrome after venous thromboembolism

Postthrombotic syndrome (PTS) is the most common complication of deep venous thrombosis (DVT). Identifying which patients are at high risk of developing PTS would help improve the management of patients with DVT and allow physicians to provide patients with individualized information on their expected prognosis. This review discusses the knowledge gained from key studies over the last decade on the incidence and determinants of PTS, with special emphasis on published studies from the last 2 years. About a third to half of DVT patients will develop PTS, in most cases within 1-2 years of acute DVT. Important risk factors for PTS appear to be ipsilateral recurrence of DVT, poor quality of initial anticoagulation for the treatment of DVT and increased body mass index. Preventing DVT recurrence by providing adequate intensity and duration of anticoagulation for the initial DVT and using effective thromboprophylaxis in high-risk settings is likely to reduce the frequency of PTS. Despite some advances in identifying risk factors for PTS, however, it is still not possible to reliably predict an individual patient's risk of developing PTS after an episode of DVT. Further studies of clinical determinants and biological markers of increased risk of PTS are needed to ultimately improve long-term prognosis after DVT.

The post‐thrombotic syndrome: progress and pitfalls

The post-thrombotic syndrome (PTS) develops in up to one half of patients after symptomatic deep venous thrombosis (DVT) and is the most common complication of DVT. Typical features of PTS include chronic pain, swelling, heaviness, oedema and skin changes in the affected limb. In severe cases, venous ulcers may develop. The frequency of PTS is likely to be reduced by preventing DVT with the use of effective thromboprophylaxis in high-risk patients and settings and by minimising the risk of ipsilateral DVT recurrence. Use of compression stockings for 2 years after DVT appears to reduce the incidence and severity of PTS but issues remain regarding their use and effectiveness. Future research should focus on elucidating the pathophysiology and risk factors for PTS, assessing the safety and effectiveness of catheter-directed thrombolysis to prevent PTS and evaluating the optimal use of compression stockings to prevent and treat PTS. In addition, new therapies to treat PTS should be sought and evaluated.

Pulmonary Embolism: A Frequent Occurrence in Indian Patients with Symptomatic Lower Limb Venous Thrombosis

Pulmonary embolism (PE) is the most severe complication of deep venous thrombosis (DVT). There have been very few studies to assess the prevalence of PE in Asian patients. The objective of this study was to define the prevalence of PE in patients presenting with suspected lower limb DVT. This was a prospective cohort study at Sir Ganga Ram Hospital, a large multispecialty hospital in New Delhi, India. From January 2001 to July 2004, 1,552 consecutive inpatients and outpatients who presented with clinically suspected lower limb DVT were enrolled in the study. Combined ascending radionuclide venography and lung perfusion scan was performed in all patients. Patients with evidence of pulmonary perfusion defects underwent ventilation lung scan. Radionuclide venography-detectable DVT was noted in 744 patients, of whom 521 (70%) had suprapopliteal DVT. Of patients with DVT, 294 (39.5%) showed a high-probability lung scan and 135 (18.1%) had an intermediate-probability lung scan. Overall, 47% of patients with a high-probability scan had no clinical manifestations suggestive of PE. PE occurs frequently in Indian patients with symptomatic DVT. Increasing awareness will provide us with clearer ideas about the prevalence of venous thromboembolism in Asian countries.

Fifteen Years Ago Laser was Supposed to Open Arteries, Now it is Supposed to Close Veins: What is the Reality Behind the Tool?

Laser first emerged as a technology for use in the vascular arena nearly 20 years ago. The ability of laser to evaporate atherosclerotic plaque was extensively studied; however, the goal of creation of an adequate channel without arterial wall perforation proved to be elusive, and the technique fell into disfavor. More than a decade later, interest in lasers was sparked again with its application to endovenous thermal ablation of axial superficial venous reflux. The mechanism of action of endovenous laser therapy involves thermal damage of the vein wall, resulting in destruction of the intima and collagen denaturation of the media with eventual fibrotic occlusion of the vein. Apart from the obvious attraction of a minimally invasive procedure to ablate superficial venous reflux with its attendant benefits, another advantage of laser ablation includes a potentially decreased incidence of neovascularization in the groin secondary to preservation of superficial venous drainage of the abdominal wall. Early success in terms of ablation of the refluxing saphenous vein has been reported as 90% to 95%. Minor complications are reported in 3% to 10% of patients and include bruising around the puncture site, transient paresthesias, superficial phlebitis, and skin burns or pigmentation. The more serious complications of deep venous thrombosis or extension of thrombus into the femoral vein have been variously reported in 0% to 2.3% of limbs treated. Pulmonary embolism is extremely rare. There is a learning curve, with a decrease in the incidence of all complications with experience. The importance of detailed preoperative and intraoperative duplex ultrasound examination cannot be overemphasized. The identification of all refluxing venous segments and their ablation is the key to optimizing the rate of successful ablation to 97% at 1 year and minimizing recurrence of varicose veins. With encouraging early and mid-term results with endovenous laser therapy, future developments in this field must mandate standardization of technical aspects, follow-up imaging, and reporting.

The Post-thrombotic Syndrome: The Forgotten Morbidity of Deep Venous Thrombosis

The postthrombotic syndrome (PTS) is the most common complication of deep venous thrombosis (DVT) yet has received little attention from clinicians and researchers. Clinically, PTS is characterized by chronic pain, swelling, heaviness and other signs in the affected limb. In severe cases, venous ulcers may develop. PTS is burdensome and costly to patients and society because of its high prevalence, severity and chronicity. Preventing DVT with the use of effective thromboprophylaxis in high-risk patients and settings and minimizing the risk of ipsilateral DVT recurrence are likely to reduce the frequency of PTS. Compression stockings worn daily after DVT appear to reduce the incidence and severity of PTS but questions regarding their use and effectiveness remain. Future research should focus on identifying patients at high risk for PTS, assessing the role of thrombolysis in preventing PTS and evaluating the optimal use of compression stockings in preventing and treating PTS. In addition, new therapies to treat PTS should be sought and evaluated.

Incidence, Timing of Onset and Severity of Post-Thrombotic Syndrome after Acute Symptomatic Deep Vein Thrombosis: Two-Year Results from a Canadian Multicenter Prospective Cohort Study (The VETO Study).

Background and Objectives: The post thrombotic syndrome (PTS) is a chronic complication of deep venous thrombosis (DVT). It is difficult to provide DVT patients with long-term prognostic information as there is little longitudinal data on the occurrence of PTS after DVT. We performed a prospective multicenter study of long-term outcomes after DVT (the Venous Thrombosis Outcomes [VETO] Study) to determine the incidence, timing of onset and severity of PTS.Methods: Consecutive patients with objectively diagnosed acute DVT were recruited at 7 participating hospital centres from April 2001-July 2002. Patients attended study visits at Baseline, 4, 8, 12 and 24 months. Clinical data were recorded and standardized assessments for PTS (using Villalta scale) were performed by trained study personnel at each follow-up visit. Patients were classified as having developed PTS if the ipsilateral Villalta score was ≥ 5 on at least 2 visits or at the final follow-up visit, and having severe PTS if a score of >14 or a venous ulcer was documented on any one occasion. The Kaplan-Meier survival method was used to estimate the cumulative probability of PTS and of severe PTS over time.Results: The study cohort consisted of 359 patients. The mean age was 56 years, 50% were male, 2/3 were outpatients, 55% had proximal DVT and 20% had previous DVT. The Kaplan-Meier estimates of cumulative risk of PTS were 29% at 4 months, 33% at 8 months, 35% at 12 months and 37% at 24 months. Corresponding risks of severe PTS were 6.6%, 6.9%, 6.9% and 6.9%, respectively. When the analysis was stratified according to history of DVT, the cumulative incidence of PTS in patients without previous DVT was 25%, 28%, 30% and 31% at 4, 8, 12 and 24 months. Corresponding rates of PTS in patients with previous DVT were 45%, 51%, 53% and 57%.Conclusions: More than one third of patients in our cohort developed PTS within 2 years of DVT, and of these, 1 in 6 was classified as severe. Most cases of PTS and of severe PTS were apparent by 4 months after DVT. Patients with previous DVT had a higher frequency of PTS and of late onset PTS. Our study provides longitudinal data on prognosis that is relevant both to patients with DVT and their treating physicians.

Successful renal transplantation in the right iliac fossa 2 years after serious deep venous thrombosis in a patient with systemic lupus erythematosus

Deep venous thrombosis (DVT) possibly occurs in the perioperative period, and induces serious complications such as a pulmonary embolism. On the other hand, allograft renal vein thrombosis leads to a high incidence of graft loss. We experienced a case in which a serious DVT occurred prior to renal transplantation; however, a successful renal transplantation in the right iliac fossa was performed after 2 years of anticoagulant therapy. It is suggested that the external iliac vein even after suffering from DVT can be anastomosed to an allograft vein successfully, when enough blood fl ow or a lower venous pressure is confirmed. However, one should be aware of the risk factors and the adequate management of thrombosis in renal transplantation because of the serious complications of DVT and the poor prognosis of allograft vein thrombosis.

Endoluminal Recanalization in a Patient with Phlegmasia Cerulea Dolens Using a Multimodality Approach

Phlegmasia cerulea dolens, a rare complication of deep venous thrombosis, has traditionally been difficult to treat. The patient described in this report posed additional therapeutic challenges based on a history of heparin-induced thrombocytopenia. She presented with severe leg pain and swelling, and a venogram showed occlusion of both her inferior vena cava and right iliac vein. The use of a multimodality approach, both chemical and mechanical, was successful in removing the venous occlusion, thereby preventing further complications, such as circulatory shock, postphlebitic syndrome, and venous gangrene.

Predictors of the post‐thrombotic syndrome during long‐term treatment of proximal deep vein thrombosis

The post-thrombotic syndrome is a chronic, poorly understood complication of deep venous thrombosis (DVT). To evaluate predictors of the post-thrombotic syndrome, including intensity of long-term anticoagulation, and to assess the impact of the post-thrombotic syndrome on quality of life. The setting was 13 Canadian hospitals and one US hospital. One hundred and forty-five patients with an unprovoked episode of proximal DVT who were initially treated with 3 months of conventional-intensity warfarin [target International Normalized Ratio (INR) of 2.5] then participated in a trial comparing two intensities of long-term warfarin therapy (target INR 2.5 vs. INR 1.7). Post-thrombotic syndrome was assessed at the end of the trial using a validated clinical scale. Generic and venous disease-specific quality of life was compared in patients with and without the post-thrombotic syndrome. Multivariable regression analyses were performed to identify predictors of the post-thrombotic syndrome and of its severity. After an average follow-up of 2.2 years, the prevalence of post-thrombotic syndrome was 37% and of severe post-thrombotic syndrome was 4%. Quality of life was worse in patients with the post-thrombotic syndrome compared with patients who did not have it. The presence of factor (F)V Leiden or the prothrombin gene mutation was an independent predictor of both a lower risk (P = 0.006) and reduced severity (P = 0.045) of the post-thrombotic syndrome. Intensity of anticoagulation did not influence the risk of developing the post-thrombotic syndrome. The post-thrombotic syndrome is a frequent and burdensome complication of proximal DVT, even among patients maintained on long-term oral anticoagulation. While the presence of FV Leiden or prothrombin gene mutation appears to be associated with a reduced risk of post-thrombotic syndrome, this finding requires further evaluation in prospective studies.

Multislice CT pulmonary angiography and CT venography

Pulmonary embolism (PE) is a common and potentially lethal complication of deep venous thrombosis. Clinical diagnosis is difficult and treatment carries significant potential side effects. High sensitivity and specificity of any diagnostic modality for PE are desirable. Helical CT pulmonary angiography (CTPA) offers this by direct visualization of embolic material within the pulmonary arteries. For a number of reasons, including the mobility and orientation of the pulmonary vessels and the peripheral nature of some emboli, the accuracy of CTPA is directly related to the spatial resolution of the technique used. The advent of multislice technology lends itself to improved spatial and temporal resolution and has led to a significant improvement on earlier CTPA results. Indirect CT venography may also be performed as an adjunct to CTPA to help demonstrate culprit thrombus within the lower limbs.

Outcomes and cost of deep venous thrombosis among patients with cancer

Study Question: What are the outcomes of patients with cancer complicated by deep venous thrombosis (DVT)? Methods: The initial medical records and outcome of 529 consecutive cancer patients in whom DVT developed from January 1, 1994, through December 31, 1997, were tracked until December 31, 2000. The study was conducted in a major cancer center, and the cost of hospitalization was obtained from the hospital’s cost-accounting system and inflated to 2002 US dollars using the Consumer Price Index for Medical Care. Logistic regression was used to identify factors associated with a high risk of poor outcomes. Results: The mean age was 55 years, and 52% were women. Seventy-seven percent of DVT cases presented as outpatients, 15% had a previous bout of DVT, and 13% developed within 30 days of a surgical procedure. Over 70% had the diagnosis established within 24 h of symptoms onset, although 20% had symptoms for at least 2 weeks; 50% were lower extremity and 40% were a major central vein alone or with an extremity. The latter were more often associated with central venous catheters (51% with vs. 35% without, p<0.001). Ninety-three percent received anticoagulants (95% received heparin). The most common complication of DVT was bleeding, which occurred in 13% of patients. Pulmonary embolus occurred in 4%. Five patients (1%) died of complications of DVT and 5 (1%) of complications of anticoagulation. Recurrence of DVT was common (17% overall), particularly among those who had inferior vena cava filters (32%, p<0.001) or a previous episode of DVT (p=0.03). All but 4 patients were hospitalized for initial anticoagulation therapy, for a mean of 11 days. The mean cost of hospitalization was 2002 US $20,065. Conclusions: Among patients with cancer, DVT frequently is associated with serious clinical outcomes. Its treatment is resource intensive and costly. More effective agents and less costly management strategies could have a significant impact on the outcomes and cost of DVT in this population. Perspective: This study demonstrates the very high rate of recurrence of DVT in cancer patients, and as with other studies that question the efficacy of IVC filters. The latter may be selection bias, but also could infer that the presence of the filter increases the risk of distant thrombosis. Unfortunately, the data cannot be used to draw any specific therapeutic conclusions. MR

Outcomes and cost of deep venous thrombosis among patients with cancer.

Although deep venous thrombosis (DVT) often complicates the clinical course in patients with cancer, few studies of the outcomes of DVT in this population have been published. Furthermore, the cost of DVT is largely undescribed. We herein report the largest study of DVT in this population to date. We reviewed the medical records of 529 consecutive cancer patients in whom DVT developed from January 1, 1994, through December 31, 1997, and followed up these patients through December 31, 2000, for outcomes. The cost of hospitalization was obtained from our hospital's cost-accounting system and inflated to 2002 US dollars using the Consumer Price Index for Medical Care. Logistic regression was used to identify factors that were associated with a high risk of poor outcomes. The most common complication of DVT was bleeding, which occurred in 13% of patients. Pulmonary embolus occurred in 4%. Five patients (1%) died of complications of DVT and 5 (1%) of complications of anticoagulation. Recurrence of DVT was common (17% overall), particularly among those who had inferior vena cava filters (32%; P<.001) or a previous episode of DVT (P =.03). All but 4 patients were hospitalized for initial anticoagulation therapy, for a mean of 11 days. The mean cost of hospitalization was 2002 US $20 065. Among patients with cancer, DVT frequently is associated with serious clinical outcomes. Its treatment is resource intensive and costly. More effective agents and less costly management strategies could have a significant impact on the outcomes and cost of DVT in this population.

Epidemiology of acute deep vein thrombosis

Although the factors leading to venous thrombosis have been known for over a century, Virchow’s initial model of thrombosis has been extensively refined. Activated coagulation is now recognized to be of primary importance in venous thrombogenesis; the concept of venous injury has been expanded to include molecular changes in the endothelium; and stasis has been redefined as a largely permissive factor. Furthermore, it is now clear that venous thrombi undergo a dynamic evolution beginning early after their formation. The natural history of acute deep venous thrombosis (DVT) is a balance between recurrent thrombotic events and processes that restore the venous lumen, both of which have important implications for the development of complications. Although pulmonary embolism (PE) is clearly the most life threatening complication of acute DVT, the long term socio-economic consequences of the post thrombotic syndrome (PTS) have perhaps been underemphasized in clinical trials. The development of post-thrombotic manifestations is related to both residual venous obstruction and valvular incompetence. Recognition of the factors contributing to a poor outcome, including recurrent thrombotic events, the rate of recanalization, the global extent of venous reflux, and the anatomic distribution of reflux and obstruction is important, as there may be therapeutic alternatives to alter the natural history of acute DVT. The treatment alternatives will continue to expand with the introduction of new therapeutic drugs, for both systemic and catheter-directed therapy, and mechanical thrombectomy devices. The primary care physician is challenged with the task of correctly evaluating deep vein thrombosis and providing his patient with access to the most clinically appropriate, and cost-effective, diagnostic and management options available. This article will review the epidemiology of DVT, its risk factors and major complications.

Relationship between deep venous thrombosis and the postthrombotic syndrome.

The postthrombotic syndrome (PTS) is a frequent complication of deep venous thrombosis (DVT). Clinically, PTS is characterized by chronic, persistent pain, swelling, and other signs in the affected limb. Rarely, ulcers may develop. Because of its prevalence, severity, and chronicity, PTS is burdensome and costly. Preventing DVT with the use of effective thromboprophylaxis in high-risk patients and settings and minimizing the risk of ipsilateral DVT recurrence are likely to reduce the risk of development of PTS. Daily use of compression stockings after DVT might reduce the incidence and severity of PTS, but consistent and convincing data about their effectiveness are not available. Future research should focus on standardizing diagnostic criteria for PTS, identifying patients at high risk for PTS, and rigorously evaluating the role of thrombolysis in preventing PTS and of compression stockings in preventing and treating PTS. In addition, novel therapies should be sought and evaluated.