Deep Vein Thrombosis Research Articles

Angiotensin II administration in severe thrombocytopenia and chronic venous thrombosis: A case report

BACKGROUND The initial trials on angiotensin II (AT II) administration indicated a high incidence of thrombocytopenia and thrombosis, as well as a positive correlation between hyperreninemia and response to the medication. CASE SUMMARY We describe a case of a patient presenting with catecholamine resistant septic shock, thrombocytopenia, deep vein thrombosis, and normal renin concentration who responded immediately to AT II treatment. We observed no worsening of thrombocytopenia and no progression of thrombosis or additional thromboses during treatment. CONCLUSION Our case underscores the need for individualized assessment of patients for potential therapy with AT II.

Perioperative Venous Thromboembolism Chemoprophylaxis Does Not Increase Risk of Complications in Free Flap Breast Reconstruction.

Patients undergoing abdominal-based free flap breast reconstruction are at risk for perioperative venous thromboembolism (VTE), but the optimal anticoagulation protocol remains unknown. We hypothesized that a standardized chemoprophylaxis protocol would minimize VTE events without increasing hematoma, flap loss, or reoperation. A retrospective review was conducted on patients who underwent abdominal-based free flap breast reconstruction from 2010 to 2023. In 2015, we implemented an enhanced recovery after surgery (ERAS) protocol including preoperative enoxaparin. Patients with a BMI < 30 and > 30 received enoxaparin for 7 and 30 days postoperatively, respectively. 2010-2015 patients were pre-ERAS and 2015-2023 patients were the ERAS cohort. Patient demographics, comorbidities, and outcomes were analyzed. The primary outcomes were VTE, hematoma, flap loss, and reoperation. 2317 patients were included: 679 were pre-ERAS and 1638 were in the ERAS cohort. The incidence of deep vein thrombosis (0.7%) and pulmonary embolism (pre-ERAS 0.6% vs. ERAS 0.5%) was low in both cohorts with no significant differences. Hematoma (pre-ERAS 7.2% vs. ERAS 5.5%) and reoperation (pre-ERAS 7.8% vs. ERAS 9.7%) were similar, but the ERAS cohort had significantly lower flap failure (0.7% vs. 2.1%, p < 0.05). A standardized perioperative anticoagulation protocol for abdominal-based breast reconstruction maintained low VTE rates without increasing hematoma, flap failure, or reoperation.

Physicians’ clinical experience and perspectives following a pilot, blended learning, point of care ultrasound course in Ghana- a mixed methods analysis

BackgroundPoint of Care ultrasound (POCUS) is rapidly gaining popularity in resource constrained settings. Optimising training is important to ensure safe and effective implementation. To expand POCUS expertise in Ghana, we co-developed and piloted a context specific, multi-disciplinary, blended learning programme, targeted at physicians of any grade or speciality providing acute care in the public health sector. In this retrospective mixed method study, we capture the “real world” experience of participants, using POCUS in their daily practice, as well as the barriers and enablers they perceived to implementation.ResultsEight emergency and internal medicine specialists and residents participated, working across three teaching hospitals, treating both general and specialist patients. They implemented each POCUS application taught, with cardiac indications, inferior vena cava (IVC) assessment, deep venous thrombosis (DVT) diagnosis, lung/pleural assessment and peripheral vascular access being most frequent at 3–6 times/week. An estimated 40% of patients could not have afforded any other diagnostic tests. They considered the pilot curriculum adequate for general practice and the majority of applications of low difficulty (71%). For cases sent for second opinion, they are self-reported that their findings were confirmed in 60–78% of cases. Perceptions about the relative advantage of POCUS over the usual approaches to diagnosing patients enabled implementation. Generally, they believed that POCUS improved their clinical decision making and that more certified training courses need to be run at lower cost to make them more accessible. All participants valued ongoing connections after training to ask for help and consolidate their skills. Continued evaluation and reflection on their POCUS practice to improve quality was unanimously reported as important, yet none had a formal system for this. The strongest barrier was access to equipment and maintenance. A lack of training opportunities and local mentors, and negative beliefs from other departments and hospital administration were further barriers.ConclusionOur new blended learning curriculum met the needs of physicians caring for patients with general and specialist presentations, with strong reported positive experience of improved bedside diagnostic capabilities, especially for the large proportion of patients unable to afford or access alternative diagnostic tests. Their experience drives the need for further training and for solutions to current barriers of equipment availability, training costs and lack of quality assurance mechanisms.

Preoperative risk factors for venous thromboembolism in major urologic cancer surgeries.

Venous thromboembolism (VTE) is a serious complication of urologic cancer surgeries. Incidence varies by procedure, with cystectomy carrying the highest risk. Our study aims to explore the preoperative risk factors for VTE development in major urologic cancer surgeries. Using the ACS-NSQIP database, cystectomy, prostatectomy or nephrectomy cases between 2011 and 2020 were identified. Patient characteristics and pre-operative variables were compared using χ2 test. Multivariate logistic regression was used to control for confounding variables. 207,861 patients were included. 2484 (1.2%) patients experienced VTE post-operatively, with a rate of 3.16% among cystectomy patients. The incidence of pulmonary embolism (PE) peaked at day 2, while that of deep venous thrombosis (DVT) peaked at days 2 and 8. On multivariate analysis, blood transfusion and cystectomy were associated with the highest risk of VTE (OR = 2.29 [1.64, 3.18], P = < 0.001 and OR = 2.96, 95%CI [2.62, 3.37], P < 0.0001; respectively). Other important risk factors included advanced age ≥ 80 years (OR = 1.98 [1.65, 2.40], P = 0.001), BMI ≥ 40kg/m2 (OR = 1.82 [1.43, 2.24], P = 0.001), congestive heart failure (OR = 1.75 [1.15, 2.66], P = 0.008), steroid use (OR = 1.55 [1.26, 1.94], P = < 0.001), thrombocytosis OR = 1.43 [1.16, 1.76], P = 0.001) and leukocytosis (OR = 1.41 [1.11, 1.54], P = < 0.001). Our study highlights important pre-operative risk factors for the development of VTE after urologic cancer surgeries. This stresses the importance of pre-operative risk assessment to guide counseling and thromboprophylaxis strategies especially among cystectomy patients who are older, obese, and requiring blood transfusion.

Analysis of outcomes of penetrating colonic injuries managed with or without fecal diversion

Traumatic colorectal injuries can be managed by either fecal diversion or primary repair / resection and anastomosis. We aimed to study differences in outcomes in adult patients managed with or without fecal diversion at time of initial operation. The National Trauma Databank (NTDB) was used to identify adult patients (ages 18–64 years) with penetrating colonic injuries for the years 2013–2015. We included patients with Injury Severity Score (ISS) of 9–24 excluding patients with concomitant extra-abdominal Abbreviated Injury Scale (AIS) score of 3 or more. Subjects arriving without signs of life, expiring in ER or with missing data were excluded. Data was collected for age, gender, vital signs on presentation, discharge disposition and length of stay (LOS). Patients were divided into two groups based on whether or not fecal diversion was performed within 1 day of presentation. Primary outcome assessed was in-hospital mortality and unplanned return to OR. Secondary outcomes were acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), deep vein thrombosis (DVT), pulmonary embolism (PE), pneumonia, organ surgical site infection (SSI), deep SSI, severe sepsis and unplanned intubation. Statistical analysis was conducted using SPSS for windows. P-value < 0.05 was considered statistically significant. Of 2,598,467 patients, 5344 (0.21%) sustained a penetrating colonic injury. 2339 (43.8%) patients met criteria for age, ISS, AIS, signs of life and ED outcome. 173 patients underwent fecal diversion within 24 h of presentation (Group 1) while 708 did not (Group 2). Patients with missing data were excluded leaving 162 patients in Group 1 and 657 patients in Group 2. Groups 1 and 2 were noted to be similar in terms of ISS (median of 10 in both), age (median of 31 vs 29 years), percentage of male patients (85.2% vs 87.8%; p = 0.44), mean systolic blood pressure (127 mmHg vs 126 mmHg; p = 0.54), mean pulse rate (95.4 vs 94.5; p = 0.60) and mean respiratory rate (20.4 vs 20.1; p = 0.56) respectively. Median LOS was 10 days in both groups. No statistically significant differences were found between groups 1 and 2 in the primary outcomes of in-hospital mortality (2.4% vs 3.5%; OR: 1.43; 95% confidence interval (CI): 0.49–4.20) or unplanned return to OR (4.3% vs 7.8%; OR: 1.86; 95% CI: 0.83–4.19). No statistically significant differences were noted between groups 1 and 2 in the secondary outcomes of AKI (3.7% vs 3.8%; OR: 1.03; 95% CI 0.41–2.55), ARDS (1.2% VS 1.7%; OR: 1.36; 95% CI 0.30–6.21), DVT (1.9% vs 4.0%; OR: 2.18; 95% CI 0.65–7.31), PE (1.9% vs 2.0%; OR: 1.07; 95% CI 0.30–3.80), pneumonia (4.9% vs 5.3%; OR: 1.08; 95% CI 0.49–2.38), organ SSI (3.7% vs 7.0%; OR: 1.96; 95% CI: 0.82–4.67), deep SSI (3.7% vs 4.4%; OR: 1.20, 95% CI 0.49–2.94), severe sepsis (3.7% vs 3.3%; OR: 0.90; 95% CI: 0.36–2.26) or unplanned intubation (1.9% vs 1.7%; OR: 0.90; 95% CI 0.25–3.27). Adult patients with penetrating colonic injuries with ISS 9–24 in the absence of serious extra-abdominal injury who undergo surgery within 24 h of presentation do not seem to derive a statistically significant benefit from fecal diversion in terms of post-operative complications and mortality. In more severely injured patients fecal diversion may continue to provide a benefit.

IVC filter use in patients with a history of venous thromboembolism undergoing bariatric surgery: a MBSAQIP study.

Research on the use of prophylactic inferior vena cave filter (IVCF) placement prior to metabolic and bariatric surgery (MBS) in high risk patients has yielded conflicting results. We evaluated thrombotic events and mortality in patients with a history of venous thromboembolism (VTE) who underwent IVCF placement in anticipation of MBS. We queried the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for all patients undergoing primary sleeve gastrectomy or Roux-en-Y gastric bypass from 2015 to 2019 with a history of VTE. We tabulated yearly IVCF use and compared 30-day rates of deep venous thrombosis (DVT), pulmonary embolism (PE), readmission, mortality, and serious adverse events in patients with and without prophylactic IVCF placement. Multivariate logistic regression was used to assess the relationship between preoperative placement of an IVCF and postoperative outcomes. Of 754,397 patients undergoing MBS, 16,683 (2.2%) had a prior VTE. Placement of IVCF in anticipation of MBS decreased from 285/2245 (10.4%) in 2015 to 85/3750 (2.2%) in 2019 (p < 0.01). The incidence of PE did not differ significantly between patients with prophylactic IVCF vs. those without (0.1% vs 0.5%, p = 0.13). Postoperative DVT was more common in patients who underwent IVCF placement (1.7% vs. 0.8%, p < 0.01). No significant differences were observed in mortality. Preoperative placement of an IVCF was an independent risk factor for development of a postoperative DVT (OR 2.45; 95% CI 1.39-4.32). These data do not support a history of VTE as an indication for prophylactic IVCF placement in anticipation of MBS.

Endovascular treatment of upper limb phlegmasia cerulea dolens in a hemodialysis patient

Phlegmasia cerulea dolens (PCD) is a rare but limb-threatening complication of deep vein thrombosis. A 72-year-old hemodialysis male patient presented with upper limb PCD. The patient underwent hemodialysis via a permanent hemodialysis central venous catheter (HD-CVC) while a new brachial-cephalic AVF was created 1 month ago. Computed tomography revealed extensive thrombosis of right subclavian and brachiocephalic vein. The HD-CVC was removed and patient was treated with anticoagulation therapy. However, his clinical condition was worsening and he was transferred to IR department. The patient underwent successful percutaneous pharmacomechanical thrombectomy (PMT) of the right subclavian and brachiocephalic vein followed by percutaneous angioplasty (PTA) with significant flow restoration and no signs of pulmonary embolization. PCD may also be developed in hemodialysis patients with well-functioned AVF. Effective and rapid revascularization is important to prevent serious complications such as venous gangrene and limb ischemia. Endovascular treatment with PMT and PTA can be a limb-saving procedure for rapid recanalization in patients with PCD.

Intraoperative Intermittent Pneumatic Compression Reduces Incidence of Venous Thromboembolism in Patients Undergoing Craniotomy: Study Protocol of a Randomized Multicenter, Single-Blind Trial

BACKGROUND AND OBJECTIVE: Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common complication in craniotomy patients. The duration of surgery has been identified as a risk factor for the development of VTE. In a pilot study, the use of intermittent pneumatic venous compression (IPC) dramatically reduced the incidence of VTE. Despite randomization, a significant difference in the duration of surgery between the groups limited the validity of this result. The study was underpowered to compensate for this problem. We now present the protocol of a multicenter trial. METHODS: All patients receive medical compression stockings and low-molecular-weight heparin from the first postoperative day. The therapy group receives IPC stockings intraoperatively. Postoperatively, all patients receive lower-extremity duplex sonography to detect/exclude DVT within the first 7 postoperative days. Contrast-enhanced chest CT is the gold standard for the detection of PE and is performed in cases of clinical suspicion of PE. EXPECTED OUTCOMES: The incidence of VTE is the primary end point. The distinction between symptomatic and asymptomatic, etiologies, influence of lesion type, duration of surgery, and mortality will be evaluated as secondary end points. The pilot study showed a VTE incidence of 26% in the control group vs 7% in the treatment group. To avoid overly optimistic treatment effect assumptions, we assume VTE rates of 9% and 24% in the treatment and control groups, respectively, and thus calculated a number of 127 patients per treatment group. DISCUSSION: If this trial shows that intraoperative IPC reduces the risk of VTE to the extent observed in our pilot study (number needed to treat: 5.24), the potential benefit to neurosurgical patients would be significant. The results would potentially influence treatment guidelines by providing the high-quality evidence needed to make robust recommendations.

Normalized Total Psoas Area Predicts Early Postoperative Mobility and Perioperative Adverse Events after Adult Spinal Deformity Surgery

Background ContextPoor muscle health has been shown to predict poor perioperative outcomes following adult spinal deformity (ASD) surgery. Currently, there is limited data concerning the correlation between muscle health and recovery among patients undergoing ASD surgery. PurposeTo determine the relationship between normalized total psoas area (NTPA), postoperative mobility and adverse events (AEs) among patients undergoing ASD surgery. Study DesignRetrospective cohort study Patient SampleA retrospective analysis was performed at a single institution between January 2014 and December 2023 of patients undergoing ASD surgery by 10 board certified fellowship-trained orthopaedic spine surgeons. Outcome MeasuresPrimary outcome measures were postoperative ambulation distance on postoperative day (POD) 1, 2, 3, and 4 as well as perioperative adverse events including post-operative anemia requiring transfusion, ileus, urinary retention wound complication including dehiscence and infection, delirium, atelectasis, urinary tract infection (UTI), deep vein thrombosis (DVT), and epidural hematoma. Secondary outcome measures were 30-day reoperation rates, 30-day readmission rates, and postoperative length of stay (LOS). MethodsPatients that underwent ASD surgery at a single center (2014-2023) were included in the study. NTPA was analyzed at the L3 and L4 mid-vertebral body on preoperative magnetic resonance imaging (MRI). Receiver operating characteristic (ROC) curve analysis was used to determine gender-specific NTPA cut-off values for predicting perioperative AEs. Patients were categorized as having a low NTPA if both L3 and L4 NTPA were below the cut-off values. Multivariate logistic regression was conducted to identify confounding predictors of perioperative AEs. Results279 patients (102 males, 177 females, mean age 61.2 ± 15.2 years) were included. ROC curve analysis demonstrated L3 NTPA <805 mm2/m2 for males and <505 mm2/m2 for females and L4 NTPA <912 mm2/m2 for males and <714 mm2/m2 for females as cut-off values predicting perioperative AEs. 103 patients (36.9%, 42 males, 61 females) were below these cut-off values and were in the low NTPA cohort. The remaining 176 patients (63.1%, 60 males, 116 females) were in the normal NTPA cohort. The low NTPA group had a higher overall perioperative AEs (70.9% vs 39.2%, p<0.001), and lower ambulation distances on postoperative day 1 and 2 compared to the normal NTPA group (p=0.021, p=0.028, respectively). On multivariate analysis, there were no other predictors of perioperative AEs. ConclusionsLow L3 and L4 NTPA is associated with lower early postoperative mobility and higher rates of perioperative AEs among patients undergoing ASD surgery. These findings stress the importance of muscle health in recovery after ASD surgery.

US of Acute Tendon Tears.

US is an effective tool for appraising acute tendon injury, allowing rapid evaluation of symptoms at bedside and paving the way for prompt diagnosis and treatment selection. It offers three main advantages in the acute or emergent setting. First, it is more sensitive and specific than physical examination. This is beneficial in tendons such as the distal triceps wherein incomplete and complete tears may manifest with similar clinical presentations. Tendon injury may also be clinically innocuous because bruising or a palpable defect is not always present and swelling may mask palpation of the tendon gap. Second, US provides important descriptors that may affect treatment selection, such as injury site, injury extent, and length of retraction. Pectoralis major tears at the tendon or musculotendinous junction warrant operative referral and are readily illustrated at US. A torn distal biceps tendon with significant retraction may require additional graft augmentation rather than reattachment to the insertion alone. Soleus and gastrocnemius strains may mimic each other clinically. Although both are managed conservatively, distinction between the two facilitates formulation of a specific rehabilitation regimen. Finally, US can narrow the differential diagnosis and rule out mimics of musculoskeletal abnormalities. Nonmusculoskeletal conditions, such as deep venous thrombosis and a ruptured Baker cyst, can manifest with the same clinical presentation as acute calf injuries and must be considered in a patient presenting with sudden calf, posterior leg, or ankle pain. The authors review the anatomic features, US techniques, and imaging findings of acute tendon injuries to aid in meaningful reporting and timely treatment selection. ©RSNA, 2024 Supplemental material is available for this article.

Trends in the Epidemiology of Deep Vein Thrombosis and Pulmonary Embolism in Patients Undergoing Surgery

Trends in the Epidemiology of Deep Vein Thrombosis and Pulmonary Embolism in Patients Undergoing Surgery

Recommendation for Management of Deep Vein Thrombosis in the Emergency Medicine

Duboka venska tromboza je multifaktorska bolest u koje dolazi do nastanka tromba u dubokim venama. Važno je njezino rano prepoznavanje i liječenje jer može uzrokovati plućnu emboliju te najopasniju komplikaciju, smrtni ishod. Cilj je ovih smjernica standardiziran pristup bolesniku u hitnoj medicinskoj službi, koji će omogućiti brzo i točno postavljanje dijagnoze i pravovremeno liječenje u bolničkim ili kućnim uvjetima. U dijagnostičkom smislu, najprije je važno procijeniti kliničku vjerojatnost pomoću Wellsova skora, potom odrediti D-dimere i, ako je potrebno, prema postupniku učiniti kolor-dopler. Osnovu liječenja duboke venske tromboze predstavlja antikoagulantna terapija, čime sprječavamo progresiju tromba i potencijalnu embolizaciju, a samim time i ozbiljne životno ugrožavajuće komplikacije.

TLR2 promotes traumatic deep venous thrombosis of the lower extremity following femoral fracture by activating the NF‑κB/COX‑2 signaling pathway in rats.

Endothelial cells (ECs) are crucial for maintaining the integrity of blood vessel walls and reducing thrombosis. Deep venous thrombosis (DVT) is a common thrombotic disease and its diagnosis and treatment remain at the stage of coagulation function examination and post-onset treatment. Thus, identifying the pathogenesis of DVT is important. The present study investigated the significance of the Toll-like receptor 2 (TLR2)/nuclear factor kappa B (NF-κB)/cyclooxygenase-2 (COX-2) signaling pathway in a human umbilical vein EC (HUVECs) oxygen glucose deprivation (OGD) model and femoral fractures were induced in anesthetized rats using a quantifiable impact device delivering 5 J of energy to each side of the proximal outer thigh, followed by external fixation with a hip spica cast to create a traumatic deep venous thrombosis (TDVT) animal model. Rats were subjected to quantitative impact fixation to establish a TDVT model. The rats were treated with a TLR2 agonist (Pam3CSK4) and a TLR2 inhibitor (C29) via intraperitoneal injection and thrombus formation was examined. HUVECs were subjected to OGD and treated with Pam3CSK4 or C29 and cell viability and apoptosis were assessed. Western blotting, immunofluorescence and reverse transcription-quantitative PCR were used to examine the inflammatory responses and signaling pathways. In vivo experiments showed that Pam3CSK4 promoted thrombus formation and increased the mRNA and protein expression of NF-κB, COX-2, Tissue factor (TF), IL-6 and P-selectin compared with the model and C29 groups. In vitro experiments showed that Pam3CSK4 treatment resulted in a higher number of apoptotic cells than C29 treatment and that it increased the levels of NF-κB, COX-2, IL-6 and P-selectin, whereas C29 decreased them. Thus, TLR2 promotes the inflammatory response in EC through the NF-κB/COX-2 signaling pathway, which may lead to EC apoptosis and the occurrence of TDVT.

Complex central vascular access in a patient with congenitally corrected transposition of the great arteries with bi-caval and bilateral iliac vein thrombosis: a case report

Complex central vascular access in a patient with congenitally corrected transposition of the great arteries with bi-caval and bilateral iliac vein thrombosis: a case report

Identification of mRNA biomarkers in extremely early hypertensive intracerebral hemorrhage (HICH)

IntroductionHypertensive intracerebral hemorrhage (HICH) stands out as a critical complication of primary hypertension. Consequently, investigating messenger RNA (mRNA) biomarkers becomes imperative, offering potential targets. This study is conducted for elucidating the expression profile of blood mRNA biomarkers in HICH.MethodsTwenty-five HICH patients were constituted the HICH group.Twenty-two healthy volunteers recruited and comprised the control group. Peripheral blood cells were extracted to identify candidate mRNA. The identified differential expressions of genes between the two groups were validated, and the potential associations between these differentially expressed genes and adverse events were analyzed. GO and KEGG enrichment of DEGs, Weighted Gene Co-expression Network and Protein Interaction Network were established. target mRNA was screened.ResultsThe study identified 3163 differentially expressed genes in HICH. 8 candidate mRNA (SPI1, HK3, HCK, SYK, CD14, FCER1G, CYBB, FGR) were pinpointed. Associations with pathways affecting HICH development included HIF-1 signaling, NF-kappa B signaling, and C-type lectin receptor signaling. In the HICH group, higher expressions of HK3, HCK, SYK, CD14, FCER1G, CYBB, and FGR, and lower SPI1 expression compared to the control group. HICH patients experienced high rates of complications: pulmonary infection (84%), epilepsy (16%), enlarged hematoma (20%), gastrointestinal bleeding (48%), malnutrition (84%), and lower limb deep vein thrombosis (DVT) (12%). Factors contributing to pulmonary infection included age and elevated expression of HCK, SYK, CD14, and FGR. SPI1 was associated with epilepsy, while its lower expression correlated with hematoma enlargement. Gastrointestinal bleeding was linked to increased cerebral hemorrhage. Malnutrition was associated with higher age, and expressions of HK3, HCK, SYK, CD14, FCER1G, CYBB, and FGR. Patients with lower limb DVT had elevated expressions of the identified genes.ConclusionIn hypertensive intracerebral hemorrhage, there are elevated expressions of HK3, HCK, SYK, CD14, FCER1G, CYBB, and FGR, along with reduced expression of SPI1. Furthermore, age, along with elevated expressions of HCK, SYK, CD14, and FGR, serves as influencing factors contributing to pulmonary infection in patients.

Antithrombotic Agents after Free Tissue Transfer in the Pediatric and Adolescent Population.

Even for the experienced microsurgeon, free tissue transfer in pediatric patients is challenging, and large patient series remain scarce in the literature. Moreover, the added value of antithrombotic agents in pediatric free tissue transfer remains unclear. We conducted a retrospective outcome analysis of pediatric free tissue transfer with respect to postoperative antithrombotic treatment at our tertiary academic center. All patients aged 0 to 18 years who underwent free tissue transfer from 1998 to 2022 were included in the study. Seventy patients received 73 free tissue transfers. The most common indications were facial paralysis, trauma, and tumor (49.3, 21.9, and 20.5%, respectively). The most common recipient sites were the head and neck (56.1%) and lower extremity (32.8%). We observed a flap revision rate of 12.5% of the cases and one flap loss (1.4%). A total of 58.9% of the population received postoperative antithrombotic agents. The rate of flap revision surgery was similar (11.6 and 10.0%, respectively), with and without antithrombotic treatment (p > 0.05). There were no major bleeding complications or deep vein thrombosis. The antithrombotic treatment did not seem to affect the flap revision rate or the bleeding complications in our cohort. Hence, the data do not support the routine administration of antithrombotic treatment in pediatric free flap reconstruction. However, these findings should be solidified in prospective randomized trials.

The incidence and significance of iliac vein stenosis in patients with deep vein thrombosis.

ObjectiveThe role of iliac vein stenosis (IVS) in the development of DVT is poorly understood. This study determines the incidence of IVS in patients diagnosed with DVT and assesses its impact on presentation and outcomes. Our hypothesis is that the presence of IVS increases the risk of long-term ipsilateral DVT recurrence. MethodsA retrospective study of the electronic medical records of consecutive adult patients treated for lower extremity DVT was performed. Only patients with cross-sectional imaging (CT or MR with intravenous contrast) were included. Patient and DVT characteristics were recorded. Cross-sectional imaging was reviewed for the presence or absence of ipsilateral IVS (≥50%). Patients were divided into 2 groups based on the presence or absence of IVS to compare characteristics and outcomes. Subgroup analyses on patients with provoked DVT, Cancer-related DVT, and unprovoked DVT were performed. ResultsThere were 548 patients with DVT and 32% had evidence of ipsilateral IVS on cross-sectional imaging. There were no significant differences in baseline characteristics or treatment methods between the 2 groups. There was a trend toward patients with IVS having less incidence of PE on presentation (22.9% vs 29.7%, P=0.1) but that difference did not reach statistical significance in the overall comparison. Subgroup analysis in patients with Cancer-related DVT (n=227) showed that patients with IVS were significantly more likely to develop ipsilateral recurrent DVT compared to patients with no IVS (12.9% vs 4.5%, P=0.045). Patients with unprovoked DVT with IVS had significantly lower PE on presentation compared to patients with unprovoked DVT without IVS (24.2% vs 39.8%, P<0.03). ConclusionIpsilateral ≥50% IVS is present in approximately a third of patients presenting with DVT. The presence of IVS seems to play a differential role in ipsilateral DVT recurrence and prevention of pulmonary embolization in different groups of patients presenting with DVT.

Spectrum of Intracranial Hemorrhages in Cerebral Venous Thrombosis: A Pictorial Case Series and Review of Pathophysiology and Management.

We aim to provide a pictorial representation of the broad spectrum of intracranial hemorrhages associated with cerebral venous thrombosis (CVT), emphasizing atypical locations and rare intracerebral hemorrhage (ICH) types. We also hypothesize the pathophysiology leading to atypical locations of the ICH in CVT and the outcomes with anticoagulation therapy. ICH complicates about 40% of cases with CVT and is known to cause various types of ICH, including subarachnoid hemorrhage (SAH) and subdural hemorrhage (SDH). A combination of hemorrhages is also reported. Patients with computed tomography and magnetic resonance imaging findings consistent with CVT examined between January 2011 and June 2014 were included in this retrospective review. Demographic and clinical data and imaging findings were reviewed with particular attention to the type and location of ICH and sinus involvement. Treatment details and 3-month outcomes, assessed using the modified Rankin Scale, were analyzed. Eleven patients (9 males), ranging in age from 22 years to 58 years, were included. The most common clinical presentations were headache (n = 8) and seizures (n = 7). Intraparenchymal hemorrhages were most common (n = 7), followed by SDH and SAH (n = 4), intraventricular hemorrhage (IVH; n = 3), and juxtacortical hemorrhage (n = 1). All patients who received anticoagulation therapy (n = 11) experienced complete resolution of their symptoms, and the median modified Rankin Scale was 0. The spectrum of intracranial hemorrhages seen in association with CVT is broad, encompassing atypical locations like basal ganglia, external capsule, and cerebellar hemispheres, and involves multiple intracranial compartments-IVH, SAH, and SDH. While SAH and SDH are seen with superior sagittal sinus thrombosis, ICH is common with lateral sinus thrombosis, and IVH with deep venous thrombosis.

Development of a predictive nomogram for early identification of pulmonary embolism in hospitalized patients: a retrospective cohort study

BackgroundHospitalized patients often present with complex clinical conditions, but there is a lack of effective tools to assess their risk of pulmonary embolism (PE). Therefore, our study aimed to develop a nomogram model for better predicting PE in hospitalized populations.MethodsData from hospitalized patients (aged ≥ 15 years) who underwent computed tomography pulmonary angiography (CTPA) to confirm PE and non-PE were collected from December 2013 to April 2023. Univariate and multivariate stepwise logistic regression analyses were conducted to identify independent predictors of PE, followed by the construction of a predictive nomogram and internal validation. The efficiency and clinical utility of the nomogram model were assessed using receiver operating characteristic (ROC) curve, decision curve analysis (DCA), and clinical impact curve (CIC).ResultsThe study included 313 PE and 339 non-PE hospitalized patients. Male gender, dyspnea or shortness of breath, interstitial lung disease, lower limb deep vein thrombosis, elevated fibrin degradation product (FDP), pulmonary arterial hypertension, and tricuspid regurgitation were identified as independent risk factors. The AUC of the predictive nomogram model was 0.956 (95% CI: 0.939–0.974), demonstrating superior performance compared with the simplified Wells score of 0.698 (95% CI: 0.654–0.741) and the modified Geneva score of 0.758 (95% CI: 0.717–0.799).ConclusionOur study demonstrated that challenges remain in the accuracy of the Wells score and revised Geneva score in assessing PE in hospitalized patients. Fortunately, the nomogram we developed has shown a favorable ability to discriminate PE cases, providing high reference value for clinical practice. However, given that this was a single-center study, we plan to expand efforts to collect data from additional centers to further validate our model.

A little goes a long way: A comparison of enterolithotomy versus single-stage cholecystectomy in the management of gallstone ileus

INTRODUCTION Gallstone ileus is an infrequent complication of cholelithiasis with no specific guidelines for its management. This study aims to compare the outcomes of patients with gallstone ileus managed with both enterolithotomy with cholecystectomy (EL-CCY) versus those managed with enterolithotomy (EL) only. METHODS In this retrospective analysis of 2011–2017 Nationwide Readmissions Database, all patients with an index admission diagnosis of gallstone ileus were included. Patients were stratified based on the type of intervention received for gallstone ileus into those who underwent EL-CCY and those who underwent EL alone and compared. Primary outcomes were in-hospital complications (surgical site infections, sepsis, pneumonia, cardiac arrest, deep vein thrombosis, intestinal obstruction) and mortality. Secondary outcomes were hospital length of stay, hospital costs, and readmissions rate and cause of readmissions. Multivariable logistic regression analysis was performed. RESULTS A total of 1,960 patients were identified. The mean age was 67 years and 67% were female. Two hundred eighty-nine patients (14.7%) were managed with EL-CCY, whereas 1,671 patients (85.3%) underwent EL only. Overall, the readmission rate was 4.8%, whereas mortality was 4.2%. There was no significant difference between groups in terms of index-admission complications (24.8% vs. 21.7%, p = 0.415), mortality (6.2% vs. 3.9%, p = 0.068), rates of readmission (3.5% vs. 5.1%, p = 0.22), and cause of readmission (p &gt; 0.05). Enterolithotomy and cholecystectomy group had significantly longer hospital length of stay (10 vs. 8 days, p &lt; 0.001) and median hospital costs ($70,959 vs. $52,147, p &lt; 0.001). On multivariable logistic regression analysis, female sex was a predictor of undergoing EL-CCY, whereas increasing age and higher grade of all-patient redefined diagnosis-related groups risk of mortality were independently associated with lower odds of undergoing EL-CCY. CONCLUSION Our findings suggest no difference between EL compared with EL-CCY in terms of complications, readmissions, and mortality. However, patients managed with EL-CCY had a longer hospital stay and higher hospital costs compared with EL. Further prospective studies are needed to validate these findings and develop management protocols for gallstone ileus. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.