Episode Of Deep Venous Thrombosis Research Articles

Visceral obesity, but not metabolic syndrome, is associated with the presence of post-thrombotic syndrome

IntroductionThe relationship between metabolic syndrome (MetS), and the development of post-thrombotic syndrome (PTS) is currently unknown. Materials and MethodsWe enrolled 120 patients with a previous episode of deep venous thrombosis (DVT) diagnosed more than 2years apart from the enrollment. Presence of MetS was identified according to NCEP ATP III criteria and Villalta Score (VS) was used to establish the presence of PTS (VS≥5). ResultsWe identified 49 (40.8%) subjects with clinical diagnosed of PTS. Patients with or without PTS showed comparable age and temporal distance from DVT event. We observed higher BMI (p=0.005) and waist circumference (p=0.006) among subjects with VS≥5 as compared to patients without PTS. No differences between the two groups were found in terms of lipid profile, blood pressure, diabetes, hs-CRP level and ongoing medications. The prevalence of MetS was equally distributed among patients with or without PTS (20% vs 26% respectively, p=0.64). Among the individual components of MetS only the prevalence of visceral adiposity was significantly increased in subjects affected by PTS (OR 2.81, p=0.008). Moreover, a significant linear correlation was found between VS and waist circumference in the entire cohort (r=0,354, p<0.0001). ConclusionThere is no evidence of association between MetS and PTS. However, the degree of visceral adiposity is strongly correlated with the presence and severity of post-thrombotic disease.

Endovascular management of symptomatic gastrointestinal complications associated with retrievable inferior vena cava filters.

With the increase in retrievable inferior vena cava (IVC) filter use, a higher than expected reported rate of pericaval tine penetration is observed. Symptomatic gastrointestinal (GI) complications associated with retrievable IVC filters have been documented; however, their management remains controversial. We describe a series of GI complications of retrievable IVC filters, detailing the spectrum of presenting symptoms and multiple treatment options, including the safety of endovascular retrieval. A retrospective chart review was performed to describe the presentation, diagnosis, and treatment of patients with symptomatic GI complications associated with retrievable IVC filters from 2008 to2014. Nine patients had symptomatic GI complications associated with a retrievable IVC filter (two G2 Recovery [Bard Peripheral Vascular, Tempe, Ariz], seven Celect [Cook Medical, Bloomington, Ind]; six women; age range, 17-81years). All patients had small bowel perforation on computed tomography scan, four confirmed by esophagogastroduodenoscopy. Concomitant aortic and vertebral penetration occurred in seven and five patients, respectively. Patients presented with various abdominal complaints; one patient presented in acute sepsis. Two patients underwent laparotomy without complications. The remaining seven patients had attempted endovascular retrieval, six of which were successful. One patient's IVC filter was unable to be retrieved, and he was managed medically. Of the six patients who had successful endovascular retrieval, all had resolution of their symptoms with no complications, except for transient sepsis in a single patient who was not receiving periprocedural antibiotics. A follow-up computed tomography scan was performed 48 to 72hours after endovascular retrieval and ruled out duodenal leak in all patients. Long-term follow-up demonstrated continued resolution of GI symptoms without further episodes of deep venous thrombosis or pulmonary embolism. GI complications of retrievable IVC filters are manifested with a wide spectrum of symptoms and frequent concomitant aortic and vertebral penetration. Endovascular retrieval can be safely used as a first-line therapy even in the setting of small bowel and aortic penetration.

Severe Post Thrombotic Syndrome Is Associated to Lower Echogenicity of the Residual Venous Thrombosis

Introduction: The post-thrombotic syndrome (PTS) is a common chronic complication of deep venous thrombosis (DVT) of the lower limbs and may occur even after an appropriate anticoagulant treatment. PTS may develop in the first two years after DVT in about 20-50% of patients; 5–10% of those may present severe manifestations of the disease. PTS is associated to an increased risk for DVT recurrence, morbidity, poor quality of life and significant cost to public health. The diagnosis of PTS is performed by clinical evaluation; particularly, the Villalta scale is recommended by the ISTH for PTS diagnosis and severity evaluation. The PTS-associated medical conditions are poorly understood, and it seems that hypercoagulability and inflammation, after the first episode of DVT, may play an important role in the disease development. Therefore, we performed a comprehensive analysis of clinical parameters, inflammation and ultrasound (US) examination of the affected limb in patients with history of previous DVT and PTS.Objective: The aim of this study was to evaluate possible medical conditions associated to PTS and its severity.Material and Methods: Between February 2013 and October 2013, consecutive patients with history of previous unprovoked DVT of lower limbs (> 6 months from the diagnosis), attended at the Hematology Center of the University of Campinas, Brasil, were included. Patients were submitted to physical evaluation for body mass index (BMI) determination and PTS diagnosis, by Villalta scale. Levels of the IL-8, IL-6 and TNF-α were performed by ELISA, D-dimer by turbidimetry and CRP by nephelometry. US examination was performed by duplex. In patients with residual venous thrombosis (RVT), the thrombus echogenicity was determined by grayscale median (GSM) evaluation, as described for atherosclerotic plaques. The GSM analysis was performed by a computer based US using specific software. Only the region containing the thrombus was analyzed, the image was depicted manually point by point to trace the line surrounding the thrombus, the final GSM values were automatic calculated and translated the thrombus echogenicity. A low GSM value (<25) suggests acute thrombosis and a high GSM vlaue (> 25) suggest subacute thrombosis.. Continuous variables were analyzed by Kruskal-Wallis test and categorical variables were compared using the Fisher´ s exact test.Results: From the 56 patients included, 15 did not present PTS, 23 were classified as mild, 11 as moderate and 7 as severe PTS. Serum levels of CRP was significantly higher in patients with severe PTS when compared to patients with mild+moderate PTS and to those without PTS (respectivelly 0.64mg/dL, 0.31mg/dL and 0.13mg/dL; P=0.02).Serum levels of IL-6 and TNF-α were higher in patients with severe PTS compared to patients with mild/moderate PTS and without PTS (IL-6= 2.81pg/mL vs. 1.48pg/mL vs. 0.80pg/mL respectively, and TNF 1.68pg/mL vs. 1.33pg/mL vs 1.17pg/mL respectively), however the differences did not reach statistical significance. Levels of IL-8 and DD were similar between severe PTS and the other two groups. The presence of RVT was similar between groups, however US-generated GSM was significantly lower in patients with severe PTS compared to patients with mild+moderate PTS and patients without PTS (GSM= 22, 31 and 28.5, respectively; P=0.04). As predicted, the BMI was also higher in patients with severe PTS when compared to mild+moderate PTS and no PTS group (BMI= 34,8 vs. 29,3 vs. 25,9, respectively P=0.007).Conclusion: Our results suggest that severe PTS may be associated with a chronic inflammatory response, characterized by obesity and higher levels of CRP. Besides, we could also observe that severe PTS may be associated with the persistence of a hypoechoic residual thrombus, determined by lower US-generated GSM values. The finding about the persistence of a hypoechoic thrombus in patients with severe PTS, even long time after the acute thrombosis event, is new and may possibly suggest that an adequate thrombus organization process is required to avoid the development of PTS. DisclosuresNo relevant conflicts of interest to declare.

Lower Echogenicity of the Residual Venous Thrombosis at Ultrasound Examination Is Associated to Recurrent Thrombosis Events

Introduction: After the first thrombotic event, up to 30% of deep venous thrombosis (DVT) cases may recur within 10 years. Unprovoked first DVT episode, male gender and persistently elevated D-dimer are important risk factors for DVT recurrence. However, additional elements may still contribute to evaluate the individual recurrence risk. The role of residual venous thrombosis (RVT) as a risk factor for recurrence is controversial. The lack of a standardized methodology for RVT evaluation by conventional ultrasonography (US) may explain, in part, why the results are divergent among different studies. Several clinical studies in arterial thrombosis have evaluated the echogenicity of atherosclerotic plaques by grayscale median (GSM) computer-assisted ultrasound (US) analysis, and carotid plaques showing lower US-generated GSM values (<25) were identified as high risk lesions since they more prone to embolization. In this context, we hypothesized that the assessment of RVT echogenicities, by US-generated GSM, could be a new tool for the evaluation of the individual recurrence risk for DVT and possibly guide further antithrombotic treatments.Aim: In patients with history of previous DVT, we evaluated whether the US-generated GSM values for RVT may predict the recurrence of thrombotic events.Material and Methods: This is a prospective study that included 52 patients with at least one episode of unprovoked DVT, or DVT provoked by hormones, attended at the Hematology Center in the University of Campinas, Brazil. Only patients with DVT in the lower limbs and diagnosed in the previous 5 years were selected. Patients with antiphospholipids antibodies and neoplasia were excluded. At the time of enrollment for the study, patients were submitted to a duplex examination and blood samples collection. Medical evaluation was performed twice a year and a new US image was achieved when DVT recurrence was suspected or by the end of the follow-up. The primary endpoint of the study was thrombosis recurrence, and was made 2 years after enrollment for the study. Laboratory analysis: IL-8, IL-6 and TNF-α levels were performed by ELISA, D-dimer by turbidimetry and CRP by nephelometry. US-generated GSM : The region containing only the residual thrombus was depicted point by point to trace a surrounding line. GSM was then calculated by specific software.Results: From 52 consecutive patients with previous DVT, 30 patients presented RVT. During the two years of follow-up, 10 patients had a new venous thrombosis event; in all cases of thrombosis recurrence, patients had a previous diagnosis of RVT. Among patients with RVT, those with lower GSM values presented more recurrent events; the GSM < 24 was the optimal cut-off value to determine the risk of thrombosis recurrence (specificity of 95%; 95% CI = 75.13 to 99.87%). The relative risk for recurrence was 2.8 (95%CI= 1.2 to 6.5; P=0.09) greater in patients with GSM <24, comparing to patients with GSM >24. The risk for recurrence was five times greater in patients with GSM < 24 (RR=5.1, 95% CI = 2.115 -12.50; P = 0.0194) if compared to patients with GSM>24 grouped with patients without RVT. We further dichotomized all patients according to the presence of RVT and GSM values; the first group was composed by individuals with thrombus GSM<24, and the second one by either patients with thrombus GSM > 24 and patients without RVT. Serum levels of TNF-α and IL-8 were significantly higher in patients with GSM <24 (6.8 vs. 2.2 pg/mL, P=0.03 and 59.1 vs. 19.0 pg/mL, P=0.001; respectively). Levels of PCR (0.37mg/dL), IL-6 (3.13pg/mL) and D-dimer (0.66mg/L) were increased in patients with GSM<24 compared to the other group (0.19 pg/mL, 1.19 pg/m and 0.46 mg/L; respectively), the differences were not statistically significant.Conclusion: Our findings suggest that RVT may be a risk factor for recurrence, particularly the recurrence risk seems to be higher among patients with very hypoechoic residual thrombus (GSM<24). Patients with thrombus GSM < 24 also presented higher levels of inflammatory markers, which may also be consistent with higher risk for thrombosis recurrence. GSM values are objectively achieved by computer-assisted US equipments and can be performed in patients taking anticoagulants. Therefore US-generated GSM value of the residual thrombus rises as a promising marker for assessment of individual risk for thrombosis recurrence. DisclosuresNo relevant conflicts of interest to declare.

In suspected PE, an age-adjusted D-dimer cutpoint improved ability to exclude PE.

ACP Journal Club15 July 2014In suspected PE, an age-adjusted D-dimer cutpoint improved ability to exclude PEEddy Lang, MDEddy Lang, MDUniversity of Calgary, Calgary, Alberta, Canada (E.L.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-161-2-201407150-02013 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Source CitationRighini M, Van Es J, Den Exter PL, et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 2014;311:1117-24. https://pubmed.ncbi.nlm.nih.gov/24643601Clinical Impact RatingsEmergency Med: Hospitalists: Hematology: Critical Care: References1 Torres-Macho J, Mancebo-Plaza AB, Crespo-Giménez A, et al. Clinical features of patients inappropriately undiagnosed of pulmonary embolism. Am J Emerg Med. 2013;31:1646-50. [PMID: 24060320] Google Scholar2 Huckins DS, Price LL, Gilley K. Utilization and yield of chest computed tomographic angiography associated with low positive D-dimer levels. J Emerg Med. 2012;43:211-20. [PMID: 21764536] Google Scholar3 Pasha SM, Klok FA, Snoep JD, et al. Safety of excluding acute pulmonary embolism based on an unlikely clinical probability by the Wells rule and normal D-dimer concentration: a meta-analysis. Thromb Res. 2010;125:e123-7. [PMID: 19942258] Google Scholar4 Linkins LA, Bates SM, Lang E, et al. Selective D-dimer testing for diagnosis of a first suspected episode of deep venous thrombosis: a randomized trial. Ann Intern Med. 2013;158:93-100. [PMID: 23318311] Google Scholar5 Schouten HJ, Geersing GJ, Koek HL, et al. Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. BMJ. 2013;346:f2492. [PMID: 23645857] Google Scholar Author, Article, and Disclosure InformationAuthors: Eddy Lang, MDAffiliations: University of Calgary, Calgary, Alberta, Canada (E.L.)This article was published at Annals.org on 1 July 2014. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byTromboembolismo pulmonar en pacientes con COVID-19: estudio de prevalencia en un hospital terciarioPulmonary embolisms in patients with COVID-19: A prevalence study in a tertiary hospital 15 July 2014Volume 161, Issue 2Page: JC13KeywordsD-dimerDeep vein thrombosisPatientsProspective studiesPulmonary embolismResearch fundingSpecificityThromboembolismThrombosisVenous thromboembolism ePublished: 15 July 2014 Issue Published: 15 July 2014 Copyright & PermissionsCopyright © 2014 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Unprovoked proximal venous thrombosis is associated with an increased risk of asymptomatic pulmonary embolism

IntroductionPulmonary embolism (PE) is common in patients with deep venous thrombosis (DVT). The outcome of DVT with concomitant symptomatic PE is worse than the outcome of isolated DVT. The risk factors for DVT and simultaneous asymptomatic PE have not been systematically studied yet. AimTo evaluate the frequency and risk factors for asymptomatic PE in patients with DVT. Patients/methodsIn 155 consecutive patients with a first episode of DVT and no PE symptoms, a ventilation-perfusion lung scan was performed. Body mass index (BMI) and waist-to-hip ratio (WHR) were calculated and concentrations of D-dimer, high-sensitivity CRP (hsCRP), tissue plasminogen activator (t-PA) and troponin were measured. Laboratory tests for thrombophilia were performed. ResultsAsymptomatic PE was present in 36% of patients. No differences in gender, age, BMI and WHR were found between the patients with and without PE. PE was more common in patients with proximal DVT than in those with distal DVT (42% vs. 17%, p<0.01), and in patients with unprovoked DVT compared to patients with provoked DVT (51% vs. 28%, p<0.01). The risk of silent PE was the highest in patients with unprovoked proximal DVT (OR, 6.9; 95% CI, 2.3–21.0). Patients with asymptomatic PE had significantly higher values of D-dimer, hsCRP, t-PA and troponin than patients with isolated DVT. ConclusionsAsymptomatic PE affected more than one third of patients with a first DVT. Unprovoked proximal DVT is the most important risk factor for the occurrence of silent PE.

Temsirolimus with or without megestrol acetate and tamoxifen for endometrial cancer: A gynecologic oncology group study

ObjectivesTo determine the response, toxicities, and progression free survival of a regimen of temsirolimus with or without hormonal therapy in the treatment of advanced, or recurrent endometrial carcinoma. BackgroundPreclinical evidence suggested that blockade of the PI3K/AKT/mTOR pathway might overcome resistance to hormonal therapy. MethodsWe performed a randomized phase II trial of intravenous temsirolimus 25mg weekly versus the combination of weekly temsirolimus with a regimen of megestrol acetate 80mg bid for three weeks alternating with tamoxifen 20mg bid for three weeks in women with recurrent or metastatic endometrial carcinoma. ResultsThere were 71 eligible patients who received at least one dose of therapy with 21 of these treated on the combination arm which was closed early because of an excess of venous thrombosis, with 5 episodes of deep venous thrombosis (DVT) and 2 pulmonary emboli. There were three responses observed in that arm (14%). A total of 50 eligible patients were treated on the single agent arm with 3 episodes of DVT and 11 responses (22%). Response rates were similar in patients with prior chemotherapy (7 of 29; 24%) and those with no prior chemotherapy (4 of 21; 19%). Two of four patients with clear cell carcinoma responded. ConclusionsAdding the combination of megestrol acetate and tamoxifen to temsirolimus therapy did not enhance activity and the combination was associated with an excess of venous thrombosis. Temsirolimus activity was preserved in patients with prior adjuvant chemotherapy.

Efficacy of the prothrombin complex concentrate prothromplex in patients requiring urgent reversal of vitamin K antagonists or presenting with uncontrolled bleeding

The objective of the present study was to investigate the efficacy of a four-factor prothrombin complex concentrate (Prothromplex, PTX) in shortening prolonged international normalized ratio or controlling life-threatening bleeding. The study was a retrospective single-centre study that included 142 patients treated with PTX and allocated in three groups: patients on vitamin K antagonists (VKA) (acenocumarol) and undergoing invasive procedure or presenting with severe bleeding (n = 76), patients treated with VKA presenting with intracranial haemorrhage (n = 22), and patients not on VKA and presenting with uncontrolled bleeding (n = 44). The primary outcome variable was international normalized ratio (INR) return to the norm after PTX infusion. Secondary outcome variables included bleeding control and reduction of transfusion rate. Overall, patients received a median of 1200 IU (≈15 IU/kg) of PTX, and INR decreased from 4 ± 3 to 1.7 ± 1.2 (P < 0.01) in all groups, although it remained at least 1.4 in 38% of patients (29.3% among patients receiving 25 IU/kg vs. 42.6% among those receiving 15 IU/kg; P < 0.05). Patients with initial INR at least 4 benefited the most from treatment. After PTX administration, there was a significant reduction in both transfused blood components units (P < 0.01) and estimated blood loss volume (from 1500 ± 1500 to 200 ± 100 ml; P < 0.01), and only one episode of deep venous thrombosis was observed. Administration of fixed doses of PTX shortened prolonged international normalized ratio and improved life-threatening bleeding in patients with or without VKA therapy. Higher dose attained a more adequate post-infusion INR.

Predictors Of The Post-Thrombotic Syndrome In a Large Cohort Of Patients With Proximal DVT: Secondary Analysis Of The Sox Trial

Background The post-thrombotic syndrome (PTS) is a frequent complication of deep venous thrombosis (DVT). Identifying predictors of PTS is important to counsel DVT patients on their expected prognosis and to identify patients who may benefit from closer monitoring or preventive strategies. Objective In a secondary analysis of the SOX Trial, we aimed to identify predictors of developing PTS during 2 years follow-up after a first episode of proximal DVT. Methods The study cohort consisted of participants in the SOX Trial, a multicenter (24 centres in Canada and U.S.) randomized placebo controlled trial of active elastic compression stockings vs. placebo stockings worn for 2 years after a first, symptomatic proximal DVT. PTS, the primary study endpoint, was diagnosed at or after the 6 month visit based on patient-reported pain and swelling of ≥ 1 month duration that were typical in character, i.e. worse at end of day or after prolonged sitting/standing and improved after rest/leg elevation (Ginsberg criteria). Cumulative incidences of PTS were compared in subgroups defined by sex, age category, body mass index (BMI) category, anatomic extent of index DVT, type of DVT (cancer-associated, secondary risk factor-associated, unprovoked) and 1-month Villalta score category (score 0-4: none; 5-9, mild; 10-14, moderate; &gt;14, severe), using Cox regression. Losses to follow-up, withdrawals and deaths were censored as of last date of follow-up. Results are presented as cumulative incidence by 750 days follow-up and hazard ratios (HR) with 95% confidence intervals (CI). Results Among the 803 participants in the SOX Trial, 60% were male, mean age was 55.1 years, and 87% were out-patients. In analyses adjusted for intervention group (i.e. allocation to active vs. placebo stockings), iliac vein DVT (HR 2.26 [95% CI 1.12, 4.53]; reference category: popliteal DVT) and Villalta score category at 1 month after DVT (score 5-9, HR 2.74 [95% CI 1.62, 4.64]; score 10-14, HR 5.81[95% CI 2.99, 11.29]; score &gt;14, HR 7.59 [95% CI 3.31, 17.44]; reference category: score &lt;5) were significant predictors of PTS. In analyses adjusted for intervention group and all predictor variables of interest, Villalta score category at 1 month was a highly statistically significant, independent predictor of PTS (see Table). Age, sex, BMI and type of DVT did not predict development of PTS. Conclusions In a large prospective cohort of patients with proximal DVT who were participants in the SOX Trial, Villalta score category (which reflects severity of venous symptoms and signs) at 1 month after DVT was strongly predictive of development of PTS during 2 years follow-up. This confirms a similar finding that we first observed in the VETO cohort study (Kahn SR et. al., Annals Intern Med 2008). More extensive DVT was also associated with PTS. Patients with these risk factors may benefit from closer monitoring after proximal DVT, and in the case of iliac vein DVT, from more aggressive strategies to treat acute DVT. Disclosures: No relevant conflicts of interest to declare.

Selective D-dimer Testing for Diagnosis of a First Suspected Episode of Deep Venous Thrombosis: A Randomized Trial: Linkins L, Bates SM, Lang E, et al. Ann Intern Med 2013;158:93–100.

Selective D-dimer Testing for Diagnosis of a First Suspected Episode of Deep Venous Thrombosis: A Randomized Trial: Linkins L, Bates SM, Lang E, et al. Ann Intern Med 2013;158:93–100.

Selective D-Dimer Testing for Diagnosis of a First Suspected Episode of Deep Venous Thrombosis: A Randomized Trial

For patients with a first episode of suspected deep vein thrombosis (DVT), selected D-dimer testing is more efficient than having everyone undergo D-dimer testing.

Indications for platelet aggregation inhibitors after venous stents

Iliofemoral venous obstruction may arise from either primary compressive lesions or may be secondary to an episode of deep venous thrombosis. Regardless of aetiology, these lesions, either alone or in association with more distal reflux, may be responsible for lower extremity pain, swelling, and ulceration. Conventional surgical procedures for the treatment of iliofemoral venous obstruction have largely been supplanted by endovascular approaches relying on the deployment of venous stents. Large series have reported good technical and clinical results from venous stenting, particularly for primary lesions. However, early stent occlusions and late re-stenosis do occur. Although most of these appear related to technical factors, there is likely a role for pharmacological adjuncts in maintaining stent patency. The use of anticoagulants and antiplatelet agents is largely based on the underlying pathophysiology and extrapolation from arterial interventions, which likely are significantly different with respect to their pathophysiology and natural history. Although lacking substantial evidence demonstrating efficacy, the use of adjunctive antiplatelet agents in stents placed for primary lesions and consideration of anticoagulation for high-risk post-thrombotic lesions appears to be reasonable.

Selectived-Dimer Testing for Diagnosis of a First Suspected Episode of Deep Venous Thrombosis

D-Dimer testing is sensitive but not specific for diagnosing deep venous thrombosis (DVT). Changing the use of testing and the threshold level for a positive test result on the basis of risk for DVT might improve the tradeoff between sensitivity and specificity and reduce the need for testing. To determine whether using a selective D-dimer testing strategy based on clinical pretest probability (C-PTP) for DVT is safe and reduces diagnostic testing compared with using a single D-dimer threshold for all patients. Randomized, multicenter, controlled trial. Patients were allocated using a central automated system. Ultrasonographers and study adjudicators but not other study personnel were blinded to trial allocation. (ClinicalTrials.gov: NCT00157677) 5 Canadian hospitals. Consecutive symptomatic patients with a first episode of suspected DVT. Selective testing (n = 860), defined as D-dimer testing for outpatients with low or moderate C-PTP (DVT excluded at D-dimer levels <1.0 µg/mL [low C-PTP] or <0.5 µg/mL [moderate C-PTP]) and venous ultrasonography without D-dimer testing for outpatients with high C-PTP and inpatients, or uniform testing (n = 863), defined as D-dimer testing for all participants (DVT excluded at D-dimer levels <0.5 µg/mL). The proportion of patients not diagnosed with DVT during initial testing who had symptomatic venous thromboembolism during 3-month follow-up and the proportion of patients undergoing D-dimer testing and ultrasonography. The incidence of symptomatic venous thromboembolism at 3 months was 0.5% in both study groups (difference, 0.0 percentage point [95% CI, -0.8 to 0.8 percentage points]). Selective testing reduced the proportion of patients who required D-dimer testing by 21.8 percentage points (CI, 19.1 to 24.8 percentage points). It reduced the proportion who required ultrasonography by 7.6 percentage points (CI, 2.9 to 12.2 percentage points) overall and by 21.0 percentage points (CI, 14.2 to 27.6 percentage points) in outpatients with low C-PTP. Results may not be generalizable to all D-dimer assays or patients with previous DVT, study personnel were not blinded, and the trial was stopped prematurely. A selective D-dimer testing strategy seems as safe as and more efficient than having everyone undergo D-dimer testing when diagnosing a first episode of suspected DVT. Heart and Stroke Foundation of Ontario.

Recurrent deep vein thrombosis and pulmonary embolism in a patient with Klinefelter’s syndrome

Klinefelter's syndrome, which is characterized by small testes, gynecomastia, hypogonadism, and infertility, is the most common cause of primary testicular failure, and commonly has an XXY karyotype. Deep vein thrombosis and thomboembolic events are a rare occurrence in these patients. Although the exact mechanism is not completely understood, it is thought that increased thromboembolic risk in hypogonadic men can be explained by hypofibrinolysis resulting from androgen deficiency. We present the case of a 48-year-old man with Klinefelter's syndrome who experienced recurrent episodes of deep venous thrombosis and pulmonary embolism while undergoing therapeutic anticoagulation. Our report discusses this association and management of the prothrombotic state in patients with Klinefelter's syndrome.

Deep Venous Thrombosis and Pulmonary Embolism Caused by an Intravascular Synovial Sarcoma of the Common Femoral Vein

Malignant tumors arising in deep veins of the lower extremities are very uncommon. To our best knowledge, this is the seventh case of a primary venous intravascular synovial sarcoma (SS) reported in literature. A 32-year-old woman was admitted with a second episode of deep venous thrombosis of the right lower limb and pulmonary embolism. Physical and radiological examinations showed besides the thrombosis a tumor arising from the right common femoral vein involving the bifurcation of the common femoral artery. At surgery, en block resection of the tumor including the deep femoral vein and arterial bifurcation was done with an arterial reconstruction using a synthetic graft. Histopathological examination revealed an intravascular SS of the common femoral vein. The mainstay of curative therapy is complete surgical resection of all tumor manifestations with negative histological margins.

Varicose veins are a risk factor for deep venous thrombosis in general practice patients

The role of varicose veins (VV) as a risk factor for development of deep venous thrombosis (DVT) is still controversial. The aim of this study in primary care was to determine the impact of varicosity as a potential risk factor for developing DVT. During the observation period between 01-Jan-2008 and 01-Jan-2011, all cases with VV (ICD code I83.9) and DVT (ICD codes I80.1 - I80.9) were identified out of the CONTENT primary care register (Heidelberg, Germany). The exposure of VV and DVT was based solely on ICD coding without regarding the accuracy of the diagnosis. The covariates age, gender, surgery, hospitalization, congestive heart failure, malignancy, pregnancy, hormonal therapy, and respiratory infection were extracted for each patient. Multivariate binary logistic regression was performed in order to assess potential risk factors for DVT. The SAS procedure "PROC GENMOD" (SAS version 9.2, 64-bit) was parameterised accordingly. A potential cluster effect (patients within practices) was regarded in the regression model. There were 132 out of 2,357 (5.6 %) DVT episodes among patients with VV compared to 728 out of 80,588 (0.9 %) in the patient cohort without VV (p < 0.0001). An increased risk of DVT was associated with previous DVT (adjusted odds ratio (OR): 9.07, 95 % confidence interval (CI): 7.78 - 10.91), VV (OR 7.33 [CI 6.14 - 8.74]), hospitalization during the last 6 months (OR 1.69 [CI 1.29 - 2.22]), malignancy (OR 1.55 [CI 1.19 - 2.02]), and age (OR 1.02 [CI 1.01 - 1.03]). There are strong associations between VV and DVT in a general practice population with documented VV. Special medical attention is required for patients with VV, a history of previous venous thromboembolism, comorbid malignancy, and recent hospital discharge, particularly those with a combination of these factors.

Early thrombus removal strategies for acute deep venous thrombosis: Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum

The anticoagulant treatment of acute deep venous thrombosis (DVT) has been historically directed toward the prevention of recurrent venous thromboembolism. However, such treatment imperfectly protects against late manifestations of the postthrombotic syndrome. By restoring venous patency and preserving valvular function, early thrombus removal strategies can potentially decrease postthrombotic morbidity. A committee of experts in venous disease was charged by the Society for Vascular Surgery and the American Venous Forum to develop evidence-based practice guidelines for early thrombus removal strategies, including catheter-directed pharmacologic thrombolysis, pharmacomechanical thrombolysis, and surgical thrombectomy. Evidence-based recommendations are based on a systematic review and meta-analysis of the relevant literature, supplemented when necessary by less rigorous data. Recommendations are made according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, incorporating the strength of the recommendation (strong: 1; weak: 2) and an evaluation of the level of the evidence (A to C). On the basis of the best evidence currently available, we recommend against routine use of the term "proximal venous thrombosis" in favor of more precise characterization of thrombi as involving the iliofemoral or femoropopliteal venous segments (Grade 1A). We further suggest the use of early thrombus removal strategies in ambulatory patients with good functional capacity and a first episode of iliofemoral DVT of <14 days in duration (Grade 2C) and strongly recommend their use in patients with limb-threatening ischemia due to iliofemoral venous outflow obstruction (Grade 1A). We suggest pharmacomechanical strategies over catheter-directed pharmacologic thrombolysis alone if resources are available and that surgical thrombectomy be considered if thrombolytic therapy is contraindicated (Grade 2C). Most data regarding early thrombus removal strategies are of low quality but do suggest patient-important benefits with respect to reducing postthrombotic morbidity. We anticipate revision of these guidelines as additional evidence becomes available.

Prolonged Versus Standard-Duration Venous Thromboprophylaxis in Major Orthopedic Surgery

The optimal duration of thromboprophylaxis after major orthopedic surgery is unclear. To compare the benefits and harms of prolonged versus standard-duration thromboprophylaxis after major orthopedic surgery in adults. Cochrane Central Register of Controlled Trials and Scopus from 1980 to July 2011 and MEDLINE from 1980 through November 2011, without language restrictions. Randomized trials reporting thromboembolic or bleeding outcomes that compared prolonged (≥21 days) with standard-duration (7 to 10 days) thromboprophylaxis. Two independent reviewers abstracted data and rated study quality and strength of evidence. Eight randomized, controlled trials (3 good-quality and 5 fair-quality) met the inclusion criteria. High-strength evidence showed that compared with standard-duration therapy, prolonged prophylaxis resulted in fewer cases of pulmonary embolism (PE) (5 trials; odds ratio [OR], 0.14 [95% CI, 0.04 to 0.47]; absolute risk reduction [ARR], 0.8%), asymptomatic deep venous thrombosis (DVT) (4 trials; relative risk [RR], 0.48 [CI, 0.31 to 0.75]; ARR, 5.8%), symptomatic DVT (4 trials; OR, 0.36 [CI, 0.16 to 0.81]; ARR, 1.5%), and proximal DVT (6 trials; RR, 0.29 [CI, 0.16 to 0.52]; ARR, 7.1%). Moderate-strength evidence showed fewer symptomatic objectively confirmed episodes of venous thromboembolism (4 trials; RR, 0.38 [CI, 0.19 to 0.77]; ARR, 5.7%), nonfatal PE (4 trials; OR, 0.13 [CI, 0.03 to 0.54]; ARR, 0.7%), and DVT (7 trials; RR, 0.37 [CI, 0.21 to 0.64]; ARR, 12.1%) with prolonged prophylaxis. High-strength evidence showed more minor bleeding events with prolonged prophylaxis (OR, 2.44 [CI, 1.41 to 4.20]; absolute risk increase, 6.3%), and insufficient evidence from 1 trial on hip fracture surgery suggested more surgical-site bleeding events (OR, 7.55 [CI, 1.51 to 37.64]) with prolonged prophylaxis. Data relevant to knee replacement or hip fracture surgery were scant and insufficient. Most trials had few events; the strength of evidence ratings that were used may not adequately capture uncertainty in such situations. Prolonged prophylaxis decreases the risk for venous thromboembolism, PE, and DVT while increasing the risk for minor bleeding in patients undergoing total hip replacement.

Recurrent deep venous thrombosis in an HIV-positive and injecting drug user woman

We report a case of recurrent deep venous thrombosis in a 44-year-old woman, intravenous drug user and HIV-infected, who injected cocaine in the groins and veins of the dorsum of the feet. She suffered several episodes of deep venous thrombosis and soft-tissue infections in the lower limbs. Images of Doppler ultrasound scan revealed thrombosis in the right popliteal vein with partial recanalization and calcified thrombi in the territory of the right femoral vein. After use of heparin and oral anticoagulation, her clinical evolution was uneventful, and she was asymptomatic at the occasion of the hospital discharge. This report calls for better awareness about injections in the groins and superficial femoral veins, which are part of the deep venous system. Thrombosis related to HIV infection is highlighted.

The treatment of venous thromboembolism with low-molecular-weight heparins

The currently recommended method of venous thromboembolism (VTE) treatment is the application of vitamin K antagonists (VKA) in most patients, and low-molecular-weight heparins (LMWH) in selected groups. The VKA dose adjustment is difficult which might well render the treatment ineffective. The study aimed to compare LMWH with VKA in treating VTE in terms of efficacy and safety. A systematic review of literature and the meta-analysis of the treatment results were performed. The main differences between LMWH and VKA in terms of their respective effectiveness in treating VTE consist in appreciably more advantageous effects of LMWH in preventing deep venous thrombosis (DVT). The key difference in terms of respective safety is the greater effectiveness of LMWH inpreventing minor bleedings. The advantage of LMWH in cancer patients consists predominantly in a significantly better protection against DVT episodes, whereas the advantage of LMWH in non-cancer patients is mainly owed to better protection against minor bleedings. In none of the analysed outcomes of VTE treatment, the application of VKA proved to hold any advantage over LMWH. Although, arguably, there might well be sufficient medical grounds to propose more widespread use of LMWH, it still remains a debatable issue whether the currently used therapeutic standard should also be modified accordingly. Apart from the actual findings of the present meta-analysis, pertinent economic considerations must also be addressed.