Evidence Of Deep Vein Thrombosis Research Articles

Diameter and depth of femoral vessels by duplex ultrasound

Background: The anatomy of the femoral artery and vein plays an integral role in vascular access. Both technical feasibility and complication rates are associated with femoral vessel diameter and depth. The goal of this study is to establish normative values for common femoral artery (CFA) and vein (CFV) depth and diameter using a large, diverse patient population. Methods: A retrospective review of all patients undergoing lower extremity venous duplex imaging over a 1 year period were reviewed. Patients with inadequate imaging or with evidence of deep vein thrombosis were excluded. The index image of all studies was a non-compressed view of the common femoral vein at the saphenous-femoral junction. All measurements were taken from this still. Vessel diameters were measured from intima to intima. Depth was measured from skin to intima. BMI and BSA were calculated using standard formulas. Chi square was used for univariate analysis. Linear regression was used to establish correlation. Results: Over the 1 year period, 983 patients met criteria for inclusion. The majority were male (53%) with a mean age of 55. The patients were 47% white and 44% black. The majority had hypertension (53%). The mean BMI and BSA were 29 and 2, respectively. Mean CFA depth was 1.7 cm, while mean CFV depth was 1.8 cm. The mean CFA and CFV diameters were 0.9 and 1.1 cm, respectively. Amongst height, weight, BMI, and BSA, weight correlated best with CFA ( R = 0.548) and CFV ( R = 0.552) depth, while BSA correlated best for diameter for both CFA ( R = 0.390) and CFV ( R = 0.440). Conclusions: This study establishes mean diameters and depths for the common femoral artery and vein using a large, diverse patient group. BSA was most closely associated with vessel diameter, while weight was correlated with depth. This study provides normative diameter and depth values for the common femoral vasculature, which may assist in vascular access planning for providers.

Pulmonary Hypertension and Patent Foramen Ovale: A Rare Risk Factor for Stroke (P12-5.022)

<h3>Objective:</h3> To illustrate the importance of a comprehensive and individualized stroke evaluation in young patients with pulmonary hypertension presenting with ischemic stroke. <h3>Background:</h3> Approximately 45% of strokes in the United States are cryptogenic. A common etiology of cryptogenic stroke is a paradoxical embolism through a patent foramen ovale (PFO). Additionally, pulmonary artery hypertension (PAH) is independently associated with 1.5 times higher odds of stroke. It is unclear the compounded risk of stroke in patients with both a PFO and PAH. <h3>Design/Methods:</h3> Case Report and Literature Review. <h3>Results:</h3> A 35-year-old woman with history of PAH presented with vertigo, nausea and headache. Her neurological assessment revealed left-sided dysmetria and truncal ataxia. Brain MRI demonstrated a large left superior cerebellar non-hemorrhagic infarct with partial effacement of the fourth ventricle. She was not a candidate for reperfusion therapy. She required external ventricular drainage. Transthoracic echocardiogram (TTE) showed a dilated right ventricle with reduced systolic function but was otherwise unrevealing. Bilateral lower extremity duplex ultrasound showed no evidence of deep vein thrombosis. The patient was seen in our outpatient multidisciplinary cryptogenic stroke clinic, where repeat TTE with agitated saline injection showed evidence of a PFO. Due to severe pulmonary hypertension, PFO closure was contraindicated, due to potential for worsening right heart function. The patient was started on apixaban for secondary stroke prevention without recurrence of embolic events. <h3>Conclusions:</h3> This unique case report highlights the importance of PFO screening in patients with PAH. Patients with PAH have an increased incidence of stroke, the mechanisms of which are not well understood. In this case, PFO was identified in a patient with severe PAH in our outpatient clinic. Right-to-left shunting in this setting may increase risk of paradoxical embolism. A multidisciplinary approach to cryptogenic stroke patients may facilitate identification of rare mechanisms of stroke as well as improve and personalize secondary stroke prevention. <b>Disclosure:</b> Mr. Arkin has nothing to disclose. Dr. Then has nothing to disclose. An immediate family member of Dr. Ragupathi has received personal compensation for serving as an employee of Merck.

LBMON138 Leg Tumeo: Is It Neuroendocrine Tumor?

Abstract Introduction Neuroendocrine tumors (NETs) are heterogenous group of epithelial neoplasms often known to produce and secrete peptides and bioamines. The presentation varies from symptomatic functional to non-functional tumors. The functional tumors cause symptoms based on the substance secreted: corticotropin, gastrin, glucagon, insulin, norepinephrine, serotonin, somatostatin, etc. The prognosis ranges from well-differentiated tumors being indolent while the poorly differentiated forms are aggressive. We present a case with an atypical presentation of NET which was noted to secrete an atypical hormone, cortisol. Case Presentation A 55-year-old Caucasian man presented with bilateral lower extremity grade 3 pitting edema for past 2 weeks. His past medical history was significant for hypertension. Lower extremity doppler showed no evidence of deep vein thrombosis. Serum potassium was critically low at 1.9mmol/L. Computed tomography of abdomen and pelvis showed a large mass involving the right hepatic lobe, upper pole of right kidney and hypoattenuated lesions in left hepatic lobe. The intrahepatic inferior vena cava appeared to be severely compressed by the mass. MRI abdomen was suggestive of hepatocellular cancer but alfaprotein levels was normal. Biochemical testing for evaluation of hormonal hypersecretion showed elevated cortisol levels (57.2mcg/dl) and markedly elevated dehydroepiandrosterone sulfate (2641mcg/dl). Serum adrenocorticotrophic hormone and aldosterone levels were within normal limits. Low dose dexamethasone suppression test showed no decline in serum cortisol level reflecting adrenal origin. Urinary evaluation showed elevated cortisol but normal metanephrine and catecholamine levels. With concerns for adrenal carcinoma, right adrenal mass biopsy was performed. The biopsy showed poorly differentiated malignant neoplasm with neuroendocrine features. Tumor cells were positive for synaptophysin (a marker for neuroendocrine differentiation) and CD 138. Soon after, he progressed to multisystem organ failure, tumor lysis syndrome and resorted to comfort care. The patient passed away within a week of diagnosis. Conclusion NETs usually originate in gastrointestinal tract, pancreas, adrenal, lung and rarely genitourinary tract. The incidence of NETs is on the rise with increased detection by imaging. Adrenal NETs, well-known as pheochromocytoma are mostly benign but small cell adrenal neuroendocrine carcinomas are rare and have a grave prognosis. Flushing, diarrhea are the commonest presentations (75-85%) for gastrointestinal NETs and symptoms are based on the substance secreted. This case highlights a case of adrenal neuroendocrine cancer presenting with lower extremity swelling and secreting an uncommon hormone, cortisol. Increasing awareness among the medical fraternity will help with early diagnosis and better outcomes. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Clinical Profile, Management and Outcome of Patients Presenting with Acute Pulmonary Embolism at Tertiary Level Cardiac Centre in Nepal

Introduction: Pulmonary embolism (PE) is a common, under diagnosed and potentially lethal clinical condition. The aim of our study was to find out the clinical profile, management and outcome of patients with acute PE. Methods: It was a retrospective study. The participants included patients admitted and diagnosed to have acute PE from January 2014 to December 2019. Patients with high clinical probability and positive D-dimer in low and intermediate clinical probability were diagnosed as acute PE clinically. Data were obtained from the records section of the hospital. Results: The most common risk factor was found to be smoking. Only two patients were found to have protein C and protein S deficiency (4.4%) and one patient had hyperhomocysteinemia (2.2%). The most common symptom was found to be shortness of breath (97.8%). The most common sign was sinus tachycardia. Right ventricular dysfunction was found in 35.5% of the patients on echocardiogram. Computerized tomography pulmonary angiogram (CTPA) was done in 60% of the patients. The most common CT finding was presence of thrombus in main pulmonary artery in 13.3% of patients. Troponin I was positive in 26.7% of patients and D-dimer was positive in 66.7%. Only 42.2% had evidence of deep vein thrombosis. Only 13.3% were thrombolysed. All the patients received low molecular weight heparin or unfractionated heparin followed by warfarin or dabigatran. The in-hospital mortality rate was 15.6% where the rest of the patients were discharged. Conclusion: The most common symptom and sign was found to be shortness of breath and sinus tachycardia. Single investigation was not conclusive so multiple investigations were done to reach the diagnosis. Though all the patients received anticoagulation, only few of them were thrombolysed. The in-hospital mortality was found to be 15.6%.

MODERNA VACCINE PULMONARY EMBOLISM: ASSOCIATION VS COINCIDENCE

TOPIC: Biotechnology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Recent case reports have called attention to cerebral venous thrombosis after receiving the Johnson & Johnson vaccine for the novel Coronavirus 2019 (COVID-19), which resulted in the temporary suspension of the single-dose viral vector option. However, as of April 13th, 2020, CDC states that there are no reports of the clotting in the approximately 180 million doses of the Pfizer and Moderna vaccines administered in the United States. Here we present a case of a healthy male who developed pulmonary embolisms after receiving the Moderna vaccine. CASE PRESENTATION: A 55-year-old healthy, physically active male of Ashkenazi Jewish descent presents with multiple bilateral segmental and sub-segmental pulmonary embolisms. Twenty-four hours prior to onset of symptoms, the two-vaccine series of Moderna was completed. The patient was both COVID-19 PCR and COVID-19 IgG antibody negative, but positive for COVID IgM antibody. There was no evidence of deep vein thrombosis. In addition, his hypercoagulable work-up was negative. DISCUSSION: COVID-19 dramatically increases the risk of pulmonary embolism through a proposed mechanism of thrombo-inflammation triggered by viral infection, which originates in the pulmonary vasculature. Initially it was theorized that the etiology of this patient's pulmonary embolisms were an acute COVID-19 infection but two PCR tests from two different laboratories resulted as negative. Increased clotting has not yet been reported in the Pfizer and Moderna mRNA vaccine cohorts. In fact, the preliminary data from the Moderna vaccine trial stated that risk of pulmonary embolism is less than 0.03%, which was lower than the placebo group.It is also unknown if the Moderna vaccine trial included patients of Ashkenazi Jewish descent. It is theorized that as more patients worldwide become vaccinated, major side effects could increase as those patients who were not originally represented in the preliminary studies. CONCLUSIONS: Although the Moderna vaccine has shown to theoretically decrease the risk of clotting by decreasing risk of COVID-19 infection, as more of the world becomes vaccinated, the incidence of side effects could increase, despite preliminary data. REFERENCE #1: Abou-Ismail MY, Diamond A, Kapoor S, Arafah Y, Nayak L. The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management [published correction appears in Thromb Res. 2020 Nov 26;:]. Thromb Res. 2020;194:101-115. doi:10.1016/j.thromres.2020.06.029 REFERENCE #2: Oliver SE, Gargano JW, Marin M, Wallace M, Curran KG, Chamberland M, McClung N, Campos-Outcalt D, Morgan RL, Mbaeyi S, Romero JR, Talbot HK, Lee GM, Bell BP, Dooling K. The Advisory Committee on Immunization Practices' Interim Recommendation for Use of Moderna COVID-19 Vaccine - United States, December 2020. MMWR Morb Mortal Wkly Rep. 2021 Jan 1;69(5152):1653-1656. doi: 10.15585/mmwr.mm695152e1. PMID: 33382675. REFERENCE #3: VRBPAC December 17, 2020 Meeting Announcement. U.S. Food and Drug Administration. https://www.fda.gov/advisory-committees/advisory-committee-calendar/vaccines-and-related-biological-products-advisory-committee-december-17-2020-meeting-announcement. Published December 17, 2020. Accessed April 27, 2021. DISCLOSURES: No relevant relationships by David Capone, source=Web Response No relevant relationships by Brett Kingsborough, source=Web Response No relevant relationships by Kathryn Saxby, source=Web Response No relevant relationships by Daisy Young, source=Web Response

Single-Session Mechanical Thrombectomy of Lower Extremity Deep Venous Thrombosis Using the ClotTriever System: A Single-Institution Experience

Abstract Purpose The aim of this study was to provide a single-center experience in utilization of the ClotTriever mechanical thrombectomy system in acute and subacute deep vein thrombosis (DVT). Methods Retrospective review was performed for all patients who underwent DVT thrombectomy using the ClotTriever system at a single academic medical center. Data recorded included age, gender, etiology, laterality of DVT, fluoroscopy time, perioperative parameters, type of anesthesia, concomitant usage of thrombolytics and/or stents. Follow-up Doppler ultrasounds or diagnostic venograms were reviewed, and time of reintervention (if performed) and Villalta scores were recorded. Results Ten patients were included in the study, with 6/10 female (60%), mean age 54.6 years (range: 24–80). Eight patients presented with acute iliofemoral DVT, one patient with subacute iliofemoral DVT, and one patient with subacute inferior vena cava thrombosis. Only one patient required concomitant intraprocedural thrombolytic administration, and four patients underwent same-session venous stent placement. Technical success was achieved in 90% patients and no procedure-related adverse events were observed. Reintervention within 30 days was required in two (20%) patients at 12 and 13 days. No patient required intensive care unit (ICU) stay, and mean postprocedure hospital length of stay was 2.3 days. On follow-up (mean: 214 days), five patients had no evidence of DVT and four patients showed chronic postthrombotic changes in femoropopliteal veins not requiring intervention. Conclusion The ClotTriever mechanical venous thrombectomy system demonstrates high efficacy in removal of thrombus from lower extremities in a single session, often obviating the need for thrombolytic therapy with low reintervention rates and short postprocedure hospital stay.

Fixed-dose enoxaparin provides efficient DVT prophylaxis in mixed ICU patients despite low anti-Xa levels: A prospective observational cohort study.

Deep vein thrombosis (DVT) is a serious but preventable complication of critical illness with a reported incidence from 4 to 17%. Anti-Xa activity in critically ill patients achieved with standard dosing of low-molecular-weight heparins (LMWH) is often below the target of 0.2-0.5 IU/mL. However, the clinical significance of this finding is unclear. The quality of thromboprophylaxis also strongly impacts the incidence of DVT. We performed a prospective observational study to evaluate the incidence of DVT in a mixed medical-surgical-trauma intensive care unit (ICU) using a thromboprophylaxis protocol with a fixed dose of enoxaparin. We also explored the relation between DVT incidence and anti-Xa activity. All consecutive patients with expected ICU stay ≥72 hours and without evidence of DVT upon admission were included. They underwent ultrasound screening for DVT twice a week until ICU discharge, death, DVT or pulmonary embolism. Peak anti-Xa activity was measured twice a week. Patients received 40 mg of enoxaparin subcutaneously (60 mg in obese, 20 mg in case of renal failure). Graduated compression stockings were used in case of LMWH or another anticoagulant contraindication. A total of 219 patients were enrolled. We observed six cases of DVT (incidence of 2.7%). The agreement between expected and delivered DVT prophylaxis was 94%. Mean peak anti-Xa activity level was 0.24 (SD, 0.13) IU/mL. There was no significant difference in anti-Xa activity in DVT and non-DVT group. A low incidence of DVT was achieved with meticulous adherence to the standard prophylactic protocol. The low incidence of DVT was observed despite low levels of anti-Xa activity. Our findings suggest that enoxaparin dose adjustment based on regular monitoring of anti-Xa activity is unlikely to result in further reduction of DVT incidence in a mixed ICU population. ClinicalTrials.gov, NCT03286985.

Tranexamic acid and reduction of blood transfusion in lower limb trauma surgery: a randomized controlled study.

Introduction: Post-operative blood loss in lower limb trauma fractures increases morbidity. Very few studies have evaluated the efficacy of Tranexamic Acid (TXA) in reducing blood loss and the consequent requirement of blood transfusion in the Indian population. Methods: This was a randomized controlled study of 100 patients with lower limb trauma. Fifty patients were given 1 g of TXA before surgery, and 50 patients were not given TXA. The requirement of blood transfusion, fall in Hb, the number of days admitted in the hospital after surgery were recorded, and evidence of deep vein thrombosis (DVT) was monitored. Results: Baseline demographics between the groups were comparable. The required blood transfusion and fall in Hb in patients receiving intra-operative TXA were significantly lower than those not given TXA (p < 0.0001). There was no significant difference in the length of hospital stay between the two groups (p = 0.6). There was no significant difference in the incidence of DVT in both groups. Discussion: TXA helps reduce the morbidity of trauma patients by reducing the requirement for blood transfusion. Its use is safe in lower limb trauma surgery and lowers the cost of therapy to the patient.

Wells Score to Predict Pulmonary Embolism in Patients with Coronavirus Disease 2019

BackgroundThe association between coronavirus disease 2019 (COVID-19) and hypercoagulability has been extensively described, and pulmonary embolism is a recognized complication of COVID-19. Currently, the need for computed tomography pulmonary angiogram (CTPA) relies on the Wells score and serum D-dimer levels. However, because COVID-19 patients have a different thrombotic and inflammatory milieu, the usefulness of the Wells score deserves further exploration for this patient population. We aimed to explore the ability of the Wells score to predict pulmonary embolism in patients with COVID-19. MethodsIn this retrospective study, patients found to have a CTPA and a COVID-19 diagnosis during the same admission were selected for analysis. Age and sex, CTPA results, and associated D-dimer levels were entered in a database. The Wells score sensitivity and specificity were calculated at different values, and the area under the curve of the receiver operating characteristic curve measured. ResultsOf 459 patients with COVID-19, 64 had a CTPA and 12 (19%) had evidence of pulmonary embolism. Previous or current evidence of deep vein thrombosis, a Wells score above 4 points, and serum D-dimer levels 5 times above age-adjusted upper normal values were associated with pulmonary embolism. However, only 33% of patients with pulmonary embolism had a Wells score of 4 points or higher. The area under the curve of the receiver operating characteristic showed non-discriminating values (0.54) ConclusionsAlthough a Wells score of 4 or more points predicted pulmonary embolism in our cohort, the outcome can be present even with lower scores.

Computed tomography characterization and outcome evaluation of COVID-19 pneumonia complicated by venous thromboembolism.

BackgroundCOVID-19 is frequently complicated by venous thromboembolism (VTE). Computed tomography (CT) of the chest—primarily usually conducted as low-dose, non-contrast enhanced CT—plays an important role in the diagnosis and follow-up of COVID-19 pneumonia. Performed as contrast-enhanced CT pulmonary angiography, it can reliably detect or rule-out pulmonary embolism (PE). Several imaging characteristics of COVID-19 pneumonia have been described for chest CT, but no study evaluated CT findings in the context of VTE/PE.PurposeIn our retrospective study, we analyzed clinical, laboratory and CT imaging characteristics of 50 consecutive patients with RT-PCR proven COVID-19 pneumonia who underwent contrast-enhanced chest CT at two tertiary care medical centers.Material and methodsAll patients with RT-PCR proven COVID-19 pneumonia and contrast-enhanced chest CT performed at two tertiary care hospitals between March 1st and April 20th 2020 were retrospectively identified. Patient characteristics (age, gender, comorbidities), symptoms, date of symptom onset, RT-PCR results, imaging results of CT and leg ultrasound, laboratory findings (C-reactive protein, differential blood count, troponine, N-terminal pro-B-type natriuretic peptide (NT-proBNP), fibrinogen, interleukin-6, D-dimer, lactate dehydrogenase (LDH), creatine kinase (CK), creatine kinase muscle-brain (CKmb) and lactate,) and patient outcome (positive: discharge or treatment on normal ward; negative: treatment on intensive care unit (ICU), need for mechanical ventilation, extracorporeal membrane oxygenation (ECMO), or death) were analyzed. Follow-up was performed until May 10th. Patients were assigned to two groups according to two endpoints: venous thromboembolism (VTE) or no VTE. For statistical analysis, univariate logistic regression models were calculated.ResultsThis study includes 50 patients. In 14 out of 50 patients (28%), pulmonary embolism was detected at contrast-enhanced chest CT. The majority of PE was detected on CTs performed on day 11–20 after symptom onset. Two patients (14%) with PE simultaneously had evidence of deep vein thrombosis. 15 patients (30%) had a negative outcome (need for intensive care, mechanical ventilation, extracorporeal membrane oxygenation, or death), and 35 patients (70%) had a positive outcome (transfer to regular ward, or discharge). Patients suffering VTE had a statistically significant higher risk of an unfavorable outcome (p = 0.028). In univariate analysis, two imaging characteristics on chest CT were associated with VTE: crazy paving pattern (p = 0.024) and air bronchogram (n = 0.021). Also, elevated levels of NT-pro BNP (p = 0.043), CK (p = 0.023) and D-dimers (p = 0.035) were significantly correlated with VTE.ConclusionCOVID-19 pneumonia is frequently complicated by pulmonary embolism (incidence of 28% in our cohort), remarkably with lacking evidence of deep vein thrombosis in nearly all thus affected patients of our cohort. As patients suffering VTE had an adverse outcome, we call for a high level of alertness for PE and advocate a lower threshold for contrast-enhanced CT in COVID-19 pneumonia. According to our observations, this might be particularly justified in the second week of disease and if a crazy paving pattern and / or air bronchogram is present on previous non-enhanced CT.

Massive pulmonary thromboembolism combined with transient thyrotoxicosis in an 18\u2009year old girl

BackgroundPulmonary thromboembolism (PTE) is thought to usually stem from deep vein thrombosis (DVT). However, evidence of DVT could not be found in many cases. Furthermore, transient thyrotoxicosis is a rare but potentially life–threatening emergency involving a systemic hypercoagulable state. We report on an 18 year-old-girl with transient thyrotoxicosis with massive PTE without DVT.Case presentationAn 18-year-old girl was admitted to the hospital with syncope. Patient had no history of trauma, any known underlying disease or oral contraceptives use. Chest computed tomography (CT) showed massive PTE in both central pulmonary arteries and diffuse goiter. However, a low extremity Doppler sonogram did not detect DVT. To manage the PTE, we administered low molecular weight heparin. On the other hands, thyroid function test indicated a state of thyrotoxicosis. In addition, patient had a partial protein S deficiency but no other immunologic abnormality. Therefore, the patient was diagnosed with massive PTE, thyrotoxicosis, and partial protein S deficiency. Patient was discharged with oral warfarin and methimazole. A follow-up echocardiogram obtained 3 months after anticoagulation therapy demonstrated normal dimensions and systolic function. After thyrotoxicosis was treated with methimazole for a month, a euthyroid state was achieved and the goiter decreased to a normal size. The methimazole was gradually tapered off and stopped at 4 months. At a 6-month follow up visit, PTE and pulmonary hypertension had disappeared but the patient still had a partial protein S deficiency. We decided to stop all medication with careful monitoring. During a 4-year follow-up period after the episode, she was asymptomatic without any evidence of recurrent systemic thromboembolism or hyperthyroidism.ConclusionsEarly recognition and appropriate treatment of PTE combined with transient thyrotoxicosis were vital to preventing other complications.

A Case Report on Paget-Schroetter Syndrome Presenting as Acute Localized Rhabdomyolysis

IntroductionThe life- or limb-threatening differential diagnosis for upper extremity swelling can include deep vein thrombosis (DVT), infectious processes, and compartment syndrome. Chronic anatomic abnormalities such as axillary vein stenosis are rarely a consideration in the emergency department.Case ReportWe present a 26-year-old female with history of Chiari type 1 malformation who presented with acute left arm swelling. Initial workup, including point-of-care ultrasound, revealed the presence of significant soft tissue swelling without evidence of DVT.ConclusionFurther workup revealed an early, localized rhabdomyolysis secondary to axillary vein stenosis or venous thoracic outlet syndrome, also known as Paget-Schroetter syndrome.

Symptomatic acute pulmonary embolism despite thromboprophylaxis after simultaneous total knee arthroplasty: Case report in an Indian female

Symptomatic acute pulmonary embolism (PE) in a post-operative orthopaedic condition is a medical emergency with grave prognosis if left undetected. Simultaneous total knee arthroplasty (TKA) need prior identification and risk assessment. A prophylactic thromboprophylaxis expectedly reduces the incidence of venous thromboembolism (VTE) including deep vein thrombosis (DVT) and PE. We report a 52-year old obese Indian female who underwent simultaneous TKA with standard operating protocol. Peri-operative mechanical and chemo-thromboprophylaxis was given with no evidence of DVT. Acute PE presented on 3rd post-operative day with an episode of breathlessness, chest pain and desaturation. A positive computed tomographic pulmonary angiography (CTPA) and high D-dimer levels were conclusive. Management with therapeutic anticoagulant therapy was done. No late mortality occurred. Return to her activities of daily living with improved knee scores was the desired outcome.Simultaneous TKA in patient with a high body mass index should receive prophylactic thromboprophylaxis. Pre-operative risk stratification in TKA with a high index of suspicion in postoperative period are necessary steps to identify and manage a potentially fatal acute PE.

Doppler ultrasonographic evaluation of brachial and femoral veins, and coagulation and lipid profiles in dogs following open splenectomy

In dogs, splenectomy is mandatory as an emergency following splenic rupture with resultant hemoperitoneum and hypotensive shock. The present work aimed to evaluate the Doppler ultrasonographic parameters of brachial and femoral veins in splenectomized dogs and to investigate the effect of splenectomy on the coagulation and lipid profiles. A total number of 9 dogs underwent clinical, abdominal ultrasonographic and laboratory examinations prior to the surgical operation and kept for 60-day observation period post-splenectomy. Follow-up ultrasonography revealed no serious complications post-splenectomy. Both brachial and femoral veins were imaged medial to their corresponding arteries. Doppler ultrasonographic parameters of both veins showed no significant changes throughout the study period (P > 0.05). Haematological analysis revealed development of anemia, leukocytosis, and thrombocytosis in dogs post-splenectomy. Coagulation profile exhibited no significant variations in prothrombin and activated partial thromboplastin times (P > 0.05). In comparison with their baseline values, the mean concentrations of total cholesterol, low-density lipoprotein, and triglycerides were significantly increased 30-day post-splenectomy. In conclusion, it may seem that open splenectomy has no influence on the Doppler ultrasonographic indices of brachial and femoral veins with no evidence of deep vein thrombosis in dogs. However, persistent leukocytosis and thrombocytosis, as well as altered lipid profile may increase the risk of vascular complications with the long run. Therefore, a further long-term study may be required.

A case of pulmonary thromboembolism secondary to hyperhomocysteinemia

Hyperhomocysteinemia (HHcy) affects hemostasis and shifts its balance in favor of thrombosis. HHcy can be a potential cause of unprovoked pulmonary thromboembolism, which may be a sole manifestation rather than typical multisystem involvement of the disease. Here, we report a rare case of a 56-year-old male presented with sudden onset of breathlessness, unexplained tachycardia, hypoxemia, who was diagnosed as a case of pulmonary embolism secondary to HHcy without any evidence of deep vein thrombosis.

Efficacy and safety of radiofrequency ablation for lower limb varicose veins

Background: Endovenous Radiofrequency Ablation (RFA) is gradually gaining widespread acceptance as a minimally invasive modality for treatment of varicose veins (VV). The objective of this study was to evaluate the efficacy based on Venous Doppler and Venous Clinical Severity Score (VCSS) and the safety of radiofrequency ablation for varicose veins.Methods: This is a prospective study of 58 consecutive patients who underwent Radiofrequency ablation of Varicose veins from January 2015 to January 2017 in a single unit of a Multispecialty Tertiary Care Hospital. The mean age was 44.10±13.74 years (19-75 years). A total of 78 limbs were treated in 58 patients. RFA was performed using Closure FastTM catheter according to the manufacturer’s recommendation. Treatment outcomes were estimated 15 days, 3 months, 6 months and 1 year after the procedure using Doppler scan and VCSS score.Results: There was 100% occlusion of the treated veins with no evidence of partial/complete recanalization. However, 2 (2.56%) patients had a GSV stump length &gt; 3cm on Doppler at 6 months, without evidence of significant reflux. Minor complications such as ecchymosis erythema, pain and induration rapidly improved over short term. One patient (1.3%) had evidence of Deep Vein thrombosis (DVT) on follow up Venous Doppler. The mean VCSS improved from mean of 7.98 preoperatively to 2.24 after 1 year (P value &lt;0.001).Conclusions: Radiofrequency ablation is a safe and effective procedure with minimal major complications. The minor complications were early and resolved rapidly.

A Case Report of Cerebral Venous Thrombosis after Taking Tamoxifen in Breast Cancer Patient

Background: Tamoxifen is commonly used in adjuvant treatment in hormonal receptor positive breast cancer patients. Cerebral venous thrombosis is one of the rare adverse events from tamoxifen. Report of the case: A 52-year-old lady was diagnosed right breast cancer (stage T3N3M0). She was undergone right modified radical mastectomy. The pathological results revealed invasive lobular carcinoma, size 6x2.3x2 cm. , grade 2, negative resected margin, ten out of fifteen lymph nodes were positive for malignancy. The immunohistochemistry was ER 90%, PR 25%, Her2 negative, and Ki67 10%. She obtained adjuvant chemotherapy, 4 cycles of Doxorubicin and cyclophosphamide followed by 4 cycles of paclitaxel every 3 weeks. She was prescribed tamoxifen during adjuvant radiation to her chest wall and regional lymph nodes. Approximately 8 months after taking tamoxifen, she complained progressive headache, dizziness, nausea and vomiting. Emergency CT brain with Contrast was done to rule out brain metastases. The scan revealed hyper dense lesion at temporal area with vasogenic edema, focal filling defect at left transverse sigmoid junction and upper portion of internal jugular vein. There was no demonstrable parenchymal metastasis. MRI and MRV of the brain showed acute dural venous sinus thrombosis of the lateral aspect of the left transverse sinus, left sigmoid sinus, left upper internal jugular vein as well as cortical venous thrombosis in the left vein of Labbe. Venous infarction in the left temporal lobe and left superior cerebellar hemisphere. Causing intraparenchymal hematoma in the left lobe. Laboratory analysis was done. Protein C/S, Lupus anticoagulant, ant thrombin, homocystein, anticardiolipin IgG/IgM, anti B2 glycoprotein I-IgG/IgM was normal. She was given enoxaparin 0.6 ml SC every 12 hours and tamoxifen was off. The scan of CT brain 6 days later showed interval decreased attenuation intraparenchymal hematoma at left posterior temporal lobe. Her headache was improved and no neurological deficit was detected. Ultrasonography of both lower extremities showed no evidence of deep vein thrombosis. She then switched to aromatase inhibitors. Discussion: Clinical risk factors for venous thromboembolism are major general or orthopedic surgery, paralysis, pelvic fracture, trauma, cancer previous venous thromboembolism, cancer, major surgery, trauma, obesity, varicose veins, cardiac disease, pregnancy and nephritic syndrome. Our patient had none of these risk factors. Although it is quite rare, cerebral venous thrombosis must be kept in mind of possible adverse effect from tamoxifen.

Gastrocnemius Tear: Incidental Finding During a Venous Doppler Exam

Calf muscle tears are relatively common. They can be identified well as incidental findings using duplex sonography when performing a lower extremity venous Doppler exam. A case is presented of a 43-year-old male patient who underwent a sonogram to diagnose deep vein thrombosis. The exam results demonstrated patent and compressible common femoral, femoral, popliteal, and calf veins without evidence of deep vein thrombosis. As the sonographer was documenting the popliteal fossa, a complex fluid-filled structure within the left gastrocnemius muscle was identified. The diagnosis was reported as a gastrocnemius muscle tear. This case demonstrates a fairly common incidental finding, gastrocnemius muscle tear, when performing a venous Doppler exam.

Abstract 47: Atrial Fibrillation is Associated With Increased Risk of Incident Venous Thromboembolism: The Atherosclerosis Risk in Communities Study

Background: It is well-established that atrial fibrillation (AF) is associated with thrombus formation in the left atrium, which can lead to ischemic stroke. Case reports, autopsies, and transesophageal echo data have indicated that clot formation also occurs in the right atrium (i.e. right-side intracardiac thrombosis) of AF patients, which could lead to pulmonary embolism (PE). However, it is unclear whether this occurrence is common. Objective: Test the hypotheses that individuals with incident AF are at elevated risk of developing venous thromboembolism (VTE), and that the association will be stronger for those presenting with PE alone versus PE and deep vein thrombosis (DVT) or DVT alone. Methods: A total of 15,205 Atherosclerosis Risk in Communities (ARIC) study participants, aged 45-64 years, were followed from baseline (1987-1989) to 2011 for incidence of AF and VTE (median follow-up 19.8 years). Incident AF and VTE events were identified via active surveillance and defined by relevant hospital discharge ICD codes. VTE events were validated by medical record review. Multivariable-adjusted Cox proportional hazards regression models were used, with AF modeled as a time-dependent covariate. We also evaluated separately risk of PE without evidence of DVT, DVT without PE, and events presenting with both PE and DVT. Results: At baseline participants were on average 54 years old, 55% female and 26% black. In the absence of AF there were 678 VTE events, for an incidence rate of 2.6 per 1000 person-years. After an AF diagnosis there were 77 events, with an incidence rate of 7.1 per 1000 person-years. In multivariable-adjusted models, having AF (versus no AF) was associated with a greater risk of incident VTE; the HR (95% CI) was 2.10 (1.65-2.68) after adjustment for demographics, 1.82 (1.42-2.32) additionally accounting for numerous AF and VTE risk factors, and 1.97 (1.53-2.53) after further adjusting for time-dependent anticoagulant use. When we restricted to PE events without evidence of DVT there were 188 events in total, of which 19 occurred following a diagnosis of AF. The HR for AF (versus no AF) was 1.53 (0.92-2.56) in fully adjusted models. For DVT alone there were 384 events in total, of which 48 occurred after AF diagnosis; the HR for AF was 2.43 (1.77-3.33). Among the 116 events presenting with both DVT and PE, 10 occurred after AF diagnosis, and the HR for AF was 1.36 (0.67-2.75). Conclusions: Diagnosis with AF was associated with a nearly 2-fold increased risk of incident VTE. The association was not stronger when isolated to those with PE without DVT, suggesting that higher risk of VTE among AF patients may be due to either the coagulation abnormalities that accompany AF, or shared risk factors that were not fully accounted for in this analysis.

Abstract WMP69: Predictive Value of Diagnostic Testing for Detection of Deep Vein Thrombosis in Ischemic Stroke Patients with Intracardiac Shunt

Background: In the pursuit of stroke etiology, cardiac imaging with bubble study often reveals an intracardiac shunt. We sought to determine the yield of bilateral lower extremity ultrasound (BLE US) and magnetic resonance venography (MRV) of the pelvis in detection of deep vein thrombosis (DVT) as a source for paradoxical embolization in patients with ischemic stroke who have an intracardiac shunt. Methods: Patients admitted with AIS from 2008 through 2015 were included if the presence of intracardiac shunt was confirmed via echocardiography with bubble study. We examined the frequency of DVT (DVT+) among patients who had BLE US only, MRV pelvis only, or both BLE US and MRV. We then compared patients with evidence of DVT (DVT+) to those without evidence of DVT (DVT-). Results: Among 1,992 patients with AIS, 145 patients had confirmed evidence of an intracardiac shunt; of these, 40 patients (27.6%) had neither BLE US nor MRV studies, 29 patients (20.0%) had BLE US only, 4 patients (2.8%) had MRV only, and 72 patients (49.7%) had both BLE US and MRV. Among those with BLE US only, 2 patients (6.9%) were DVT+; of those who had MRV only, 2 patients (50.0%) were DVT+; of those who had both BLE US and MRV, 11 (15.3%) were DVT+. Overall, 14.3% of patients with an intracardiac shunt and work-up for DVT were found to have an occult DVT. No statistically significant differences were detected in demographic, baseline, in-hospital, or discharge characteristics when comparing DVT+ and DVT- patients. Discussion: The findings of this study support the use of BLE US and MRV to detect occult DVT among ischemic stroke patients with intracardiac shunt. In our sample population, 14.3% of patients were positive for occult DVT though no patient characteristics were associated with predicting the presence of DVT. This supports the need for adequate DVT screening in patients with AIS and positive bubble study.