Evidence Of Deep Venous Thrombosis Research Articles

Incidence of Deep Venous Thrombosis and Sickle Cell Disease in Patients Undergoing Spinal Surgery in South Gujarat, India: A Prospective Observational Study.

Introduction:Our objective of this study was to assess the incidence of Deep Venous Thrombosis in patients including those with sickle cell disease who underwent spine surgery, and also to determine the association of Sickle Cell Disease as a clinical predictor for Deep Venous Thrombosis in spinal surgery patients.Materials and methods:All patients who underwent spinal surgery from January 2016 to October 2016 were included in this study. Detailed history, demographic data, physical findings, pre-operative haematological and radiological investigations were documented. All the patients underwent daily clinical evaluation for clinical signs of Deep Venous Thrombosis and also underwent a post-operative venous Doppler and D-dimer test.Results:Seventy-nine consecutive patients were included in the study with the mean age of 41 years. All patients had normal venous Doppler pre-operatively. A total of 2.5% patients had deep vein thrombosis in bilateral lower limbs while 2 patients (2.5%) had evidence of venous stasis but no thrombosis on Doppler ultrasound done post-operatively. Nine patients (11.4%) were sickle cell positive from which 4 patients showed evidence of Deep Venous Thrombosis or Venous Stasis. D-dimer was positive in 5 (8.3%) patients which included 4 patients with Sickle Cell Disease.Conclusion:This study concludes that Sickle Cell Disease is a risk factor for developing Deep Venous Thrombosis in patients undergoing spinal surgery. The study also concludes the effectiveness of mechanical prophylaxis in preventing Deep Venous Thrombosis and recommends pharmacological prophylaxis after assessing the risk profile or positive D-dimer test.

Upper extremity deep vein thrombosis in COVID-19: Incidence and correlated risk factors in a cohort of non-ICU patients.

Venous thromboembolism is a frequent complication of COVID-19 infection. Less than 50% of pulmonary embolism (PE) is associated with the evidence of deep venous thrombosis (DVT) of the lower extremities. DVT may also occur in the venous system of the upper limbs especially if provoking conditions are present such as continuous positive airway pressure (CPAP). The aim of this study was to evaluate the incidence of UEDVT in patients affected by moderate-severe COVID-19 infection and to identify potential associated risk factors for its occurrence. We performed a retrospective analysis of all patients affected by moderate-severe COVID-19 infection admitted to our unit. In accordance with the local protocol, all patients had undergone a systematic screening for the diagnosis of UEDVT, by vein compression ultrasonography (CUS). All the patients were receiving pharmacological thromboprophylaxis according to international guidelines recommendations. Univariate and multivariate analyses were used to identify risk factors associated with UEDVT. 257 patients were included in the study, 28 patients were affected by UEDVT with an incidence of 10.9% (95% CI, 7.1-14.7). At univariate analysis UEDVT appeared to be significantly associated (p< 0.05) with pneumonia, ARDS, PaO2/FiO2, D-dimer value higher than the age adjusted cut off value and need for CPAP ventilation. Multivariate analysis showed a significant association between UEDVT and the need for CPAP ventilation (OR 5.95; 95% IC 1.33-26.58). Increased mortality was found in patients affected by UEDVT compared to those who were not (OR 3.71; 95% CI, 1.41-9.78). UEDVT can occur in COVID-19 patients despite adequate prophylaxis especially in patients undergoing helmet CPAP ventilation. Further studies are needed to identify the correct strategy to prevent DVT in these patients.

Probative Value of the D-Dimer Assay for Diagnosis of Deep Venous Thrombosis in the Coronavirus Disease 2019 Syndrome.

To describe the predictive utility of the D-dimer assay among patients with the coronavirus disease 2019 syndrome for unprovoked lower extremity deep venous thrombosis. Prospective observational study with retrospective data analysis. Academic medical center surgical ICU. Seventy-two intubated patients with critical illness from coronavirus disease 2019. Therapeutic anticoagulation after imaging diagnosis of the first three deep venous thrombosis cases was confirmed; therapeutic anticoagulation as prophylaxis thereafter to all subsequent ICU admissions. Seventy-two patients with severe coronavirus disease 2019 were screened for deep venous thrombosis after ICU admission with 102 duplex ultrasound examinations, with 12 cases (16.7%) of lower extremity deep venous thrombosis identified. There were no differences between groups with respect to age, renal function, or biomarkers except for D-dimer (median, 12,858 ng/mL [interquartile range, 3,176-30,770 ng/mL] for lower extremity deep venous thrombosis vs 2,087 ng/mL [interquartile range, 638-3,735 ng/mL] for no evidence of deep venous thrombosis; p < 0.0001). Clinical screening tools (Wells score and Dutch Primary Care Rule) had no utility. The C-statistic for D-dimer concentration was 0.874 ± 0.065. At the model-predicted cutoff value of 3,000 ng/mL, sensitivity was 100%, specificity was 51.1%, positive predictive value was 21.8%, and negative predictive value was 100%. Lower extremity deep venous thrombosis is prevalent in coronavirus disease 2019 disease and can be present on ICU admission. Screening has been recommended in the context of the pro-inflammatory, hypercoagulable background milieu. D-dimer concentrations are elevated in nearly all coronavirus disease 2019 patients, and the test appears reliable for screening for lower extremity deep venous thrombosis at or above a concentration of 3,000 ng/mL (more than 13-fold above the normal range). Full anticoagulation is indicated if the diagnosis is confirmed, and therapeutic anticoagulation should be considered for prophylaxis, as all coronavirus disease 2019 patients are at increased risk.

P888 How many diagnoses can one heart gather?

Abstract Background Apical hyperthrophic cardiomyopathy (AHCM) is an uncommon form of hyperthrophic cardiomyopathy (HCM) with less prevalent detection of gene mutations and sudden cardiac death compared with other types of HCM. Purpose We present the case of a 76 years old patient with multiple cardiovascular risk factors (hypertension, dyslipidemia, obesity, former smoker) with history of unprovoked pulmonary embolism - PE (2018), without evidence of deep venous thrombosis, in treatment with rivaroxaban, who presented with worsening severe dyspnea at effort and peripheral edemas, symptoms started a few days before admission. He denied angina or palpitations. Methods On clinical examination we identified obesity grade II and bilateral leg edema and routine laboratory tests revealed controlled dyslipidemia. The electrocardiogram (ECG) showed atrial flutter (AF) with block 5:1, heart rate 50/min, with negative T waves in DI, aVL and V2-V6. Transthoracic echocardiography with contrast was performed showing no wall motion abnormalities otherwise with a mild concentric left ventricle hypertrophy (LVH) except for the apex where there was severe LVH suggestive for AHCM; there was an increased aortic velocity with an aortic valve with degenerative changes. We thought that the changes on the ECG were most likely due to AHCM. A thoracic tomography scan with contrast was also performed because of associated dyspnea which excluded an acute recurrence of PE. The next day the T waves on ECG normalized, putting forward for consideration an acute coronary syndrome. We performed a coronarography which confirmed a 80% stenosis of proximal left anterior descending (LAD) artery with subsequent placement of a drug eluting stent. We also did a transesophageal echocardiography (noncompliant patient) for exclusion of intracardiac thrombi (which also showed bicuspid aortic valve) and then we performed radiofrequency ablation of the cavotricuspid isthmus followed by atrial overdrive pacing for typical AF, but unsuccessful, with degeneration into atrial fibrillation. Results Sometimes heart failure might occur due to multiple etiological factors and mechanisms of decompensation. We had a patient with AHCM with an ECG that could be interpreted as typical for this pathology but with concomitent severely affected LAD coronary artery, with AF and high grade atrioventricular block plus mild aortic stenosis with a bicuspid aortic valve with indication for strict follow up. Conclusions AHCM was first described in Japan where has the highest prevalence, but is also documented in other countries (rare in Caucasian population). Note that AHCM often mimic acute coronary syndromes through clinical manifestations and electrocardiographic aspects. Our case report showed a Caucasian patient with AHCM with concomitent severe atherosclerotic desease and aortic stenosis on a bicuspid valve.

Superficial Venous Thrombosis Associated with Emergency Contraceptive Pill Usage (Levonorgestrel) – Case Report and Review of Literature

Introduction: The association between contraceptive pill and venous thromboembolism (VTE) is well documented. Currently, Levonorgestrel used in combined contraceptive pill is considered to have lower risk of venous thromboembolism compared to other hormonal combinations. Progesterone only contraceptive pill and emergency contraceptive pills are considered not to increase the risk of VTE and are recommended for patients who are at high risk of VTE or with previous history of VTE. The aim of this paper is to present our experience in manging two patients with superficial venous thrombosis associated with progesterone only emergency contraceptive pill (Levonorgestrel) and review the literature. Methods: Case 1: A 25-year-old female presented with a 2-day history of pain and discomfort in the left thigh. She does not have significant past medical history and has taken emergency contraceptive pill (1.5 mg of Levonorgestrol) three days ago. Clinical examination revealed tenderness over the lower and medial aspect of left thigh along the great saphenous vein. Venous doppler confirmed thrombus in the great saphenous vein extending for a short segment in the left thigh. She was treated with low molecular weight heparin for 5 days followed by 6 weeks course of Dabigatran 150 mg twice daily. Repeat venous doppler at one week did not reveal extension of thrombus into the deep veins. Case 2: A 21-year-old female presented with a 3-day history of pain, swelling and skin discoloration over the left leg and thigh. She has taken emergency contraceptive pill (1.5 mg of Levonorgestrel) five days ago. She is otherwise fit and active without any significant past medical history. Clinical examination revealed multiple patches of skin discoloration over the thrombosed veins in the left leg and thigh. Venous doppler showed superficial venous thrombosis without any evidence of deep venous thrombosis. Venous doppler was repeated at one week, confirming lack of extension into the deep veins. She was treated with low molecular weight heparin for 5 days followed by 6 weeks course of Dabigatran 150 mg twice daily. Results: Literature review was performed using PubMed search engine from 1992 to 2019 with the keyword's levonorgestrel and venous thromboembolism. The search retrieved 36 articles, which compared the risk of deep venous thrombosis with levonorgestrel with other combined contraceptive pills. Levonorgestrel is considered to have lower risk of venous thromboembolism compared to other hormonal contraceptives. No article was found on the association between isolated superficial venous thrombosis and high dose levonorgestrel used as emergency contraceptive pill. Conclusion: Usage of high dose Levonorgestrel (emergency contraceptive pill) can be associated with Isolated superficial venous thrombosis. To our knowledge, this association has not been reported before. In our experience, it can be managed similar to other causes of superficial venous thrombosis with 6 weeks of anticoagulation. The role of thrombophilia screen, risk of recurrence and alternative contraceptive methods in these patients is unknown. Disclosure: Nothing to disclose

Hyponatremia induced compartment syndrome of all extremities: Case report and review

Background: Compartment syndrome is a well-recognised complication from trauma, burns, orthopaedic, vascular, or other surgery of the limbs. Hyponatremia related rhabdomyolysis leading to compartment syndrome of all four extremities with renal and hepatic impairment is rare.1,2,3 Although the rhabdomyolysis can occur without hyponatremia. Young men have the highest incidence of compartment syndrome, particularly after long-bone extremity fractures and strenuous exercise.4,5 We present a case of compartment syndrome of all four extremities following a brief episode of recreational jogging. Case: A 39-year-old Indian male, known hypertensive on nifidipine and indapamide was presented to the emergency department with generalized weakness, lower leg pain and cramps for 3 days. He had jogged for 2 km in warm temperatures. His symptoms worsened and he was unable to walk. Other complaints were headache, pain in both arms, and passing dark coloured urine for two days. Both his calf muscles were tender, tense to feel, and painful on flexion and extension. Dorsalis pedis pulses were weak but palpable bilaterally. Capillary refill was less than three seconds and sensation were intact in both lower limbs. Oxygen saturation of toes on both feet was 99%. Other body systems were unremarkable. His respiratory rate was 20 min− 1, blood pressure 210/110 mmHg, temperature 36.6°C, oxygen saturation (SpO2) 99%. Initial biochemistry results were serum creatinine 142 umol.l− 1, myoglobin 5791 ng.ml− 1, creatinine phosphokinase 19032 U.l− 1, sodium: 124 mmol.l− 1, aspartate aminotransferase (AST) 167 U.l− 1, and alanine aminotransferase (ALT) 49 U.l− 1 (Table 1). Doppler ultrasound of leg vessels showed no evidence of deep venous thrombosis, echogenicity of the muscles in the thigh and lower leg appeared within normal limits. Rhabdomyolysis was diagnosed and rehydration begun with Hartman's solution 1000 ml followed by 125 ml.h− 1. The patient was admitted to the ward for continued hydration and analgesia to treat the pain. His leg pain worsened overnight despite intravenous analgesia. His pulse in both feet became feeble and renal and hepatic function worsened. Compartment syndrome was suspected and orthopaedic surgery was consulted. He had an emergency fasciotomy of all compartments and in all four limbs. Post-procedure pulse oximetry of digits and toes had a 99% saturation, but peripheral pulses remained weak. He was able to move fingers of both hands, but had no movement of his ankles and toes. The patient was transferred to the intensive care unit (ICU) for further management. His maintenance intravenous fluid was changed to 0.9% sodium chloride due to persistent hyponatremia. His wounds were re-explored and debrided on the fifth post-operative day. Wounds culture were growing pseudomonas aeruginosa that was treated with Meropenam according to the sensitivity. Six sittings of wound debridement and irrigation were performed. Over two weeks his renal function, liver function, and serum sodium concentration normalised (Table 1) without requiring renal replacement therapy. He was transferred to the ward on day 16 and discharged home to be followed in outpatient clinic. Conclusion: Physical exercise in the presence of hyponatremia can cause rhabdomyolysis and compartment syndrome of all extremities leading to multi-organ failure.

Non-Fatal Thrombin Based Hemostatic Matrix Pulmonary Embolism in Laparoscopic Surgery. A Case Report

Locally applied hemostatic agents, are used in various surgical procedures. In our case a thrombin based hemostatic matrix (FloSealTM) was used in the hepatic bed to facilitate haemostasis in a 63 year old-male undergoing video-laparoscopic cholecystectomy. Immediately after the surgery the patient developed severe anxiety, acute shortness of breath with associated hypoxia. An angiographic computerized tomography chest scan demonstrated multiple bilateral sub segmental pulmonary emboli that resolved in the following 12 h. A bilateral lower extremity duplex ultrasound showed no evidence of deep venous thrombosis.

Mass in Right Pulmonary Artery—Case Report

AbstractThe authors present a case of mass in the right pulmoary artery in a 60-year-old female patient who had dyspnea on exertion for 1 month before admission. Two-dimensional echocardiography and computed tomography pulmonary angiogram revealed mass in the right pulmonary artery. There was no evidence of deep venous thrombosis. Though the final diagnosis was not made, the authors present this case mainly for identifying and differentiating pulmonary artery thrombosis from chronic thromboembolic pulmonary hypertension and tumor.

Primary Intravascular Lipoma of the Superior Vena Cava.

To the Editor, Lipomatous tumors of the heart and major central veins are considered to be unusual pathological findings. Primary venous tumors are unusual in any location and the walls of the veins are rarely the site of origin of a neoplasm. In this case, we report an unusual mass arising from the superior vena cava (SVC), later pathologically described as lipoma. A 48-year-old man, who had nasopharyngeal carcinoma 4 years previously, was admitted to our clinic. He had swelling of the right upper extremity and numbness in his arms. A Duplex ultrasonography showed no evidence of deep venous thrombosis in the right arm. A contrast-enhanced computerized tomography (SOMATOM Sensation, Siemens Medical Solutions, Erlangen, Germany) showed a lesion of fat density within the SVC (Figure 1a). On further examination using contrast-enhanced magnetic resonance venography (MAGNETOM Symphony, Siemens, Erlangen, Germany), an intraluminal mass was found, which markedly enlarged the lumen of the SVC, partially allowing contrast leakage along the sides of the tumor (Figure 1b). Because of the symptoms, he was taken into surgery. Written and signed informed consent were acquired from the patient for the surgery and for the visual material to be published. Through the mini-J sternotomy, the SVC was explored and by performing a venotomy a 5 × 2 cm capsulated mass arising from the lumen of the SVC was removed (Figure 1c). The pathological specimen was further reported as lipoma. The patient was discharged from the hospital without any problem on post-operative day 5 with 100 mg of acetyl salicylic acid treatment. One week after discharge, he was rehospitalized with dyspnea, diagnosed with pulmonary embolism and received medical treatment. He is still under the supervision of our clinic with complaints resolved and no other complications. FIG. 1. a–c. Contrast-enhanced computerized tomography showing a lesion of fat density within the superior vena cava (arrow) (a), intraluminal mass (in circle), which markedly enlarged the lumen of the superior vena cava, in contrast-enhanced magnetic resonance venography ... Although lipomas are the most common soft tissue tumors, such a case of a primary intraluminal lipoma arising directly from the SVC is extremely rare. Lipomas can occur at any location of the body, particularly in subcutaneous tissues of the upper half of the body and proximal arteries (1). Intravascular lipomas may be asymptomatic, incidentally revealed by imaging, or they may cause a venous obstruction or mediastinal syndromes by virtue of an excessive size causing compressive effects. This reflects the benign nature, the slow growth of the tumor and the compressibility of lipomas in general (2). We believe that symptomatic patients should be operated on. If the Duplex scan of the venous system shows no major findings in the case of swelling of an extremity, any mass arising from the lumen of the vein or compression from the surrounding masses should be taken into consideration by the clinician.

English

BACKGROUND: Spine surgeries may involve uncontrolled bleeding, resulting primarily from large vein and persists even after the wound is closed. Proper patient positioning, use of hypotensive anaesthesia regimen and normothermia reduces blood loss, additional measures to reduce bleeding & transfusion requirement must be considered in spine surgery. MATERIALS AND METHODS: Forty patients of both sexes between the age group 21 to 60 years belonging to ASA I to III who were scheduled for spine stabilization surgeries was enrolled for the study were randomized into two groups with 20 in each. Anaesthetic technique was standardized. Group T received Tranexamic acid bolus of 10 mg/kg i.v. over 15 min. after patient positioning followed maintenance infusion of 1mg/kg/hr. And Group N Equivalent volume of Normal saline. Intra-operative blood losses was measured by weighing sponges, measuring suction drainage and estimates of blood loss on the surgical drapes and gowns by the attending anesthesiologist. Post-operative blood losses were assessed by measuring wound drainage until drains withdrawal. Investigations like Hb, Platelet, PT and APTT were done pre and post-operatively. Patients were assessed postoperatively daily for any clinical evidence of deep venous thrombosis. RESULTS: Pre-operative haemoglobin in group T and N were 13.56±1.171 and 12.98±1.488 gm% respectively. Post-operative haemoglobin in group T and N were 11.97±1.351 and 11.07±1.044 gm% respectively. There was a statistically significant drop in haemoglobin in control group post operatively. (p=0.024)Mean intra-operative blood loss in group T was 1042.65 ± 147.535 ml and in group N 1149.25 ± 157.85 ml. Control group had higher intra- operative blood loss compared to Tranexamic acid group, which was statistically significant. (p=0.033).There was no difference in mean drop in haemoglobin, mean number of units of blood transfusion among study groups. CONCLUSION: Tranexamic acid in bolusdosage of 10 mg/kg i.v. over 15 min. after patient positioning followed maintenance infusion of 1mg/kg/hr significantly decreases intra-operative blood loss, thereby decreasing the requirement of intraoperative blood transfusion. However it does not have any major impact on post-operative blood loss. No thrombotic

A Mobile Compression Device for Thrombosis Prevention in Hip and Knee Arthroplasty

Venous thromboembolic events, either deep venous thrombosis or pulmonary embolism, are important complications in patients undergoing knee or hip arthroplasty. The purpose of this study was to evaluate the effectiveness of a mobile compression device (ActiveCare+S.F.T.) with or without aspirin compared with current pharmacological protocols for prophylaxis against venous thromboembolism in patients undergoing elective primary unilateral arthroplasty of a lower-extremity joint. A multicenter registry was established to capture the rate of symptomatic venous thromboembolic events following primary knee arthroplasty (1551 patients) or hip arthroplasty (1509 patients) from ten sites. All patients were eighteen years of age or older with no known history of venous thromboembolism, coagulation disorder, or solid tumor. Use of the compression device began perioperatively and continued for a minimum of ten days. Patients with symptoms of deep venous thrombosis or pulmonary embolism underwent duplex ultrasonography and/or spiral computed tomography. All patients were evaluated at three months postoperatively to document any evidence of deep venous thrombosis or pulmonary embolism. Of 3060 patients, twenty-eight (0.92%) had venous thromboembolism (twenty distal deep venous thrombi, three proximal deep venous thrombi, and five pulmonary emboli). One death occurred, with no autopsy performed. Symptomatic venous thromboembolic rates observed in patients who had an arthroplasty of a lower-extremity joint using the mobile compression device were noninferior (not worse than), at a margin of 1.0%, to the rates reported for pharmacological prophylaxis, including warfarin, enoxaparin, rivaroxaban, and dabigatran, except in the knee arthroplasty group, in which the mobile compression device fell short of the rate reported for rivaroxaban by 0.06%. Use of the mobile compression device with or without aspirin for patients undergoing arthroplasty of a lower-extremity joint provides a noninferior risk for the development of venous thromboembolism compared with current pharmacological protocols.

Prospective Study of Venous Thromboembolism in Patients With Head and Neck Cancer After Surgery

Venous thromboembolism (VTE) is associated with significant morbidity and mortality in surgery patients, but little data exist on the incidence of VTE in head and neck cancer surgical patients. To determine the incidence of VTE in postoperative patients with head and neck cancer. A prospective study of 100 consecutive patients hospitalized at a tertiary care academic surgical center who underwent surgery to treat head and neck cancer. Routine chemoprophylaxis was not used. On postoperative day (POD) 2 or 3, participants received clinical examination and duplex ultrasonographic evaluation (US). Participants with negative findings on clinical examination and US were followed up clinically; participants with evidence of deep venous thrombosis (DVT) or pulmonary embolism (PE) were given therapeutic anticoagulation. Participants with superficial VTE underwent repeated US on POD 4, 5, or 6. Participants were monitored for 30 days after surgery. Total number of new cases of VTE (superficial and deep) identified within 30 days of surgery and confirmed on diagnostic imaging. Of the 111 participants enrolled, 11 withdrew before completing the study; thus, 100 participants were included. The overall incidence of VTE was 13%. Eight participants were identified with clinically significant VTE: 7 DVT and 1 PE. An additional 5 participants had asymptomatic lower extremity superficial VTE detected on US alone. Fourteen percent of patients received some form of postoperative anticoagulation therapy; the rate of bleeding complications in these patients (30.1%) was higher than that in patients without anticoagulation therapy (5.6%) (P = .01). Hospitalized patients with head and neck cancer not routinely receiving anticoagulation therapy after surgery have an increased risk of VTE. Bleeding complications are elevated in patients receiving postoperative anticoagulation.

Iceberg in Small Pulmonary Embolism

An 82-year-old man presented to our emergency department complaining of shortness of breath over recent days. He had a medical history of hypertension, dilated cardiomyopathy, and chronic atrial fibrillation. Electrocardiography showed atrial fibrillation with rapid ventricular rate. We carried out contrast-enhanced computed tomography due to his high Modified Well's scores and elevated D-dimer. This revealed a small filling defect over the left lateral basal segmental artery and posterior branch of the basal trunk of the right pulmonary artery with patent bilateral main pulmonary trunks. This was compatible with pulmonary embolism (Fig. 1A and B, arrow). The Pulmonary Embolism Severity Index was 112.1) No vasopressor was needed after admission except oxygen supplement. Intravenous unfractionated heparin was given according to Raschke Nomogram.2) Doppler was used for evaluation of the limbs, which showed no evidence of deep venous thrombosis. Standard transthoracic echocardiography (TTE) was used the next day, which disclosed one huge floating thrombus located over the right atrium (Fig. 1C). This moved into the right ventricle during diastolic phase (Fig. 1D). The patient succumbed suddenly with pulseless electrical activity before the emergent operation. Emergent TTE showed disappearance of the floating thrombus and severe right ventricle dysfunction. Even though echocardiography is not recommended as a routine diagnostic test for PE, especially in hemodynamically stable subjects, this case serves as a reminder of the importance of TTE in PE patients. This is true not only in terms of right ventricle function evaluation, but also because it may facilitate the earlier identification and aggressive management of possible existing intra-cardiac thrombus. Fig. 1

Iliac-Femoral Venous Stenting for Lower Extremity Venous Stasis Symptoms

Venous outflow obstruction may play a role in patients with chronic venous stasis symptoms who fail to improve despite conventional modalities of treatment that focus on the reflux component of the disease with little attention to the possibility of an obstructive component. The introduction of minimally invasive venous stenting using venography and intravenous ultrasonography (IVUS) provides the ability to treat the "obstructive" component of the disease. We undertook a retrospective review of 56 limbs in 53 patients with chronic venous stasis symptoms. Initial transcutaneous Doppler ultrasonographic evaluation of the inferior vena cava, iliac, femoral, greater saphenous, and perforator veins was performed looking for any evidence of deep venous thrombosis, superficial venous thrombosis, perforator veins, and reflux (location and degree). Afterword, the patients were managed in the conventional fashion (leg elevation, compression, and great saphenous vein (GSV) and perforator ablation, if present) for a period of 3 months. If ulcer healing was not noted, iliac-femoral venography and IVUS were undertaken. A significant stenosis was defined as a 50% reduction in vein cross-sectional area as measured by IVUS.(1,2,3) Stenotic lesions were managed with stenting followed by balloon angioplasty. Patients were followed up for ulcer healing or improvement of stasis symptoms. Of the 56 limbs, 10 (17.8%) had postthrombotic changes, 7 (12.5%) had incompetent perforators, and 27 (48.2%) had an incompetent superficial venous system. In the stented group (n = 29), 3 limbs had perforator ablation alone, 13 limbs had GSV ablation alone, and 1 limb had both perforator and GSV ablation. In the unstented group (n = 27), 10 limbs had GSV ablation alone, and 3 limbs had both perforator and GSV ablation. The overall incidence of deep reflux was 51.8%; 17 of 29 limbs (58.6%) in the stented group had evidence of deep reflux, and 12 of 27 limbs (44.4%) in the unstented group had deep reflux. All venograms except one (98.2%) were performed under local anesthesia with sedation. The procedure was performed in an ambulatory setting in 69.6% (39 of 56) of the limbs. CEAP clinical severity class distribution was as follows: C2, 4%; C3, 16%; C4, 18%; C5, 5%; C6, 57%. Over half of the limbs (29 of 56) were found to have stenotic lesions and required stenting. Eight patients (11 limbs) did not return for ulcer healing assessment. The majority (19 of 29) of limbs in the stented group had a CEAP of 6. Among the patients with CEAP 6 who returned for follow-up (n = 26), 7 had no evidence of stenosis and required no stenting. Only one of those (14.3%) healed his ulcers after 3 months (average follow-up of 4.8 months). The remainder 19 limbs were found to have stenotic lesions and underwent stenting. The ulcers healed in 11 of those (58%) over a period of 1 week to 8 months (average of 5 months), with average follow-up of 3.6 months (p = 0.08). The cumulative primary and secondary patency rates were 93.1% (27 of 29) and 100% (29 of 29), respectively. Two stent thromboses occurred within 4 weeks of the initial procedure. Both occurred in patients with postthrombotic obstruction. One patient developed a superficial femoral artery pseudoaneurysm. Over half of our patients with open ulcers had stenotic lesions. The ulcers healed in 58% of the stented limbs. That indicates that outflow obstruction may play a significant role in patients with chronic venous stasis symptoms, especially those with open ulcers who failed to respond to other treatment modalities. The procedure itself is relatively safe and simple and can be performed on an ambulatory basis.

Diagnosis and Management of Isolated Subsegmental Pulmonary Embolism: Review and Assessment of the Options

We assessed the potential safety of withholding treatment of pulmonary embolism (PE) limited to subsegmental branches. Literature review showed that untreated patients with mostly subsegmental PE had no fatal recurrences in 1 to 3 months and no nonfatal recurrences of PE in 3 months. Patients with suspected PE who had nondiagnostic ventilation/perfusion lung scans, adequate cardiorespiratory reserve or low or moderate clinical probability, and negative serial noninvasive leg tests were shown not to require treatment. It appears safe, therefore, to withhold treatment of subsegmental PE providing (1) pulmonary-respiratory reserve is good; (2) no evidence of deep venous thrombosis (DVT) on serial testing; (3) major risk factor for PE was transient and no longer present; (4) no history of central venous catheterization or atrial fibrillation; and (5) willingness to return for serial venous ultrasound. After fully informing patients, some may choose to be treated and some may choose not to be treated.

Microscopic thrombi in anaplastic astrocytoma predict worse survival?

The purpose of this study is to determine whether anaplastic astrocytoma patients with intratumoral vascular thrombi have a worse survival than anaplastic astrocytoma patients without thrombi. A retrospective review of 101 patients (60 males; mean age, 53.3 years) with anaplastic astrocytoma (World Health Organization grade III) was conducted. Thrombi were counted relative to the number of involved blood vessels in the initially resected tumor (69 biopsies, 32 subtotal resections) and were correlated with survival and development of postoperative deep venous thrombosis (DVT). Of tumors with thrombi (n = 17), the percentage of blood vessels with thrombi ranged from 1.5% to 20% (mean, 5.6%). Of these patients, 16 died of tumor (mean survival, 15.4 months), and 1 patient was alive with tumor at 180 months. Eighty-four patients with anaplastic astrocytoma had no intravascular tumor thrombi; 75 of these patients died of tumor (mean survival, 26.5 months), 4 patients were alive, and 5 patients were lost to follow-up. Evidence of DVT was found in 2 (18.2%) of 11 tested patients with thrombi vs 10 (18.5%) of 54 patients without thrombi. Patients with microscopic intratumoral thrombi (17% of anaplastic astrocytoma) had a worse survival compared with patients without thrombi; the difference did not reach statistical significance. There was no correlation between the presence of intratumoral thrombi and the development of DVT.

脳内出血患者における深部静脈血栓の発生部位とD-dimer値の関連についての検討

We investigated the association of the presence and the location of deep venous thrombosis (DVT) with D-dimer value in acute intracerebral hemorrhage (ICH). We analyzed the data regarding DVT in patients with ICH. Based on an ultrasonographic examination 2 weeks after the occurrence of ICH, the patients were divided according to the presence/absence and the location of DVT, i.e. no evidence of DVT (n-DVT), calf DVT (c-DVT), and proximal DVT (p-DVT). D-dimer value was measured 2 weeks later and compared among the groups. The numbers of patients with n-DVT, c-DVT and p-DVT were 27, 19, and 2, respectively. Univariate analysis indicated that D-dimer values were significantly different between patients with n-DVT and c-DVT and between patients with n-DVT and p-DVT (p<0.05, respectively). The cut-off value for estimating the presence of DVT and p-DVT was 3.9 µg/mL and 18.5 µg/mL, respectively. D-dimer value assessment after 2 weeks may be associated with the presence and the location of DVT in patients with ICH.

Clinical outcomes in patients with isolated subsegmental pulmonary emboli diagnosed by multidetector CT pulmonary angiography

Introduction CT Pulmonary Angiography has been shown to be equivalent to Ventilation/ Perfusion scanning in 3-month outcome studies, but it detects more pulmonary emboli. Isolated subsegmental pulmonary emboli are thought to account for some of the increase in diagnosis, but it is not known whether these emboli represent a harbinger for future thromboembolic events. The objective of this study was to determine the 3-month clinical outcomes of a cohort of patients diagnosed with isolated subsegmental pulmonary emboli. Materials and Methods Review of 10,453 consecutive CTPA radiology reports over 74-month period since the implementation of Multidetector CT Pulmonary Angiography identified a cohort of 93 patients found to have acute pulmonary embolism isolated to subsegmental pulmonary arteries without other evidence of deep venous thrombosis at one institution. The study measured 3-month clinical outcomes (anticoagulation use, recurrence, death, hemorrhage) determined by review of records and telephone interviews with physicians. Results Seventy-one patients (76%) were treated with anticoagulation and/or IVC filter, while 22 (24%) were observed without therapy. One patient (1/93, 1.05%; 95% CI: 0-6.6%) who was treated with anticoagulants and a vena caval filter had a recurrent subsegmental pulmonary embolus. No patients died of pulmonary embolism. There were 8 hemorrhages, including 5 (5.3%) major hemorrhages without any hemorrhage-related mortality. Conclusions Patients diagnosed with isolated subsegmental pulmonary emboli have favorable 3-month outcomes. Short-term prognosis for recurrent thromboembolism may be lower than the risk of adverse events with anticoagulation in patients at high risk of hemorrhage.

Primary tibial vein aneurysm with recurrent pulmonary emboli

We report the case of a 42-year-old man with pleuritic chest pain, shortness of breath, and associated tachycardia. Three months before, he had been treated for similar features with the diagnosis of pulmonary emboli. Computed tomography scan showed multiple bilateral pulmonary emboli. He had no clinical evidence of deep venous thrombosis, but an accurate venous duplex examination revealed a thrombosis of the posterior tibial vein aneurysm. Thrombolysis, a temporary inferior cava filter (ICV filter), and tangential aneurysmectomy and lateral venorrhaphy were performed. Accurate duplex scan evaluation of lower limb venous system is mandatory in all cases of pulmonary embolism; anticoagulation may be ineffective in preventing pulmonary embolism, and the surgical repair is treatment of choice of this pathology because it is safe and effective.

An Unusual Cause of Recurrent Pulmonary Emboli

The authors report a 51-year-old female primary care physician who attended the emergency medical department with pleuritic chest pain, shortness of breath and associated tachycardia. She had 6 weeks previously been admitted and treated for similar features with the diagnosis of pulmonary emboli made from a positive ventilation–perfusion scan. CT scanning confirmed the diagnosis of multiple bilateral pulmonary emboli but no abdominal or pelvic pathology and without evidence of deep venous thrombosis. Further clinical assessment found generalised hyperflexibility and swelling of the left popliteal region. Duplex ultrasonography followed by venography confirmed a 5-cm unilateral saccular aneurysm of the above knee popliteal vein containing central thrombus. A temporary IVC filter (Cook, Tulip) was placed and primary aneurysmectomy was performed through a posterior approach.Popliteal venous aneurysms are rare but can present at any age and are associated with wall weakness from many causes. Pulmonary embolism is the most frequent presentation and is not dependant on visualized clot on imaging. As anticoagulation may be ineffective in preventing pulmonary embolism it is recommended all patients should undergo surgical repair.