Frequency Of Deep Venous Thrombosis Research Articles

Prevalence of the G1691A mutation in the factor V gene (factor V Leiden) and the G20210A prothrombin gene mutation in the Thai population.

We investigated the prevalence of a genetic variation in the factor V gene (G1691A Leiden mutation) and the prothrombin gene (G20210A) using polymerase chain reaction techniques in samples from 500 normal Thai population and among 50 unselected Thai patients with an objectively confirmed history of deep venous thrombosis. The prevalence of factor V Leiden and the prothrombin G20210A gene mutation in a group of 500 healthy controls was 0.2% in both groups (allele frequency of 0.1%). Of the 50 adult patients studied, none was a carrier of factor V Leiden or the prothrombin G20210A gene mutation. Our findings confirm that the prevalence of factor V Leiden and prothrombin G20210A gene mutation is lower among Asians than Caucasians and that the distribution of factor V Leiden is similar to that of the prothrombin G20210A variant. The low prevalence of these two mutations can, at least in part, account for the lower frequency of deep venous thrombosis reported in the Thai population. Screening for factor V Leiden and prothrombin gene mutation is of limited benefit and may not be cost-effective in Thai patients with the first episode of deep venous thrombosis.

The incidence of the factor V Leiden mutation in an obstetric population and its relationship to deep vein thrombosis

OBJECTIVE: A common missense mutation in the factor V gene, the Leiden mutation, renders factor Va resistant to cleavage inactivation by activated protein C and predisposes patients to thrombotic events. We sought to evaluate the prevalence of the Leiden mutation and the associated thromboembolic events in a community hospital's low-risk obstetric population. STUDY DESIGN: Deoxyribonucleic acid was extracted from whole blood of 407 women. The polymerase chain reaction was used to amplify exon 10 of the factor V gene, followed by enzymatic digestion with Mnl 1 for mutation detection. Medical charts were reviewed and patient characteristics, including age, gravidity, parity, obstetric complications, medical complications, and mode of delivery, were recorded. RESULTS: Fourteen of the 407 women carried the factor V Leiden mutation (13 heterozygotes and 1 homozygous mutant) for an allele frequency of 3%, consistent with the published carrier rate. Four of the 14 carriers (28%) had deep venous thrombosis, whereas the frequency of deep venous thrombosis in this obstetric population was <1%. Another patient carrying the mutation had a consumptive coagulopathy of unknown etiology at 20 weeks' gestation, necessitating delivery. CONCLUSIONS: The Leiden mutation is relatively common in the general obstetric population. The high rate of deep venous thrombosis noted in our series suggests the need for genetic testing for this mutation in women with a thrombotic event during pregnancy. (Am J Obstet Gynecol 1997;176:883-6.)

Prolonged Thromboprophylaxis Following Hip Replacement Surgery – Results of a Double-blind, Prospective, Randomised, Placebo-controlled Study with Dalteparin (Fragmin®)

Discontinuation of thromboprophylaxis a few days after surgery may unmask delayed hypercoagulability and contribute to late formation of deep venous thrombosis (DVT). To investigate whether thromboprophylaxis should be prolonged beyond the hospital stay, a prospective, double-blind randomised study was conducted in 308 patients. All patients received initial thromboprophylaxis with dalteparin, dextran and graded elastic stockings. On day 7, patients were randomised to receive dalteparin (Fragmin) 5000 i.u. once daily, or placebo, for 4 weeks. All patients were subjected to bilateral venography, perfusion ventilation scintigraphy and chest X-ray on days 7 and 35. Patients with venographically verified proximal DVT on day 7 were withdrawn from the randomised study to receive anticoagulant treatment. The overall prevalence of DVT on day 7 was 15.9%. On day 35, the prevalence of DVT was 31.7% in placebo-treated patients compared with 19.3% in dalteparin-treated patients (p = 0.034). The incidence of DVT from day 7 to day 35 was 25.8% in the placebo-treated group versus 11.8% in the dalteparin-treated group (p = 0.017). The incidence of symptomatic pulmonary embolism (PE) from day 7 to day 35 was 2.8% in the placebo-treated group compared with zero in the dalteparin-treated group. This included one patient who died from PE. No patients experienced serious complications related to the injections of dalteparin or placebo. This study shows that prolonged thromboprophylaxis with dalteparin. 5000 IU, once daily for 35 days significantly reduces the frequency of DVT and should be recommended for 5 weeks after hip replacement surgery.

THE FREQUENCY OF VENOUS THROMBOSIS IN CEMENTED AND NON-CEMENTED HIP ARTHROPLASTY

We randomised 250 patients undergoing unilateral, elective hip arthroplasty for osteoarthritis to receive either a cemented or a non-cemented Mallory Head prosthesis. Aspirin was used as prophylaxis against thromboembolism during the first half of the study and adjusted-dose warfarin during the second half. Postoperatively, all patients were asked to have bilateral venography and 80% agreed. All were evaluated clinically for pulmonary embolism. There was no difference in the frequency of deep-venous thrombosis between the two groups (50% cemented nu 47% non-cemented, p = 0.73; 95% CI of the difference -13.6% to 19.3%). Three of the 64 patients (5%) in whom venography had demonstrated isolated distal thrombi developed pulmonary emboli.

Fatal Pulmonary Embolism during Manipulation after Total Knee Arthroplasty. A Case Report*

Deep venous thrombosis occurs in approximately 40 to 60 per cent of patients who have a total knee arthroplasty5,10,11,13,15,17,18. However, symptomatic pulmonary embolism occurs in only 1 to 2 per cent9,10,17-19, and fatal pulmonary embolism has been reported in 0.2 per cent of patients who received no anticoagulation therapy8. The relatively high frequency of deep venous thrombosis and low prevalence of pulmonary embolism may be related to the location of the thrombus. Most deep venous thrombi occur in the calf10,13,18, and they do not appear to be associated with as serious a risk of pulmonary embolism as more proximal thrombi. The role of routine anticoagulation therapy for treatment of the relatively common thrombosis of the calf and for prevention of the relatively uncommon fatal pulmonary embolism has recently been questioned8. Complications of manipulation after total knee arthroplasty include rupture of the patellar ligament, fracture of the supracondylar region of the femur, avulsion of the collateral ligament, wound dehiscence, hemarthrosis, and heterotopic formation of bone1,3,4,6,7,12,14. However, pulmonary embolism has not generally been considered as a direct risk associated with this procedure. The following case of fatal pulmonary embolism that developed during a manipulation performed three weeks after a total knee arthroplasty demonstrates that thromboembolism can be an important risk. A sixty-four-year-old man with a medical history that included hypertension and non-insulin-dependent diabetes mellitus was managed with a right total knee arthroplasty for osteoarthrosis on October 18, 1993. The procedure was performed with the patient under spinal anesthesia. Preoperative examination of the knee had revealed a …

Bilateral lower extremity US in the patient with bilateral symptoms of deep venous thrombosis: assessment of need.

To assess the frequency of lower extremity deep venous thrombosis (DVT) detected with ultrasound (US) in patients with bilateral symptoms suggestive of DVT. Fifty patients with bilateral lower extremity symptoms suggestive of DVT were examined prospectively for predisposing factors and type of symptoms. Charts were reviewed for previous lower extremity disease or chronic illness that could explain the patient's symptoms. The frequency of DVT diagnosed with US in this patient group was determined. No DVT was identified in the patients with bilateral symptoms suggestive of DVT. Retrospective review demonstrated that 34 (68%) of the patients had a preexisting condition (cardiac disease, venous insufficiency, chronic swelling, cellulitis or thrombophlebitis, peripheral arterial disease). Because compression US has a greater than 90% sensitivity and specificity for the diagnosis of DVT, these results were statistically significant (P < .001). The likelihood of DVT in patients with bilateral lower extremity symptoms is extremely low. Alternative causes should be carefully explored before lower extremity US is considered.

Prevalence of Deep Venous Thrombosis Among Patients in Medical Intensive Care

OBJECTIVE--To determine the frequency of deep venous thrombosis (DVT) in medical intensive care unit (MICU) patients. DESIGN--Prospective ultrasound case series. SETTING--An MICU in a large tertiary care hospital in Boston, Mass. SUBJECTS--Patients older than 18 years of age admitted to the MICU with an anticipated stay of more than 48 hours. MAIN OUTCOME MEASURE--Deep venous thrombosis as detected by ultrasonography with color Doppler imaging performed twice weekly in the MICU and once within 1 week of discharge from the MICU. RESULTS--Deep venous thrombosis was detected in 33% (95% confidence interval, 24% to 43%) of 100 eligible patients during the 8-month study period. Forty-eight percent (16/33) were proximal lower extremity DVT, and 15% (5/33) were upper extremity DVT associated with central venous catheters, with one patient having both upper and proximal lower extremity DVT. Ultrasound examination results led to inferior vena cava filter placement in three patients, initiation of full-dose anticoagulation in four patients, initiation or continuation of low-dose subcutaneous heparin in 10 patients, follow-up ultrasound studies in three patients, central line removal in one patient, and no intervention in 10 patients due to active bleeding, prior filter, or heparin-induced thrombocytopenia. Two patients remained anticoagulated for other reasons. In this series, there was no difference in age, gender, body mass index, diagnosis of cancer, recent surgery, duration of hospitalization prior to DVT detection, and DVT prophylaxis between patients with DVT and those without. CONCLUSIONS--An unexpectedly high rate of DVT was detected by ultrasound in these MICU patients despite prophylaxis in 61%. Traditionally recognized DVT risk factors failed to identify patients who developed DVT. Routine ultrasound surveillance or more intensive prophylaxis regimens may be warranted in this patient population if these DVT rates are confirmed in other settings.

Frequency of deep venous thrombosis in asymptomatic patients with coronary artery bypass grafts

The frequency of deep vein thrombosis (DVT) in patients undergoing coronary artery bypass graft (CABG) surgery has not been established. Therefore to estimate the frequency of clinically slient DVT, we performed ultrasound examinations of the leg veins in 29 asymptomatic CABG patients before hospital discharge. We used high-resolution B-mode ultrasonography with color Doppler imaging. Fourteen (48.3%, 95% confidence interval 30.1 to 66.4%) had 20 documented leg vein thromboses, and all but one patient had DVT limited to the calf veins. Of the 20 thrombi 10 (50.0%) were present in the leg ipsilateral and 10 (50.0%) in the leg contralateral to the saphenous vein harvest site. None of the DVTs were suspected clinically. DVT was not associated with any local sign attributed to saphenous vein harvest such as pitting edema, incisional drainage, or local tenderness or with any putative risk factor for DVT such as cigarette use, distant history of malignancy, or varicose veins. Follow-up of these patients 5 to 11 months after CABG surgery showed no clinical evidence of DVT or pulmonary embolism. Our findings indicate that asymptomatic DVT of the calf occurs with surprisingly high frequency, 44.8% after CABG surgery. Future studies in patients undergoing CABG surgery should address the natural history of asymptomatic DVT, determine its clinical importance, and develop optimal strategies for prophylaxis and treatment.

Venous duplex imaging: Should it replace hemodynamic tests for deep venous thrombosis?

Noninvasive diagnosis of deep venous thrombosis has traditionally relied on detection of alterations in venous hemodynamics. Although phleborheography is among the most sensitive tests, it is inadequate for diagnosing infrapopliteal and nonocclusive proximal thrombi and for surveillance of patients at high risk for deep venous thrombosis. Venous duplex imaging is a new technique being rapidly accepted, however, without the same critical analysis given to previous diagnostic modalities. The purpose of this study is to evaluate the diagnostic acumen of venous duplex imaging compared to phleborheography and ascending phlebography in two distinct patient groups, and to determine whether patient selection, and thus the location or magnitude of thrombi have significant influence on these diagnostic tests. One hundred ten extremities in 103 patients were prospectively evaluated with venous duplex imaging, phleborheography, and ascending phlebography within the same 24-hour period. Patients were categorized into one of two groups: Diagnostic--patients evaluated because of clinical suspicion of acute deep venous thrombosis; and Surveillance--patients at high risk of postoperative deep venous thrombosis after total joint replacement, but not symptomatic. Patients in the diagnostic group had a greater frequency of deep venous thrombosis (p less than 0.001) and significantly more occluding above-knee thrombi (p = 0.054) compared to those in the surveillance group. Phleborheography detected 73% (27/37) of above-knee thrombi in the diagnostic group compared to 29% (2/7) in the surveillance group (p = 0.036). This difference was not noted with venous duplex imaging, which detected 100% of above-knee thrombi in both diagnostic and surveillance groups and 78% (7/9) of all below-knee thrombi.(ABSTRACT TRUNCATED AT 250 WORDS)

Venous duplex imaging: Should it replace hemodynamic tests for deep venous thrombosis?

Noninvasive diagnosis of deep venous thrombosis has traditionally relied on detection of alterations in venous hemodynamics. Although phleborheography is among the most sensitive tests, it is inadequate for diagnosing infrapopliteal and nonocclusive proximal thrombi and for surveillance of patients at high risk for deep venous thrombosis. Venous duplex imaging is a new technique being rapidly accepted, however, without the same critical analysis given to previous diagnostic modalities. The purpose of this study is to evaluate the diagnostic acumen of venous duplex imaging compared to phleborheography and ascending phlebography in two distinct patient groups, and to determine whether patient selection, and thus the location or magnitude of thrombi have significant influence on these diagnostic tests. One hundred ten extremities in 103 patients were prospectively evaluated with venous duplex imaging, phleborheography, and ascending phlebography within the same 24-hour period. Patients were categorized into one of two groups: Diagnostic—patients evaluated because of clinical suspicion of acute deep venous thrombosis; and Surveillance—patients at high risk of postoperative deep venous thrombosis after total joint replacement, but not symptomatic. Patients in the diagnostic group had a greater frequency of deep venous thrombosis (p < 0.001) and significantly more occluding above-knee thrombi (p = 0.054) compared to those in the surveillance group. Phleborheography detected 73% (2737) of above-knee thrombi in the diagnostic group compared to 29% (27) in the surveillance group (p = 0.036). This difference was not noted with venous duplex imaging, which detected 100% of above-knee thrombi in both diagnostic and surveillance groups and 78% (79) of all below-knee thrombi. Venous duplex imaging was significantly more sensitive than phleborheography for detecting both above-knee and below-knee thrombi (p < 0.001) and importantly, the negative predictive value of venous duplex imaging was significantly higher than phleborheography (p < 0.001). Based on these observations it appears that venous duplex imaging offers superior noninvasive, diagnostic acumen without the limitations of traditional hemodynamic techniques. Venous duplex imaging reliably diagnosed nonocclusive and infrapopliteal thrombi, thereby offering superior epidemiologic and natural history capability in patients with acute deep venous thrombosis. In experienced vascular laboratories venous duplex imaging may be more sensitive than ascending phlebography and may become the new diagnostic standard for deep venous thrombosis.

Thromboprophylaxis-in-hip arthroplasty: Dextran with graded compression or preoperative dextran compared in 150 patients

Totally, 150 patients, subjected to total hip arthroplasty, were randomly allocated into three prophylactic groups with either conventional dextran alone or with additional graded compression stockings or with additional preoperative administration of dextran. The overall frequency of deep venous thrombosis (DVT), as studied by radioactive fibrinogen uptake test and ascending phlebography of the operated on thigh was in the conventional dextran group 46 percent, the additional stockinged group 30 percent, and in the additional preoperative dextran group 52 percent. In the stockinged group, there was a lower frequency of DVT in the nonoperated on leg as well as, on an average, about 350 mL less peroperative bleeding as compared with the other two groups. No adverse reaction occurred from dextran administration. Increased and prolonged postoperative administration of dextran decrease the number of femoral DVTs.

Prophylaxis of Deep Venous Thrombosis with a Low-Molecular-Weight Heparin (Kabi 2165/Fragmin®) in Stroke Patients

In a group of 60 patients in the acute phase of an ischemic stroke the assumption that low-molecular-weight heparin Kabi 2165 in the dose of 2 X 2,500 anti-Xa units s.c. could prevent thromboembolic complications was tested using a double-blind, placebo-controlled, randomized trial design. Thirty patients were allocated to each group. Both treatment groups were comparable with regard to neurological status and general condition. In the Kabi 2165 group there were 6 cases of deep venous thrombosis (DVT) compared to 15 in the placebo group (p = 0.05). In the placebo group there were 4 deaths during the trial versus 9 in the Kabi-2165-treated group (NS). Cerebral bleeding complicated 2 cases in the placebo group versus 4 in the Kabi 2165 group (NS). These results indicate that in ischemic stroke patients Kabi 2165 2 X 2,500 anti-Xa units s.c./24 h reduces the frequency of DVT. Because of the small number of patients it is impossible to evaluate the safety.

Postoperative deep venous thrombosis after renal transplantation. Effects of cyclosporine.

In this prospective study the frequency of deep venous thrombosis during the first three weeks after renal transplantation was determined using a combination of strain gauge plethysmography and thermography for objective diagnosis. Ninety-seven consecutive patients were studied, 30 patients having juvenile diabetes mellitus. As immunosuppression cyclosporine and low-dose steroids were used. The series was compared with a similar group of 83 patients, 33 having juvenile diabetes mellitus treated with azathioprine and high-dose steroids as immunosuppression, in which the diagnosis of deep venous thrombosis was made with an identical technique. The overall frequency of thrombosis was 9.3% in the cyclosporine-treated group, which is a significant reduction in comparison with the azathioprine group (24.1%). It is concluded that the combination of cyclosporine and low-dose steroids does not increase the frequency of deep venous thrombosis in comparison with azathioprine and high-dose steroids in renal transplanted patients.

Impact of prophylactic therapy for postoperative thromboembolism on prospective payment.

Widescale implementation of prospective payment systems as a means of reimbursing hospitals on the basis of diagnosis-related group designation has important implications with respect to the selection of drug therapy. Instead of analyzing costs on a departmental basis, pharmacists need to identify the impact of optimal drug therapy on overall profitability. Clinically evident deep venous thrombosis and pulmonary embolism occur in approximately 3.5% and 1.8% of patients undergoing general surgery. Treatment of these complications consumes hospital resources, but the hospital absorbs the cost of treatment under the prospective payment system. Effective prophylactic measures increase profitability by preventing complications and minimizing the proportion of outliers due to increased length of stay. In selecting prophylactic measures, this impact on overall profitability is as important as acquisition cost. For example, in comparison with no prophylaxis, dihydroergotamine-heparin reduces the frequency of deep venous thrombosis in patients undergoing general surgery by 61.5% and heparin alone reduces it by 31.2%. The relative effect of this combination on postoperative complications and resultant savings in terms of treating them compensates for differences in acquisition costs between these measures.

Thromboembolic prophylaxis with dihydroergotamine-heparin in abdominal surgery: A controlled, randomized study

The prophylactic affect of dihydroergotamine-heparin (0.5 mg dihydroergotamine plus 5,000 units of heparin administered twice daily) against postoperative thromboembolic complications after gastrointestinal surgery was compared with the affect of 5,000 units of heparin administered three times daily in a controlled, randomized study. Fifty patients received the dihydroergotamine and heparin combination twice daily and 50 patients received 5,000 units of heparin three times daily. The two groups were comparable with respect to age, sex, body weight, and type of operation. The presence or absence of deep venous thrombosis in the legs was determined postoperatively by the radiofibrinogen uptake test. The frequency of deep venous thrombosis in the dihydroergotamine and heparin group was 12 percent compared with 18 percent in the heparin group (0.1 > p > 0.05). Wound hematoma developed in two patients in the heparin group and in one patient in the dihydroergotamine and heparin group (4 and 2 percent, respectively). No other hemorrhagic complications occurred. By combining heparin with dihydroergotamine it is possible to reduce the daily heparin dose by one third and still obtain the same level of prophylaxis against thromboembolism. The frequency of bleeding complications was very low in both groups, since only one wound hematoma occurred in the dihydroergotamine and heparin group and two in the heparin group.

Prophylaxis of deep venous thrombosis in colorectal surgery.

A group of 230 patients undergoing elective colorectal surgery was analyzed for the presence of deep venous thrombosis (DVT). Prophylaxis against DVT was practiced with low-dose heparin (either 5000 IU every eight hours, or 5000 IU every 12 hours for seven days) in 199 patients. Prevention of infection was attempted with preoperative administration of Enterobiotic in 155 patients and of Vibramycin in 11 patients. DVT was diagnosed in 46 patients. The frequency of DVT did not differ significantly between patients who underwent resections of the colon and those who underwent rectal surgery. DVT was diagnosed in 27 of the 73 infected patients, which was significantly higher than the incidence of 19 with DVT among the 157 uninfected patients. The frequency of DVT among patients in the two heparin regimens was 15 and 17 per cent respectively, which was significantly lower than with untreated patients. No lethal pulmonary embolism was found and no patient showed clinical signs of embolism. It is assumed that measures aimed at reducing postoperative infection, combined with low-dose heparin, will reduce the incidence of postoperative DVT after colorectal surgery.

Postoperative deep venous thrombosis and infectious complications. A clinical study of patients undergoing colo-rectal surgery.

The connection between deep venous thrombosis (DVT) and postoperative infectious complications (PIC) was studied in 170 patients (mean age 65.7 and 40--86 years) who had undergone open large bowel or rectal surgery. DVT was diagnosed by the 125I-fibrinogen method. DVT of the legs was found in 36 patients. In 58 patients with PIC the frequency of DVT in 41 patients receiving low-dose heparin was 29% and in 17 patients without heparin prophylaxis 71% (P less than 0.01). In 112 patients without infection the frequency of DVT in 98 patients receiving low-dose heparin was 12% and 14 patients without heparin prophylaxis 7%. The frequency of DVT was significantly lower in patients without infection compared to those with PIC (P less than 0.001). Serious DVTs were more common in patients with PIC compared to those without PIC (P less than 0.05). It is concluded that infections after open large bowel and rectal surgery is an important risk factor for the development of DVT. Low-dose heparin significantly reduces the frequency of DVT in infected patients.

Deep venous thrombosis and multiple regression analyses of the influence from various clinical factors on the fibrinogen half-life in surgical patients, using 125I-fibrinogen

The biological half-life (T B) of 125I-fibrinogen and detection of deep venous thrombosis (DVT) have been studied simultaneously in 153 patients after major surgery. Multiple regression analyses of the influence from various clinical factors on the shortened T B indicated operation time as the most important factor. Malignancy not removed at operation, postoperative infections and DVT were also significant, but less important. The frequency of DVT was significantly increased in the postoperative patients receiving blood transfusions. It is concluded that the T B of 125I-fibrinogen is not useful in the diagnosis of DVT in the postoperative period, when other clinical factors with significant influence on the T B are present. The possibility of using the T B for early diagnosis of disseminated intravascular coagulation (DIC) is discussed.

WARFARIN SODIUM IN PREVENTION OF DEEP VENOUS THROMBOSIS AND PULMONARY EMBOLISM IN PATIENTS WITH FRACTURED NECK OF FEMUR

In a prospective controlled randomised trial, the prophylactic value of warfarin sodium (in doses aimed at maintaining a 'Thrombotest' value of 10% and given from the day of admission until independent mobility had been achieved or for 3 mo, whichever was the sooner) was assessed in 160 elderly patients who had sustained a fracture of the femoral neck. Treatment significantly reduced the frequency of deep venous thrombosis (D.V.T.), whether indicated by the 125I-fibrinogen test during life or assessed by detailed post-mortem studies. Pulmonary embolism was eliminated in treated patients, but the difference in mortality between the treatment and control groups was not significant, indicating that causes of death other than pulmonary embolism are of major importance in these elderly patients. A case is made out for prophylactic anticoagulation on a selective basis.