History Of Deep Vein Thrombosis Research Articles

Treatment of Superficial Venous Reflux in CEAP 6 Patients: A Comparison of Cyanoacrylate Glue and Radiofrequency Ablation Techniques

Abstract Objective Venous leg ulcers (CEAP [clinical, etiologic, anatomic, pathophysiologic] class 6) represent the most severe form of chronic venous insufficiency. As closure techniques for superficial venous reflux evolve, direct outcome comparisons of treatments are integral, because many studies have already demonstrated that early endovenous intervention improves wound healing. The present study compared the rates of venous wound healing between two techniques of superficial vein closure: ClosureFast radiofrequency ablation (RFA) and adhesive closure (VenaSeal; both Medtronic, Inc, Minneapolis, Minn). Methods We performed a multi-institutional retrospective review of all patients with CEAP class 6 who had undergone closure of their truncal veins from 2015 to 2020. Patients undergoing ClosureFast RFA were compared with those undergoing VenaSeal adhesive closure. The primary endpoint was the interval to wound healing from initial vein closure. The secondary endpoints included ulcer recurrence and infection rates. Bivariate analysis involved the χ2, Fisher exact, t, and Wilcoxon rank sum tests. Multivariate linear regression analysis was used to examine the factors affecting the time to wound healing in the most predictive model. Statistical significance was defined as P Results A total of 119 patients with CEAP 6 were included, with a median follow-up of 105 days (interquartile range, 44-208 days). Of the 119 limbs, 68 were treated with RFA and 51 with VenaSeal. Significantly more patients undergoing RFA had had a history of deep vein thrombosis (29% vs 10%; P = .01) and deep venous reflux (82% vs 51%; P = .003). The VenaSeal patients were older (72 years vs 65 years; P = .02) with a greater rate of coronary artery disease (16% vs 37%; P = .01). The median time to wound healing after the procedure was significantly shorter for VenaSeal than for RFA (43 vs 104 days; P = .001). Two RFA patients developed a postprocedure infection. The ulcer recurrence rate was 19.3% (22.1% for RFA vs 13.7% for VenaSeal; P = .25). On multivariate analysis, the treatment modality was the only significant predictor of the time to wound healing. When stratified by ulcer size as small ( 3 cm2), VenaSeal closure healed the wounds significantly faster for all ulcers. Conclusion ClosureFast and VenaSeal are both safe and effective treatments to eliminate truncal venous insufficiency. VenaSeal showed a superior time to wound healing compared with ClosureFast in both large and small ulcers.

Factors Associated with Mortality Among 4,227 Patients with COVID-19 in Massachusetts: A Retrospective Cohort Study

Background: Originating in Wuhan, China, SARS-Cov 2 (COVID-19) has since spread across the globe. Numerous patient characteristics and co-morbidities have been associated with COVID-19 severity and mortality, though most studies have occurred outside the United States and many have utilized relatively small sample sizes. The present study investigated factors related to mortality using a large and diverse sample of COVID-19 patients hospitalized in Massachusetts.Methods: Multi-site retrospective cohort study of 4,227 patients with laboratory-confirmed COVID-19 who were admitted to a hospital and either discharged or died by July 17, 2020. Hospitalization occurred within Mass General Brigham, a healthcare system which includes two academic medical centers, community and specialty hospitals, a large physician network, and other health care entities across the Commonwealth of Massachusetts. Demographic, clinical, and pharmacological data were extracted from electronic health records. Multivariable logistic regression analyses were utilized to investigate factors associated with COVID-19 mortality.Findings: 17,971 patients had tested positive for COVID-19 within the Mass General Brigham system. Of those, 4,227 (23·5%) patients had been admitted to hospital and either expired or discharged. Of the patients hospitalized, there were 3,674 (86%) who discharged and 553 (14%) who died. The mean age was 60·6 (SD = 19·1) and 53·1% were male. Of 2669 (63·1%) cases having at least one co-morbidity, 439 (16·5%) of those cases resulted in death. In multivariate logistic regression analysis, factors associated with mortality were age 75 years or older (odds ratio [OR] = 6·98, 95% CI: 4·13, 11·79), age 65-74 years old (OR = 3·22, 95% CI: 1·90, 5·45), male sex (OR = 1·58, 95% CI: 1·25, 2·00), blood cancer (OR = 2·00, 95% CI: 1·10, 3·63), chronic kidney disease (OR = 1·38, 95% CI: 1·05, 1·81), history of stroke (OR = 1·51, 95% CI: 1·09, 2·10), congestive heart failure (OR = 1·70, 95% CI: 1·26, 2·29), SSRI use (OR = 1·86, 95% CI: 1·15, 2·98), and BMI of 40+ (OR = 1·91, 95% CI: 1·19, 3·06). Subgroup analyses revealed COPD (OR = 1·62, 95% CI: 1·02, 2·57) as a unique risk factor for males and cardiovascular disease (OR = 2·57, 95% CI: 1·42, 4·63) and history of deep vein thrombosis or pulmonary embolism (OR = 2·83, 95% CI: 1·26, 6·36) for those under 65 years of age.Interpretation: Age and sex were the strongest demographic predictors of mortality. Many of the factors associated with mortality in the present study are also related to inflammation and hypercoagulability. The presence of these comorbidities and characteristics likely contribute to mortality risk, given that COVID-19 has been independently found to affect the hematologic system. It would be prudent to give special consideration to COVID-19 patients who have these characteristics or pre-existing conditions, when making decisions regarding treatment and level of care.Funding: None applicable.Declaration of Interests: None declared by all authors.Ethics Approval Statement: As the analyses were conducted for quality improvement and the report involves routinely collected and de-identified data, no ethical approval was required.

Venous Duplex Ultrasound Surveillance in the Neurosurgical Population: A Single-Center Quality Improvement Initiative

Venous thromboembolism (VTE) represents a significant source of morbidity and mortality in the inpatient population and is considered a leading preventable cause of death among inpatients. Neurosurgical inpatients are of particular interest because of the greater rates of immobility, steroid use, and potential consequences of postoperative hemorrhage. A consensus protocol for VTE screening in this population has not yet been developed, and institutional protocols vary widely. We performed a retrospective review of lower extremity venous duplex ultrasonography (VDUS) usage at our institution and applied this information to the development of a neurosurgery department protocol, with consideration of high-risk patient risk factors and indications for VDUS ordering. We then implemented this protocol, which consisted of preoperative screening of patients at high risk of VTE and limited postoperative surveillance, for a 6-month period and compared VDUS usage and VTE occurrence. Preoperative VDUS screening before nonemergent neurosurgical procedures in high-risk patients with active cancer, an inability to ambulate, or a history of deep vein thrombosis (DVT) identified proximal DVTs that were then treated. Postoperative routine surveillance VDUS scans only diagnosed incidental isolated calf DVT for which no clinically relevant sequelae occurred. Overall, postoperative surveillance VDUS usage decreased significantly (66.9% vs. 13.5%; P= 0.001). Our findings lend support to preoperative screening of high-risk patients and suggest that routine postoperative VDUS surveillance of asymptomatic patients is unnecessary.

Peripherally Inserted Central Catheter Thrombosis After Placement via Electrocardiography vs Traditional Methods

BackgroundPeripherally inserted central catheter tip placement at the cavoatrial junction is associated with reduced catheter-related deep vein thrombosis. Electrocardiographic tip confirmation purportedly improves accuracy of tip placement, but whether this approach can reduce deep vein thrombosis is unknown. MethodsProspectively collected data from patients that received peripherally inserted central catheters at 52 Michigan hospitals were analyzed. The method used to confirm tip confirmation at insertion and deep vein thrombosis outcomes were extracted from medical records. Multivariate models (accounting for the clustered nature of the data) were fitted to assess the association between peripherally inserted central catheter-related deep vein thrombosis and method of tip confirmation (electrocardiographic vs radiographic imaging). ResultsA total of 42,687 peripherally inserted central catheters (21,098 radiology vs 21,589 electrocardiographic) were included. Patients receiving electrocardiographic-confirmed peripherally inserted central catheters had fewer comorbidities compared with those that underwent placement via radiology. Overall, deep vein thrombosis occurred in 594 (1.3%) of all peripherally inserted central catheters. Larger catheter size (odds radio [OR] 1.32; 95% confidence interval [CI], 0.93-1.90 per unit increase in gauge), history of deep vein thrombosis, and cancer were associated with increased risk of deep vein thrombosis (OR 2.00; 95% CI, 1.65-2.43 and OR 1.62; 95% CI, 1.16-2.26, respectively) using logistic regression. Following adjustment, electrocardiographic guidance was associated with a significant reduction in peripherally inserted central catheter-related deep vein thrombosis compared with radiographic imaging (OR 0.74; 95% CI, 0.58-0.93; P = .0098). ConclusionThe use of electrocardiography to confirm peripherally inserted central catheter tip placement at the cavoatrial junction was associated with significantly fewer deep vein thrombosis events than radiographic imaging. Use of this approach for peripherally inserted central catheter insertion may help improve patient safety, particularly in high-risk patients.

Multimodal prophylaxis in patients with a history of venous thromboembolism undergoing primary elective hip arthroplasty.

We studied the safety and efficacy of multimodal thromboprophylaxis in patients with a history of venous thromboembolism (VTE) who undergo total hip arthroplasty (THA) within the first 120 postoperative days, and the mortality during the first year. Multimodal prophylaxis includes discontinuation of procoagulant medications, VTE risk stratification, regional anaesthesia, an intravenous bolus of unfractionated heparin prior to femoral preparation, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient's risk of VTE. Between 2004 to 2018, 257 patients with a proven history of VTE underwent 277 primary elective THA procedures by two surgeons at a single institution. The patients had a history of deep vein thrombosis (DVT) (186, 67%), pulmonary embolism (PE) (43, 15.5%), or both (48, 17.5%). Chemoprophylaxis included aspirin (38 patients), anticoagulation (215 patients), or a combination of aspirin and anticoagulation (24 patients). A total of 50 patients (18%) had a vena cava filter in situ at the time of surgery. Patients were followed for 120 days to record complications, and for one year to record mortality. Postoperative VTE was diagnosed in seven patients (2.5%): DVT in five, and PE with and without DVT in one patient each. After hospitalization, three patients required readmiss-ion for evacuation of a haematoma, one for wound drainage, and one for monitoring of an elevated international normalized ratio (INR). Seven patients died (2.5%). One patient died five months postoperatively of a PE during open thrombectomy. She had discontinued anticoagulation. One patient died of a haemorrhagic stroke while receiving Coumadin. PE or bleeding was not suspected in the remaining five fatalities. Multimodal prophylaxis is safe and effective in patients with a history of VTE. Postoperative anticoagulation should be prudent as very few patients developed VTE (2.5%) or died of suspected or confirmed PE. Mortality during the first year was mostly unrelated to either VTE or bleeding. Cite this article: Bone Joint J 2020;102-B(7 Supple B):71-77.

Mesenteric Panniculitis in a Patient with Homozygous Factor V Leiden Gene Mutation: A Case and Literature to Review

A 30-year-old Asian male with a significant history of deep vein thrombosis and family history positive for pulmonary embolism presented with complaints of fever, nonradiating epigastric pain, and a sense of abdominal fullness. After the initial workup, ultrasonography of the whole abdomen was carried out which showed thrombus formation in the portal vein. A CT scan of the abdomen was performed, which showed findings suggestive of mesenteric panniculitis. Keeping the significant family history and imaging findings in mind, the clotting and thrombin profiles were analysed and came back positive for the factor V Leiden gene (homozygous). A CT angiogram was performed to demonstrate extensive thrombosis throughout the abdominal vasculature with cavernous transformation. It is asserted that the chronic thrombosis on a background of factor V mutation led towards chronic inflammation of the mesentery. To the authors’ knowledge it is the first reported case of mesenteric panniculitis in a patient with factor V homozygous gene mutation.

Incidental Saccular Popliteal Vein Aneurysm: Two Case Reports

Venous aneurysms are rare lesions that have been described within the venous system and may be discovered at any age. The lower extremities are most frequently involved, with the popliteal vein being the most common location. Clinical presentations are often initially classified as subcutaneous masses or alternatively, as an incidental finding during imaging studies for pain or chronic venous disease of the lower limb. They may be asymptomatic and/or initially present as a pulmonary embolism (PE), thrombosis, or vessel rupture with bleeding. Although benign, venous aneurysms have the potential for complications depending on location, size, and type. Here, the author presents two cases of saccular popliteal vein aneurysm that did not receive surgical treatment. Case 1: A 66-year-old male presented with a venous aneurysm without any previously reported symptoms that suggested new onset of claudication. He had an episode of PE in the past. Upon outpatient follow-up for his arterial exam, duplex ultrasound was performed, and a popliteal vein outpouching was visualized. Results: The ultrasound demonstrated a patent arterial bypass graft, with an incidental finding of saccular popliteal vein aneurysm without evidence of thrombus. The patient received no further surgical treatment (considering his comorbidities) and began daily warfarin with close clinical monitoring. Case 2: A 49-year-old male presented with bilateral varicose veins (worse on the left side) with recurrent posterior calf pain. He was referred for a bilateral venous insufficiency ultrasound. The patient had no prior history of deep vein thrombosis or PE. Results: Deep and superficial venous insufficiency was identified bilaterally. In addition, a saccular vein aneurysm without thrombus measuring 3.3 × 2.7 × 2.1 cm was identified in the popliteal vein. The patient received surgical treatment for venous insufficiency and is doing well.

Decompensated Aortic Stenosis in a Young Patient with Multiple Comorbidities - A Case Report

Abstract Aortic valve replacement is a safe therapy that can reverse cardiac remodeling and increase cardiac contractility, improve symptoms and quality of life. We presented a case of a 35-year-old male patient admitted to the Emergency Institute for Cardiovascular Disease and Transplantation of Târgu Mureș, Romania, due to severe aortic stenosis with severely depressed ejection fraction, left atrial myxome and a history of deep vein thrombosis and pulmonary thromboembolism. He underwent excision of the aortic valve and replacement with a mechanical prosthesis, excision of left atrial myxoma and tricuspid annuloplasty. The postoperative evolution was favourable with a significant recovery of the left ventricular systolic function and regression of cardiac symptomatology. This case was particular due to the rapid progression of the aortic pathology with the reduction of cardiac (systolic) function in a relatively short time as well as the occurrence of the thromboembolic event unrelated to the left atrial myxoma and rather associated with the background of cardiac failure with low cardiac output.

Pulmonary Embolism in Acute Asthma Exacerbation: Clinical Characteristics, Prediction Model and Hospital Outcomes.

Little is known about the characteristics and impact of acute pulmonary embolism (PE) during episodes of asthma exacerbation. We aimed to characterize patients diagnosed with acute PE in the setting of asthma exacerbation, develop a prediction model to help identify future patients and assess the impact of acute PE on hospital outcomes. We included 758 patients who were treated for asthma exacerbation and underwent a computed tomographic pulmonary angiography (CTA) during the same encounter at a university-based hospital between June 2011 and October 2018. We compared clinical characteristics of patients with and without acute PE and developed a machine learning prediction model to classify the PE status based on the clinical variables. We used multivariable regression analysis to evaluate the impact of acute PE on hospital outcomes. Twenty percent of the asthma exacerbation patients who underwent CTA had an acute PE. Factors associated with acute PE included previous history of PE, high CHA2DS2-VASc score, hyperlipidemia, history of deep vein thrombosis, malignancy, chronic systemic corticosteroids use, high body mass index and atrial fibrillation. Using these factors, we developed a random forest machine learning prediction model which had an 88% accuracy in classifying the acute PE status of the patients (area under the receiver operating characteristic curve = 0.899; 95% confidence interval: 0.885-0.913). Acute PE in asthma exacerbation was associated with longer hospital stay and intensive care unit stay. It is important to consider acute PE, a potentially life-threatening event, in the setting of asthma exacerbation especially when other risk factors are present.

Unlike a high-fat diet model, mitochondrial ROS production does not appear to contribute to bed rest-induced insulin resistance.

Unlike a high-fat diet model, mitochondrial ROS production does not appear to contribute to bed rest-induced insulin resistance.

Surgeon-specific risk stratification model for early complications after complex adult spinal deformity surgery.

Retrospective outcome analysis of a prospectively collected single-surgeon cases OBJECTIVES: Identify risk factors for complications in adult surgical spine deformity patients, develop a surgeon-specific risk stratification model, and predict the likelihood of 6-week postoperative complications based on prospectively collected preoperative measures. Adult spinal deformity surgery is challenging technically as well as economically. Although many risk factors are well known for spine surgery, complications after complex spine deformity surgery remain a significant problem worldwide. We reviewed 124 consecutive adult patients who have undergone instrumented spinal fusion with nine or more levels over a 21-month period in a single institution. We extracted data from patient medical records. Complications within the 6weeks after surgery were identified. Univariate and logistic regression analyses (LRAs) were implemented. We generated a formula based on the LRA predictive algorithm-a numeric probabilistic likelihood statistic representing an individual patient's risk of developing a complication. A total of 34 (27%) patients had complications that were categorized into either 21 (17%) medical or 17 (13.7%) surgical complications, including 3 (2.4%) proximal junctional kyphosis, 8 (6.4%) neurologic deficit, and 9 (6.5%) any wound issue. The predictive model was significant and calibrated using area under the receiver operating characteristics curve analysis. The model correctly classified 83.1% cases. Patients with a three-column osteotomy or history of deep vein thrombosis have 6 and 19 times higher overall complications, respectively, compared with patients without. Patients with a three-column osteotomy or body mass index > 30, respectively, are 24 and 11 times more likely to develop a wound complication. Patients with a three-column osteotomy have 10 times higher rates of surgical complication. Complex spine deformity is often associated with complications. No single variable effectively predicts postoperative complications for such a complicated situation. However, when all risk factors are considered, patients with three-column osteotomy have a significantly higher chance to develop early complications. Level IV.

Iliac Vein Stenting for Chronic Proximal Venous Outflow Obstruction in a Predominantly Asian-American Cohort

We investigated the outcome of vein stenting placement for chronic proximal venous outflow obstruction (PVOO) in a predominantly Asian-American cohort to improve patient selection, enhance technical approach, and better define quality measurements of this emerging vascular intervention. A total of 462 consecutive patients, 73% Asian American (n=336), who underwent iliac vein stenting for chronic PVOO from October 2013 to July 2016 were reviewed. Postoperative outcomes at five follow-up visits were assessed. Wilcoxon-Mann-Whitney and Kruskal-Wallis tests were run for demographic and operative variables. Ordered logistic regressions were run for the outcome at each time point, and Chi-squared tests as well as Fisher's exact tests were used for categorical variables. Follow-up was maintained in 90% of patients, with a mean follow-up time of 695days. Asian-American patients were more likely to present with varicose veins (77.4% vs. 54.8%, P<0.001), and non-Asian patients were more likely to present with active ulceration (26.2% vs. 5.1%, P<0.001). Asian-American patients were more likely to have bilateral stents placed (61.6% vs. 50%, P=0.026) and were less likely to have reinterventions (11.3% vs. 27.8%, P<0.001), a history of deep vein thrombosis (8.3% vs. 29.4%, P<0.001), or intraoperative findings of chronic postphlebitic changes (17.6% vs. 33.3%, P<0.001). Kruskal-Wallis tests were significant for improvement in patients of all the Clinical, Etiology, Anatomy, Pathophysiology classes at 30days (P=0.041), 90days (P=0.045), 6months (P=0.041), and 1year (P<0.01). The Asian-American population had improved but comparatively lower follow-up scores at the 30-day mark (48% significantly improved or better vs. 63%, P=0.008) but higher follow-up scores at the >1year mark (80% significantly improved or better vs. 59%, P<0.001). Asian-American patients undergoing vein stent placement for chronic PVOO had comparatively worse outcomes than non-Asian patients at 30 days and better outcomes after one year. These patient groups had different outcomes postoperatively and outcomes which evolve differently over time.

Post-pulmonary embolism syndrome phenotyping with systematic multiparametric evaluation: A Prospective Study on 153 patients

Persistence of symptoms and discomfort after pulmonary embolism (PE) is frequent and poorly understood. To identify patients who remained symptomatic 6 months after an acute PE, and to determine factors associated with a 6-months functional impairment. One hundred and fifty-three patients with acute symptomatic PE were prospectively included from February 2015 to January 2017 at the University hospital of Toulouse, France. Clinical and paraclinical data were evaluated at inclusion and after 6 months of follow-up. Six-month follow-up included clinical evaluation, psychiatric survey, echocardiography and functional cardiopulmonary test. Symptomatic patients (i.e. patients with dyspnea and/or chest discomfort) underwent a ventilation-perfusion scintigraphy scan. Sixty (39%) patients remained symptomatic 6 months after the acute PE. After multivariate analysis, only an initial history of deep vein thrombosis (DVT) was predictive of 6-months symptoms (OR 3.35, 95% CI [1.19–9.39], P = 0.022), while initial use of low molecular weight heparin (LMWH) was protective (OR 0.36, 95% CI [0.13–0.96], P = 0.041). The six-month functional test appears to be related to symptoms. There was no difference in clinical, laboratory or echocardiographic parameters between symptomatic and asymptomatic patients. No pathological defect was found on ventilation-perfusion scintigraphy for 27 (52%) of symptomatic patients. Persistence of symptoms at six months of PE is frequent and is associated with a history of DVT and less frequent with initial LMWH therapy. Pathophysiology of post-pulmonary embolism syndrome is complex and not related to the initial PE severity nor the parameters of echocardiography.

Clinical Factors Associated with Deep Vein Thrombosis in Rehabilitation Patients Suspected of Thromboembolism after Cerebral Infarction.

The aim of this study is to investigate the association between characteristics of cerebral infarction lesion (vascular territory, etiology, and size), functional status and the occurrence of thromboembolism in patients suspected of having thromboembolism in a rehabilitation setting after cerebral infarction. Cerebral infarction patients who were suspected of having thromboembolism and who had undergone deep vein thrombosis (DVT) evaluation were included in analyses. Of the total 916 cerebral infarction patients, 65 patients were suspected of having DVT; 27 patients belonged to the DVT group and 38 patients belonged to the non-DVT group. The DVT (+) group was more likely to have a higher ratio of female, previous DVT history, middle cerebral artery (MCA) infarction, large arterial disease, modified Rankin Scale (mRS) score 5, abnormal speech and higher D-dimer. In multivariate logistic regression analysis, female sex, MCA infarction and mRS score 5 were significantly associated with the occurrence of thromboembolism in patients suspected of having thromboembolism. In contrast, other functional status, cerebral infarction etiology (Trial of ORG 10172 in Acute Stroke Treatment [TOAST] classification), and infarct volume were not associated with the occurrence of thromboembolism. In this study, female gender, MCA infarction, and mRS score 5 could be potential risk factors for thromboembolism in rehabilitation patients after cerebral infarction.

Etiology of iliocaval stent thrombosis

ObjectiveAlthough correction of iliac vein stenosis is safe and efficacious, one of its major complications is iliac vein stent thrombosis. In an attempt to examine the cause of iliac vein stent thrombosis, we reviewed the location of underlying lesions encountered after thrombectomy or thrombolysis of iliac vein stents. MethodsA retrospective analysis was performed of all iliac vein venograms with intravascular ultrasound examinations at our office-based surgical center from February 2012 to July 2016. Patients included in the study had chronic venous insufficiency and failed compression therapy. All procedures were performed with local anesthesia and conscious sedation. Wallstents were used in all procedures for nonthrombotic iliac vein stenosis, ranging from 8 to 24 mm in diameter and 40 to 90 mm in length. Patients were followed with transcutaneous duplex every 3 months for the first year and every 6 to 12 months thereafter. Patients were placed on clopidogrel for 3 months or continued on their preexisting anticoagulants. ResultsFrom February 2012 to July 2016, we performed 2228 iliac vein venograms with intravascular ultrasound examination in 1381 patients. The mean age of the patient population was 65 ±14 years (range, 21-99 years), among which 876 were female. A total of 1037 procedures were performed in the left lower extremity. Of these, 240 venograms were diagnostic. Presenting symptoms based on CEAP classification included C2 (n = 21), C3 (n = 633), C4 (n = 1065), C5 (n = 269), and C6 (n = 241). Complete thrombosis of the iliac vein stent was noted in 18 patients (0.8%) who thereafter underwent suction thrombectomy with thrombolysis. None of these patients had a prior history of deep vein thrombosis. In-stent restenosis was noted in 11 patients. Proximal lesions were found in no patients. An external iliac vein lesion was found distal to the common iliac vein stent in two patients. Common femoral vein lesions were found in six patients. These encountered lesions were then stented. All patients who underwent thrombectomy were placed on anticoagulation for 6 months. No patient were noted to suffer rethrombosis upon follow-up. No correlation with stent thrombosis was encountered for age, gender, laterality, location, presenting symptoms, or length or diameter of the stent. ConclusionsBased on our experience, in-stent restenosis followed by inflow lesions in the common femoral vein are the most common causes of stent thrombosis. These data suggest a need for future research to target these areas.

Approaching Venous Thromboembolism Disease (DVT) from Another Perspective: Better Management in a Multidisciplinary DVT Unit Improves Clinical Outcomes and Post Thrombotic Syndrome. One-Year Experience in Our Hospital

INTRODUCTION: Deep vein thrombosis (DVT) is a frequent cause or morbidity and mortality, and multiple genetic and environmental factors are involved in its etiopathogenesis. Besides investigating about personal and familiar DVT history, thrombophilia testing is often asked by physicians in order to diagnose patients, even if current validated markers won't be decisive to set duration of treatment. DVT is a multidisciplinary management entity, so it`s important to unify the diagnosis and treatment circuit with the specialists involved, in order to get a positive impact in the prognostic of the disease. MATERIALS AND METHODS: We developed an observational and prospective study between January 2017 and December 2017 in our University Tertiary Hospital in order to register the patients with DVT that were treated in our DVT unit conformed by specialists of Hemostasis, Angiology and Intern Medicine. As secondary objectives, we wanted to know how a systematic circuit would improve the management and the complications of patients with DVT. After diagnosis in Emergency Service by Angiology -or Intern Medicine if pulmonary embolism (PE), they were sent to Hemostasis Unit within the first 7-10 days to optimize treatment according patient's necessities. After 3-6 months of starting treatment, patients were seen conjunctly by specialists of Angiology and Hemostasis to perform a doppler ultrasound and thrombophilia study in selected patients, in order to make the best decision about treatment. RESULTS: We included 172 patients with DVT, most of them were men (56.9%), the average age was 66.4 years old, and the incidence increased from 50 years old, on. Only 26.2% had a positive personal history of DVT and 18% familiar history. We found that 75 (43.6%) patients had idiopathic DVT. About anatomical localization, the majority presented in the lower limbs (83.1%) and 12.7% associated pulmonary embolism at diagnosis. All of them started treatment with LMWH, and after the first clinical visit, 26.7% continued with it, while 51.2% changed to VKA and 22.1% to DOACs. We tested only 69 patients for thrombophilia, according to guidelines (especially in incidental DVT): 23.8% were diagnosed of antiphospholipid syndrome, 19% of S protein deficiency, 14.3% of C protein deficiency and 14.3% of prothrombin mutation, as the most common findings. Patients with positive study or antiphospholipid syndrome and 21 of the 41 patients with negative study, received permanent anticoagulation. In the conjunct visit we found a 61.1% of residual/chronic DVT, 38.4% resolved, and 0.5% of recurrence (local extension). Only 18.6% of patients had post thrombotic syndrome and we didn`t see any hemorrhagic complications during the follow up period. We also identified a reduction of almost a 50% of clinical visits because of the systematic circuit. CONCLUSIONS: An ordered flow of patients diagnosed of DTV contributed in our clinical practice to avoid redundant hospital visits and complementary tests, and specially to release a better follow up of patients with a less percentage of bleeding (0%) and post thrombotic syndrome (18.6% vs 40% in world registries), as well as we found. It would be interesting to amplify the time of follow up, so that we would know if these benefits remain within time. Disclosures Bosch: Kyte: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; F. Hoffmann-La Roche Ltd/Genentech, Inc.: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Takeda: Honoraria, Research Funding; AstraZeneca: Honoraria, Research Funding; AbbVie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Celgene: Honoraria, Research Funding; Acerta: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau.

DVT prophylaxis in critical care: role of NOACS

The incidence of deep vein thrombosis (DVT) in the critically ill ranges from 3.6% to 37%. Despite seemingly adequate prophylaxis the risk for DVT is still between 4 and 15%.Currently the known risk factors can be divided into inherited and acquired. In addition, the underlying disease and comorbidities play a major role, e.g., history of DVT, malignancy, ongoing infectious disease, cardiovascular disease and pregnancy1.DVT prevention is applied in various ways and timings. Principally, the choice is between mechanical, pharmacological and a combination of both.Regarding the mechanical prophylaxis, recommendations point more to the use of intermittent pneumatic stockings (IPS), which are more effective with less side effects than simple stockings2. Whenever pharmacological treatment carries a relatively high risk (e.g., fresh bleeding, traumatic brain injury) mechanical prevention might be started. However, it is still under debate whether the combination of IPS with pharmacological prophylaxis is superior.Like all anticoagulant therapy, the risk (and consequences) of DVT should be balanced against the risk of bleeding. A variety of scoring systems, like the Well's score, the Caprini score and the Has-Bled score exist to group the risks. In terms of risk assessment, bleeding after peripheral surgery might be less dangerous than after intracranial surgery.In general, low molecular weight heparins (LMWH) are preferred above unfractionated heparin (UFH). One reason might be the risk of heparin induced thrombocytopenia (HIT), which is higher with UFH than with LMWH. On the other hand, UFH have a shorter half-life necessitating at least two daily injections, while the LMWH schemes apply a once daily injection3. However, the shorter half-life and the ease of reversal might be an argument for UFH use in patients at bleeding risk. In contrast, LMWH's carry a higher risk of bioaccumulation4,5. The route of application seems to be another point of concern. In the critically ill, peripheral organ perfusion might be disturbed by the disease or the therapy (i.e. vasoconstriction or edema).It is still a debate if oral anticoagulants should be used in critical care. Mainly concerns are raised from pharmacological considerations. For instance, if enteral feeding is only possible via tubes, grinding of tablets will change the galenic of the drugs and their bioavailability. In addition, it is not clear whether orally applied drugs will be resorbed completely. Excretion of drugs might be altered due to impairment of kidney and/or liver function which could result in their accumulation.Finally, changes in the coagulation system due to the underlying disease might occur unexpectedly and therefore unanticipated.In concert with difficulties in laboratory measurement and reversal of the drug benefits of oral anticoagulants do not outweigh risks and disadvantages. Therefore, it seems not recommendable to start any kind of oral anticoagulation before the patient's condition is stable enough which is mostly the moment of discharge from the ICU.

Proximal deep vein thrombosis among hospitalised medical and obstetric patients in Rwandan university teaching hospitals: prevalence and associated risk factors: a cross-sectional study

ObjectivesTo determine the prevalence of proximal deep vein thrombosis (DVT) by ultrasound scanning, as well as associated clinical features and known risk factors, among medical and obstetrics–gynaecology inpatients in two...

ADALIMUMAB (HUMIRA) AND THE RISK OF RECURRENT VENOUS THROMBOEMBOLISM

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Anti-TNF alpha agents have increasingly been used to treat several types of auto-immune diseases, including rheumatoid arthritis and Crohn’s disease. Deep vein thrombosis is an uncommon but important side effect of this medication. Optimum duration of anticoagulation therapy is unknown due to lack of large data studies or guidelines.. In this case, we discuss the possible necessity of indefinite anticoagulation for patients taking adalimumab after having a venous thrombotic event. CASE PRESENTATION: A 54 year old African American female with past medical history significant for obesity, uveitis, retinal detachment and rheumatoid arthritis, presented to the ED with generalized fatigue, dizziness, and shortness of breath. She had no other significant cardiac history. She did not have any history of prior deep vein thrombosis or family history of a hyper-coagulable disorder. She had started Adalimumab 4-5 months prior to this visit. Notable vitals included heart rate of 140 and EKG showing atrial fibrillation with no changes indicating ischemia. CXR showed mild pulmonary vascular congestion. She was given diltiazem 20mg IV in the ED and started on diltiazem 30mg PO every 6 hours. CT angiography of the chest revealed bilateral main pulmonary artery emboli, segmental, and subsegmental pulmonary emboli. She was started on tPA via catheter directed thrombolysis for 24 hours and heparin drip. Ultrasound of BLE was significant for non-occlusive deep vein thrombosis (DVT) in right popliteal vein. Patient was discharged on apixaban 10mg BID for 6 days to switch to 5mg BID for 6 months. After 6 months, apixaban was discontinued. Two months after discontinuation of apixaban, she presented to the ED with left calf pain. LLE Venous Duplex was performed and revealed left popliteal DVT. Anticoagulation therapy with apixaban was reinstituted. DISCUSSION: Adalimumab is associated with increased risk of DVT. Since our patient did not have a prior history of DVT, we believed the use of Adalimumab resulted in a hyper-coagulable state. Despite causing a lupus-like syndrome, the true mechanism is unknown. Previous studies discussed that patients with Adalimumab antibodies may have an increased risk of thromboembolic events compared to those without. A subsequent larger study refuted this association. The temporality of events, including recurrence of DVT after discontinuation of anticoagulation therapy strongly suggests possibility of ongoing risk of thromboembolism and need of continued anticoagulation therapy, similar to the patients with other chronic hyper-coagulable states and certain types of cancer. CONCLUSIONS: This case demonstrates the need for evaluation of anticoagulation guidelines in patients taking Adalimumab due to the persistence of hyper-coagulable state after previous thromboembolic events. Reference #1: Korswagen, L. A., Bartelds, G. M., Krieckaert, C. L., Turkstra, F. , Nurmohamed, M. T., van Schaardenburg, D. , Wijbrandts, C. A., Tak, P. P., Lems, W. F., Dijkmans, B. A., van Vugt, R. M. and Wolbink, G. J. (2011), Venous and arterial thromboembolic events in adalimumab-treated patients with antiadalimumab antibodies: A case series and cohort study. Arthritis & Rheumatism, 63: 877-883. https://doi.org/10.1002/art.30209 DISCLOSURES: No relevant relationships by Chinmaya Sharma, source=Web Response

1404TiP - HORMONET: Study of tamoxifen in well differentiated neuroendocrine tumours and hormone receptor positive expression

BackgroundPatients (pts) with advanced neuroendocrine tumors (NET) represent an unmet medical need, what motivates the development of new treatments. Prior retrospective study conducted by our group showed that among 96 NET, immunohistochemistry (IHC) expression for estrogen (ER) and progesterone receptors (PR) were observed in 20.8% and 18.8% of cases, respectively. Additionally, an old clinical trial (Mortel C, 1984) suggested antitumor effects of estrogen/progesterone-directed therapies in NET pts. Yet the effects of an antiestrogen agent in NET pts whose tumor express ER and/or PR are unknown. Hence we will conduct a clinical trial to test the efficacy of tamoxifen in ER/PR positive NET pts. Trial designSingle-arm phase II multicenter trial of tamoxifen 20mg PO continuously until intolerance and/or tumor progression. Eligible pts must be≥18 years old, have histologically confirmed advanced, irresectable well-differentiated lung or gastroeteropancreatic NET, IHC expression of ER and/or PR≥1%, documented progression in the prior 12 months, measurable disease, prior treatments with standard therapies and/or no indication to start new treatment due to lack of access, risk of toxicities or without clinical indication (patients who meet criteria for watchful waiting may be included), ECOG 0-2, adequate organ function. Main exclusion criteria are: aggressive disease requiring cytotoxic therapy, use of oral anticoagulants, previous history of deep vein thrombosis or pulmonary embolism in the last 12 months, postmenopausal vaginal bleeding with no defined etiology. The primary endpoint is disease control rate (DCR) at week 24 as per RECIST 1.1. Secondary endpoints are progression-free survival, biochemical response, response rate. Exploratory evaluations: circulating tumor cells kinetics (qualitative and quantitative) and PET-CT gallium-68 intake intensity variation (at baseline and at week 24). Sample size assumptions: the H0 is DCR at week 24 of 50% and H1, 70%; with a type I error of 10%, power of 80% and attrition rate of 30%, the final sample size will be 22 pts. Clinical trial identificationNCT03870399. Legal entity responsible for the studyRachel Riechelmann. FundingAC Camargo Cancer Center. DisclosureM. Barros: Honoraria (self): Novartis. J.F. Rego: Honoraria (self): Novartis. R.P. Riechelmann: Honoraria (self): Novartis. All other authors have declared no conflicts of interest.