History Of Deep Venous Thrombosis Research Articles

Inflammatory and Procoagulant Mediator Interactions in an Experimental Baboon Model of Venous Thrombosis

Theoretic and in vitro evidence suggests that thrombosis and inflammation are interrelated. The purpose of the present study was to define the relationship between inflammation and deep venous thrombosis (DVT) in an in vivo model. Initiation of DVT was accomplished by administration of antibody to protein C (HPC4, 2 mg/kg) and tumor necrosis factor (TNF, 150 micrograms/kg); stasis; and subtle venous catheter injury. Thrombosis was assessed by thrombin-antithrombin assay (TAT), 125I-fibrinogen scanning (scan) over both the proximal and distal iliac veins, and ascending venography. Cytokines TNF, interleukin-6 (IL-6), monocyte chemotactic protein-1 (MCP-1), and interleukin-8 (IL-8) were measured along with differential white blood cell counts, platelet counts, fibrinogen (FIB), and erythrocyte sedimentation rates (ESR). Baboon pairs were sacrificed on day 3 (T + 3d), T + 6d, and T + 9d and veins removed. All animals developed inferior vena cava and left iliofemoral DVT by venography; no right DVT was found. TAT was elevated by T + 1hr and peaked at T + 3hrs. Left iliofemoral DVT was found at T + 1hr by scan and reached a 20% uptake difference between the affected left and nonaffected right side at T + 3hrs. TNF peaked at T + 1hr; MCP-1 peaked at T + 6hrs; IL-8 and IL-6 peaked on T + 2d; all cytokines declined to baseline. TNF and TAT elevations were found to correlate with all cytokines; elevations in IL-8 were correlated with elevations in MCP-1 and IL-6 (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Venous thromboembolism associated with hip and knee arthroplasty: current prophylactic practices and outcomes.

Joint registry and hospital data bases for 5,024 total hip and total knee arthroplasties done between 1986 and 1988 at the Mayo Clinic were used to study prophylactic measures and frequency of symptomatic deep venous thrombosis and pulmonary embolism. In virtually all patients, graduated compression stockings were used, with or without another type of prophylaxis. Only 44 of 3,115 patients who underwent hip arthroplasty (1.4%) and 32 of 1,909 patients who underwent knee arthroplasty (1.7%) had definite or probable deep venous thrombosis or pulmonary embolism. Death definitely or possibly attributable to pulmonary embolism occurred in 11 patients who underwent hip arthroplasty (0.35%) and 1 patient who underwent knee arthroplasty (0.05%). Although patients with a history of deep venous thrombosis or pulmonary embolism were more likely to receive warfarin than were patients without such a history, the relative risk of symptomatic deep venous thrombosis or pulmonary embolism in patients who underwent hip arthroplasty and received warfarin postoperatively was approximately half that in patients who received other types of prophylaxis. The risk of death from pulmonary embolism was similarly diminished in the group that received warfarin. The lower rates of these complications in the patients who received warfarin support the prophylactic use of this agent after total hip arthroplasty.

Indurated Telangiectatic Plaques

REPORT OF A CASE A 60-year-old woman with a history of deep venous thrombosis was referred for evaluation of persistent superficial thrombophlebitis. Six months before admission, tender red areas developed initially on her thighs and subsequently spread to her abdomen. Otherwise, she was in excellent health. Her physical examination showed normal findings except for her skin, where large areas of induration were seen on both thighs and the lower abdomen (Fig 1). Overlying the indurated areas were numerous partially blanching, arborizing superficial telangiectasias (Fig 2). Pitting edema without telangiectasias was present below the knees. Abnormal laboratory findings included the following: hematocrit, 0.27; erythrocyte sedimentation rate, 111 mm/h; and lactate dehydrogenase, 1141 U/L (normal, 230 to 450 U/L). Normal laboratory findings included the following results: serum electrolytes, leukocytes, platelets, prothrombin time, partial thromboplastin time, aspartate aminotransferase, and alanine aminotransferase. A skin biopsy was performed and the specimen sent for histopathologic

Deep Venous Thrombosis and Pulmonary Embolism

All surgical patients are at risk for the development of deep venous thrombosis and subsequent pulmonary embolism or postphlebitic syndrome. The evolution of ultrasonographic imaging has increased the awareness of prevention, diagnosis, and treatment of deep venous thrombosis. Duplex imaging and Doppler color flow imaging have made the diagnosis of deep venous thrombosis relatively simple, painless, inexpensive, and definitive. These procedures have gained acceptance by both patients and physicians. Several risk factors have been identified that increase the chance of the development of deep venous thrombosis. These factors include a history of deep venous thrombosis, presence of a malignant process, increasing age, cigarette smoking, obesity, prolonged bed rest, and general anesthesia. The greater the number of risk factors, the more aggressive prophylaxis should be. Means of prophylaxis have improved, and surgeons now generally agree that some form of prophylaxis is required. Heparin and intermittent compression devices appear to be equally effective in preventing deep venous thrombosis. The addition of venous monitoring in high-risk patients permits immediate identification of the presence of deep venous thrombosis. During the last decade, the treatment of patients with deep venous thrombosis has changed little. Heparin followed by warfarin remains the treatment of choice. A small group of patients receive fibrinolytic therapy for deep venous thrombosis. Although the incidence of postoperative deep venous thrombosis has decreased during the last decade, it remains a significant complication.

Deep venous thrombosis: longitudinal study with duplex US.

Forty-nine patients with deep venous thrombosis (DVT) of the lower limb were studied with repeated duplex ultrasound (US) for at least 1 year or until the vein became normal at US. Standard anticoagulant therapy was given for 3 months. In 36 patients, the veins became normal within 1 year. The likelihood of normalization increased if the lesion was located in only one site, if the pelvic veins were unaffected, if the affected leg was the left one, if the initial clot was nonocclusive, if there was no history of DVT, and if the symptoms had lasted less than than 24 hours. The average time before normalization was shorter if the symptoms had lasted less than 24 hours, that is, 11 weeks versus 25 weeks (P less than .02). The rate of sequelae at 1 year was lower if the US scan was normal or showed regression at 3 months, 6% versus 83% (P less than .00005).

Use of the inferior vena cava clip in patients at high risk for pulmonary embolism

Sixteen gynecologic oncology patients at high risk of developing a postoperative pulmonary embolism underwent prophylactic clipping of the inferior vena cava during laparotomy for tumor resection. All patients had a prior history of deep venous thrombosis or pulmonary embolism or had an active deep venous thrombosis at the time of their surgery. Additionally, this group of 16 patients was characterized as being at high risk for recurrent thrombosis in the postoperative period based on traditional risk factors that are representative of most gynecologic oncology patients. The Adams-DeWeese or Moretz clip was used in this series. There were no pulmonary emboli in our 16 patients in the postoperative period or during follow-up. There were no signs of venous stasis attributable to clip placement. The procedure was quick, simple, and complication free and the external clip has the advantage of maintaining effectiveness throughout the patient's lifetime. Prophylactic clipping of the inferior vena cava at the time of laparotomy in patients at an increased risk of thrombosis deserves further study.

Duplex Scanning of Central Vascular Access Sites in Burn Patients

Seventy-one burned patients requiring intensive care unit management underwent 570 central venous and 167 femoral arterial catheterizations. These patients were surveyed by repeated physical examinations and duplex scans for vascular-related complications. Catheter sites were rotated every 3 days. No arterial thrombi or occlusions were noted. Fourteen patients (19.6%) had 19 positive venous duplex scans. Five patients (7%) had symptomatic deep venous thrombosis (DVT) and nine (12.6%) had asymptomatic DVT. Mean number of venous cannulations before a positive scan was 4.3 (range 1 to 17). All five symptomatic patients had DVT that originated in the lower extremities. No patient had clinical evidence of a pulmonary embolus, or limb morbidity resulting from the DVT. Follow-up duplex scans in the five asymptomatic and three symptomatic patients showed complete resolution in each case. This study demonstrates the high incidence and natural history of central DVT in a group of critically ill burn patients.

Deep venous thrombosis of extremities: role of MR imaging in the diagnosis.

Current noninvasive imaging techniques for diagnosis of deep venous thrombosis (DVT) of extremities are limited in their ability to demonstrate central vein involvement and to distinguish acute from chronic changes. The utility of spin-echo magnetic resonance (MR) imaging for DVT was evaluated in 100 patients suspected of having either upper- (n = 25) or lower-extremity (n = 75) DVT. Ninety-seven patients were imaged successfully. In a subset of 36 patients, prospective comparison of MR imaging with contrast venography revealed a sensitivity of 90%, specificity of 100%, and Kappa level of agreement of .752 (P less than .0001). MR imaging showed more central extent of thrombus than did venography in all five patients with upper-extremity DVT and in 13 of 25 patients (52%) with lower-extremity DVT. Although all patients in the study were evaluated for acute symptoms, 13 of 59 (22%) MR imaging studies positive for DVT demonstrated chronic disease. MR images demonstrated ancillary abnormalities in 18 of 41 (44%) patients who did not have DVT. Thus, MR imaging has a role as the definitive examination when the results of initial screening studies are unsatisfactory, or as a first-line examination if (a) there is suspicion of upper-extremity or pelvic vein thrombosis, (b) there is a history of prior DVT that necessitates distinction of acute from chronic changes, or (c) other tests are unavailable.

Warfarin resistance associated with nafcillin therapy

A woman with a history of diabetes mellitus, peptic ulcer disease, hypothyroidism, systemic lupus erythematous, and myasthenia gravis was admitted to the hospital for an elective thymectomy. She had a past history of deep venous thrombosis and received long-term anticoagulation therapy with warfarin. In hospital, the patient developed staphylococcal sepsis from an infected catheter. Intravenous administration of nafcillin was starded. Then, warfarin had no effects on prothrombin time

Mesenteric venous thrombosis

Sixteen patients with mesenteric venous thrombosis were reviewed retrospectively during a period from 1983 to 1987. Twelve patients had progressive abdominal pain, three had gastrointestinal bleeding, and one had general malaise. Seven of these 16 patients had previous deep-vein thrombosis. After negative routine gastrointestinal and hepatobiliary evaluation, 11 patients underwent an infusion computerized tomographic scan. Of these, 10 had superior mesenteric vein thrombosis; three of these 10 patients had portal vein thrombosis. Selective arteriography was done in two patients because of gastrointestinal bleeding, and a diagnosis of mesenteric vein thrombosis was made on the venous phase of the examination. The remaining four patients developed acute abdominal symptoms requiring surgical exploration, at which time mesenteric venous thrombosis was discovered. An identifiable coagulopathy was detected in nine patients (protein C deficiency in six, protein S deficiency in two, and factor IX deficiency treated with factor IX concentrate in one). No case of congenital antithrombin-III deficiency was identified. Six of these nine patients had a past history of deep venous thrombosis. Of five patients who underwent surgical exploration, all required bowel resection. In follow-up, two patients died of intestinal necrosis and a third died of associated pancreatic cancer. Thirteen patients were discharged from the hospital. Treatment of coagulopathy was by heparin in three patients and sodium warfarin (Coumadin) in four patients. Long-term anticoagulation was not instituted because of gastrointestinal bleeding in three and cirrhosis in three patients. Mesenteric venous thrombosis can occur without gangrenous bowel. Diagnosis should be suspected when acute abdominal symptoms develop in patients with prior thrombotic episodes and a coagulopathy. Infusion computerized tomographic scanning facilitates the diagnosis and treatment whereas anticoagulation allows preservation of bowel viability, especially if an associated coagulopathy exists.

Cancer and Deep Venous Thrombosis

To the Editor. —We read with interest the article by Goldberg et al 1 in the February 1987 issue of theArchivesin which the association between occult malignant neoplasm and deep venous thrombosis (DVT) was reviewed, along with the accompanying editorial. 2 We agree with Goldhaber et al 2 in the desirability of a careful screening among patients with DVT. Our experience appears to confirm the need for careful screening. Since January 1985, we have studied 104 consecutive patients who were admitted because of a deep-vein thrombosis of the lower limbs. The diagnosis of DVT was always established by bilateral phlebography. In 37 patients, the DVT developed shortly after a surgical procedure or a bone fracture, and, in 20 patients, after bed rest for more than eight days. Among the remaining 49 patients, ten had previously diagnosed cancer, six had a history of pulmonary embolism or DVT, six had

228 Natural history of impaired fibrinolytic response in patients with a history of deep venous thrombosis

228 Natural history of impaired fibrinolytic response in patients with a history of deep venous thrombosis

Variables associated with postoperative deep venous thrombosis: A prospective study of 411 gynecology patients and creation of a prognostic model

Deep venous thrombosis is a major complication following gynecologic surgery. Assessing a patient's risk of developing deep venous thrombosis is important for patient selection and in choosing appropriate prophylactic methods. Four hundred eleven patients undergoing major gynecologic surgery were evaluated prospectively. All known variables associated with deep venous thrombosis were recorded. Deep venous thrombosis was diagnosed by 125I fibrinogen leg counting of all patients. Univariate analysis of all variables identified the following to be significantly related (P less than .05) to postoperative deep venous thrombosis: a prior history of deep venous thrombosis, leg edema or venous stasis changes, venous varicosities, degree of preoperative ambulation, type of surgery, nonwhite race, recurrent malignancy, prior pelvic radiation therapy, age above 45 years, excessive body weight, intraoperative blood loss, and duration of anesthesia. A stepwise logistic regression analysis of these variables was performed. The following preoperative prognostic factors remained significant: type of surgery, age, leg edema, nonwhite patients, severity of venous varicosities, prior radiation therapy, and prior history of deep venous thrombosis. Duration of anesthesia was also important when intraoperative factors were considered in the analysis. Using these factors, a prognostic model was created and tested. The model resulted in a degree of concordance of 0.82 and allows one to evaluate the risks of postoperative deep venous thrombosis for an individual patient.

Diagnosis of Recurrent Deep Venous Thrombosis Using B-Mode Ultrasonic Imaging

Accurate diagnosis of recurrent deep venous thrombosis (DVT) in patients with postphlebitic syndrome or a history of previous DVT can be extremely difficult. Real-time B-mode ultrasonic imaging (UI) was compared to ascending contrast venography (ACV) in a prospective study of 38 limbs with suspected recurrent DVT to determine if UI could reliably detect recurrent thrombosis. Six limbs had normal deep veins and 32 had evidence of previous DVT by both techniques. Acute thrombus was diagnosed by both UI and ACV in 9 limbs and by UI alone in an additional three limbs. New thrombus was found in 13 popliteal-proximal and 10 calf veins by UI; while ACV detected 12 popliteal-proximal and five new calf vein thromboses. UI is comparable to ACV in detecting recurrent thrombosis and may be particularly useful in assessing the calf veins.

Venous function five to eight years after clinically suspected deep venous thrombosis.

One hundred and fifty-four patients, who had been subjected to phlebography 5-8 years previously because of clinical suspicion of deep venous thrombosis (DVT), were investigated to evaluate the frequency of deep venous insufficiency (DVI). The evaluation included clinical examination, registration of subjective complaints and objective measurements with plethysmography, venous pressure and Doppler ultrasound. DVT had been present in 75 legs. There were no statistically significant differences between legs with and without earlier DVT apart from more venous outflow obstruction in the former. DVI was as common after calf vein thrombosis as after more proximal DVT. DVI was more frequent in elderly patients and in patients with a history of previous DVI or DVT. The sufficiency of the popliteal vein seemed to be of great importance in the development of DVI. More than one third of legs without DVT had developed DVI at follow-up.

Prediction of Thromboembolism Following Total Hip Replacement

Obesity, edema in the legs before surgery, a history of deep venous thrombosis, varicose veins, and a diagnosis of osteoarthrosis were associated with an increased risk for postoperative thromboembolism. Selective administration of anticoagulants to high risk but not to low risk patients should result in a reduction in total mortality following surgery. It is therefore suggested that when deciding whether prophylactic anticoagulants should be administered to a patient, consideration should be given to that patient's likelihood of developing fatal pulmonary embolism if the anticoagulant is not given, compared to the potential reduction in his risk for fatal pulmonary embolism and the increase in risk for fatal bleeding complications if the anticoagulant is used.

Heart sounds

The Villalta scale (VS) is a recommended and widely used clinical severity score for diagnosis and grading of post-thrombotic syndrome (PTS). However, patients with primary chronic venous disease (CVD) who have a history of deep venous thrombosis (DVT) may be classified as having PTS even though post-thrombotic disease is not actually present. The purpose of this study was to investigate the biases of the VS with use in patients with pre-existing CVD.This single-center, prospective, observational study included patients who were diagnosed with CVD during a 12-month period from 2016 to 2017. The VS and the Venous Clinical Severity Score (VCSS) were completed, and bilateral lower extremity venous duplex ultrasound studies were performed. The correlation of the VS with the VCSS was analyzed. Sensitivity, specificity, positive bias, and negative bias of the VS combined with a history of DVT were calculated. For patients in whom DVT developed during the study, the VS score was taken 12 months after the onset of DVT and compared with the score before DVT.A total of 288 patients were included. The VS score correlated well with the VCSS, with a correlation coefficient of 0.86 (P < .001). The two scores changed similarly over time. The accuracy of the VS combined with a history of DVT was 94.1%, with a sensitivity of 71.4% and a specificity of 95.9%. The positive bias was as high as 42.3%, although the negative bias was 2.3%. The VS score decreased to a normal level during follow-up in 41.7% of the CVD patients in whom a new DVT developed (n = 12).The use of the VS for defining PTS appeared to misclassify those with primary CVD and a history of DVT as having PTS by 42.3%. Using the VS at follow-up in patients with PTS and pre-existing CVD may be misleading. Re-evaluation of the results of previous studies that used the VS may be needed.