History Of Deep Venous Thrombosis Research Articles

Penile Amputation After Trazodone-Induced Priapism

To the Editor: Painful persisting penile erection (priapism) is a rare but very serious side effect that can occur with antidepressants in general1–4 and with trazodone in particular.5,6 Trazodone is a very commonly prescribed antidepressant.7,8 Although clear evidence is lacking, trazodone is often administered, in clinical practice, to treat disordered sleep as in insomnia (eg, see Mendelson8). Case report. Mr A, a 35-year-old white man, was admitted in 2006 to the emergency ward with priapism lasting for about 15 hours. Clinical interview did not reveal previous events of priapism, substance abuse, or genital trauma. His clinical history contained an episode of a deep vein thrombosis, followed by a pulmonary embolism, at the age of 21 years. He was treated since then with antivitamin K anticoagulant medication (acenocoumarol). The underlying etiology of this thrombotic event had never been determined. Other than priapism, findings of physical examination, blood sample, and toxicologic analyses were within normal limits. Anticoagulant therapy resulted in an international normalized ratio (INR) of 3.8, which was higher than the reference range (0.8–1.2). Screening for psychoactive drugs and urine toxicology was negative. Antidepressants had not been screened. Aspirated blood from the corpus cavernosum was submitted for blood gas testing and was consistent with an ischemic priapism. After a successful Winter shunting, a complete remission of priapism was obtained and the patient was discharged within 3 days. Unfortunately, the patient did not mention, at first anamnesis, a recent introduction of trazodone in his medical treatment for a complaint of disordered sleep by a psychiatrist. The patient did not show up for a follow-up visit, but instead he was readmitted 10 days later for recurrent priapism lasting for 4 hours. This time, clinical interview revealed the introduction of trazodone 150 mg/d (at bedtime) by a psychiatrist 3 weeks ago for a sleep disorder complaint. The patient also admitted that he did take 300 mg instead of 150 mg several times during this period. Psychiatric diagnosis given by the treating physician was (1) dyssomnia not otherwise specified on Axis 1 and (2) personality disorder not otherwise specified on Axis 2, according to DSM-IV criteria. Blood tests revealed no abnormalities with the exception of an INR at 12 (verified on 2 different blood samples). Despite a new shunting, an incision of the corpus cavernous and spongious, and anticoagulant therapy with an INR at 12, the patient had an unfavorable outcome with persistent thrombosis. Forty-eight hours later, a dry necrosis of the glans appeared. After 3 weeks of conservative treatment, amputation of the penis with perineostomy had to be realized (Figure 1). Figure 1 (Left) Dry Necrosis of the Penis and Scrotum, (Middle) Per-Operative Procedure, and (Right) Final Perineostomy (pictures from the recurrent episode only) Although the present case combined several risk factors with a history of deep venous thrombosis and a genotype investigation that showed a heterozygote mutation R506Q for the Leiden V factor, we cannot explain a thrombosis with an INR at 12 and normal levels of antithrombin III and proteins C and S. Moreover, no episode of priapism occurred prior to the introduction of trazodone in this patient. Prescription of antidepressants and probably of trazodone in particular should be carefully administered and closely monitored in patients with history of coagulopathy or clotting disorders.

Impact of high titre of antiphospholipid antibodies on postoperative outcome following pulmonary endarterectomy☆

Antiphospholipid (a-PL) antibodies, especially IgG isotype, have been associated with a variety of neurological manifestations related to thrombotic mechanism and reactivity against nervous tissues. Furthermore, high titre of a-PL antibodies has been also correlated to chronic thromboembolic pulmonary hypertension (CTEPH) and, therefore, is frequently reported in patients undergoing pulmonary endarterectomy (PEA). The impact of a-PL antibodies in postoperative outcome following PEA, however, has not been clearly evaluated yet. In this paper, we investigated the impact of a high a-PL IgG titre (HAPT) on postoperative outcome following PEA. From April 1994 to October 2008, out of 204 patients undergoing PEA at our centre, 184 were prospectively screened for a-PL antibodies. According to the preoperative IgG titre, patients were divided into two groups: Group A (high a-PL antibodies titre - HAPT) with a-PL IgG titre >10 U/ml and Group B (low a-PL antibodies titre - LAPT) with a-PL IgG titre <or=10 U/ml. Early outcomes were compared between the two groups. Twenty-eight patients (15%) were included in Group A, whereas 156 (85%) patients were included in Group B. HAPT influenced preoperative parameters as patients of Group A were younger compared to those of Group B (42+/-16 and 52+/-16 for Group A and B, respectively, P=0.001) and presented more frequently a previous history of deep venous thrombosis (DVT) (96% and 62% for Group A and B, respectively, P=0.001). The two groups were homogeneous for all other operative parameters. As far as postoperative outcome, in terms of mortality and major complications, there were no differences between the two groups. Incidence of transient neurological complications, however, was significantly different (32% and 10% for Group A and B, respectively, P=0.023). The presence of high titre of IgG isotype a-PL antibodies significantly influences preoperative characteristics of patients undergoing PEA. Furthermore, despite that no significant differences were shown in major end points, the presence of high titre of a-PL did interfere with postoperative course as caused by an increased rate of minor and transient neurological impairment (TNI). An accurate monitoring especially during hypothermic circulatory arrest (CA) period seems, therefore, mandatory in this subgroup of patients undergoing PEA.

Superficial Venous Thrombosis and Venous Thromboembolism

Superficial venous thrombosis (SVT) is perceived to have a benign prognosis. To assess the prevalence of venous thromboembolism in patients with SVT and to determine the 3-month incidence of thromboembolic complications. National cross-sectional and prospective epidemiologic cohort study. (ClinicalTrials.gov registration number: NCT00818688) French office- and hospital-based vascular medicine specialists. 844 consecutive patients with symptomatic SVT of the lower limbs that was at least 5 cm on compression ultrasonography. Incidence of venous thromboembolism and extension or recurrence of SVT in patients with isolated SVT at presentation. Among 844 patients with SVT at inclusion (median age, 65 years; 547 women), 210 (24.9%) also had deep venous thrombosis (DVT) or symptomatic pulmonary embolism. Among 600 patients without DVT or pulmonary embolism at inclusion who were eligible for 3-month follow-up, 58 (10.2%) developed thromboembolic complications at 3 months (pulmonary embolism, 3 [0.5%]; DVT, 15 [2.8%]; extension of SVT, 18 [3.3%]; and recurrence of SVT, 10 [1.9%]), despite 540 patients (90.5%) having received anticoagulants. Risk factors for complications at 3 months were male sex, history of DVT or pulmonary embolism, previous cancer, and absence of varicose veins. The findings are from a specialist referral setting, and the study was terminated before the target patient population was reached because of slow recruitment. A substantial number of patients with SVT exhibit venous thromboembolism at presentation, and some that do not can develop this complication in the subsequent 3 months. GlaxoSmithKline, sanofi-aventis, and the Ministère Francais de la Santé et des Sports (Programme Hospitalier de Recherche Clinique).

Case 37-2009

A 46-year-old woman with chronic kidney disease and a history of deep venous thrombosis presented with swelling of the leg and skin changes. Thickening and erythema of the skin of both legs developed, leading to difficulty walking, sitting, and bending.

Hereditary Spherocytosis (HS) Associated with a Heterozygous MTHFR C677T Mutation and with Elevated Anticardiolipin Antibodies.

Abstract 5069 BackgroundHereditary spherocytosis (HS) is a spectrum of inherited erythrocyte membrane defects that result in hemolysis and varying degrees of anemia, usually not associated with increased thrombotic risk. However, there is some concern about post-splenectomy thrombocytosis, since both arterial and venous thromboembolic events have been reported in patients splenectomized for HS.A review of the medical literature revealed only a few cases of thrombosis associated with pregnancy and hereditary spherocytosis, and none of them had methyl tetrahydrofolate reductase (MTHFR) mutations or the presence of elevated anticardiolipin antibodies (both considered risk factors for thromboembolic disease). MethodsCase report ResultsA 34-year-old Caucasian female with history of hereditary spherocytosis and splenectomy at age five, underwent evaluation for infertility. The patient was found to have a high titer of anticardiolipin antibodies and the presence of heterozygosity for the MTHFR C677T mutation. She denied any personal or family history of deep venous thrombosis. Subsequently the patient became pregnant. Because the combination of thrombophilic states appears to increase the risk of thromboembolic events, it was decided to start the patient prophyllactically with oral aspirin 81 mg daily, Foltx® (Folic acid 2.5 mg, cyanocobalamin 2000 mcg, and pyridoxine hydrochloride 25 mg), and heparin 5000 mg subcutaneously twice a day. On her most recent evaluation, at 26 weeks of pregnancy, no medical or obstetric problems have been observed. ConclusionOur case illustrates an unusual combination of thrombophilic states. Further studies are needed to evaluate the clinical significance of this association. DisclosuresNo relevant conflicts of interest to declare.

Post-Thrombotic Syndrome Affecting the Upper Venous System in Children: Validation of Outcome Measurement and Application in a Single-Institutional Prospective Inception Cohort Study.

Abstract 2979Poster Board II-952▪▪This icon denotes an abstract that is clinically relevant. BACKGROUND AND OBJECTIVES:Post-thrombotic syndrome (PTS) is an important long-term sequela of deep venous thrombosis (DVT) in children, which may involve the upper or lower venous systems (UVS, LVS). The understanding of pediatric PTS has been limited by variability in outcome measurement, and prospective data are particularly lacking for DVT involving the UVS. Validation data have been published for the performance of a pediatric PTS outcome measure (the Manco-Johnson instrument; Figure 1) in the LVS (Goldenberg et al., Blood 2007).The aims of the present work were to: (1) investigate validity of the Manco-Johnson instrument in the UVS in children, via a cross-sectional derivation cohort/validation cohort design; and (2) preliminarily determine the cumulative incidence of PTS in a prospective inception cohort study of children with DVT affecting the UVS.METHODS AND RESULTS: Validation study:All parameters of the Manco-Johnson instrument were assessed in a derivation cohort (n=78) consisting of healthy children aged 12 months to 21 years who were without personal or first-degree family history of thromboembolism before age 55 years, grouped by age as follows: preschool (12 mo – <6 y; n=30); school age (6 - <13 y, n=28); adolescent (13 – 21 y, n=20). Inter-rater reliability in each parameter of the instrument was evaluated in a mixed validation cohort (n=41) of healthy children and patients with history of DVT affecting the UVS. In the derivation cohort, the upper limit of normal values for contralateral difference in upper limb circumference was 1.0 cm for mid-forearm and mid-upper arm measurements, as calculated by the non-parametric method of Tukey. In addition, dilated superficial collateral veins, venous stasis dermatitis, venous stasis ulcers, and chronic pain of the upper limb, chest or neck that limits activities of daily living or aerobic exercise were all absent among these healthy children. Inter-rater reliability, measured as percent agreement, exceeded 95% for all parameters when applied in the validation cohort by mutually-blinded dual examiners trained in the use of the instrument. Prospective inception cohort study:Inclusion criteria consisted of radiologically confirmed DVT of the subclavian vein, brachiocephalic vein, and/or superior vena cava (SVC), and study enrollment between March 2006 and July 2009. All children underwent comprehensive thrombophilia testing and were managed with anticoagulation in accordance with ACCP pediatric guidelines, for a minimum duration of 3 months. In some cases, acute thrombolytic therapy was instituted based upon clinical decisions. Children were evaluated for PTS using the Manco-Johnson instrument at 3-6 months, 12 months, and annually thereafter in long-term follow-up. Repeat imaging was performed at minimum at 3-6 months post-diagnosis, and if persistent, again at 1 year. Prevalence of PTS was analyzed based upon findings at latest follow-up (minimum 1 year post-diagnosis). Individual patient data on diagnostic findings, treatment, thrombus resolution, and PTS outcome are given in Table 1. Among 13 subjects meeting eligibility criteria, median age at DVT diagnosis was 16 years (range: 2 - 21 years). The SVC was involved in one child. Clinical predisposition consisted of central venous catheterization in approximately 50% of cases and an underlying anatomic vascular abnormality (thoracic outlet syndrome, Paget-Schroetter syndrome) in an additional 23%. Thrombophilia at presentation consisted of elevated factor VIII in 70% and antiphospholipid antibodies in nearly 50%. Thrombolysis was employed in the 2 children with anatomic defects and one with catastrophic antiphospholipid antibody syndrome. DVT persisted following a 3-6 course of anticoagulant therapy in 50% of evaluable patients. The cumulative incidence of PTS at 1-2 years among 7 evaluable patients was 29%, and involved both physical findings and functional impairment (i.e., chronic pain limitation) in each case. CONCLUSIONS:The present findings demonstrate the validity of the Manco-Johnson instrument for pediatric PTS outcome measurement involving the UVS. Using this instrument, PTS appears to be common in children with DVT affecting the UVS, and functionally significant. Broader use of the Manco-Johnson instrument for PTS outcome assessment in prospective studies and clinical trials of pediatric DVT is warranted. [Display omitted] [Display omitted] Disclosures:Off Label Use: The presentation refers to the use of anticoagulants as a drug class in general in the treatment of venous thromboembolism (VTE) in children. Despite their use in the standard care for pediatric VTE, all anticoagulants remain off-label for this indication in children.

Prothrombin gene G20210A mutation in acute deep venous thrombosis patients with poor response to warfarin therapy.

Aim:The pathogenesis of deep venous thrombosis (DVT) involves an interaction between hereditary and acquired factors. Prothrombin gene mutation is one of the hereditary risk factors. We evaluated the frequency of the prothrombin gene mutation in patients with DVT and its relation to oral warfarin anticoagulant therapy response.Methods:Prothrombin gene mutation was looked for in 40 DVT patients with poor response to warfarin. The results were compared with 40 DVT patients with a normal response to warfarin and 30 healthy blood donors. Blood samples were also assessed for protein C, protein S, anti-thrombin III and anticardiolipin antibodies (ACA) levels.Results:Prothrombin gene mutation was found in normal and poor DVT responders (6/40 and 13/40, respectively; p = NS) as well as in healthy controls (1/30). Patients with recurrent DVT or a family history of DVT were significantly (p<0.0001) more likely to have the prothrombin mutation than other DVT patients. Non prothrombin abnormalities (protein C, anti-thrombin III and ACA) were more common in poor responders than controls (p<0.0037) as were ACA (p<0.034).Conclusions:Prothrombin gene mutation is present in several DVT patients, especially those with recurrent DVT or a family history of DVT. This mutation may contribute to a poor response to warfarin.

Pericardial Calcification Noted Long after Sydenham's Chorea

A 76-year-old native Dutch woman was admitted to our intensive care unit for hemodynamic monitoring after undergoing vulvectomy and inguinal lymph-node dissection for vulvar carcinoma. Preoperative evaluation had revealed a history of deep venous thrombosis, type 2 diabetes mellitus, and atrial fibrillation, with a slightly reduced tolerance for exercise (New York Heart Association functional class II) and peripheral edema. There was no known history of mitral-valve disease and no murmur on examination. Previous cataract surgery and drainage of a subdural hematoma had been performed with no complications. Two chest radiographs (Panels A and B) and a computed tomographic scan (Panel . . .

Chronic thrombotic scarring in patients with acute deep venous thrombosis of the lower limbs

Some patients with acute deep venous thrombosis of the lower limbs may present risk factors for recurrent disease. Aims: To analyze the most important conditions related to recurrent deep venous thrombosis of the lower limbs, other than thrombophilias. Patients and methods: We examined 88 consecutive patients (47 males-53.41%, average age 64.9±13.9 years) admitted to a Medical Clinic in 2007. Duplex ultrasonography was performed to assess acute deep venous thrombosis and post-thrombotic syndrome. Anamnesis and physical examination were used to detect risk factors for recurrent disease. The 28 subjects with acute deep venous thrombosis and post-thrombotic syndrome were included in group A (31.82%). Group B comprised 60 patients (68.18%) with acute deep venous thrombosis without postthrombotic syndrome. Results: Risk factors for recurrent disease in groups A and B were the following: personal history of deep venous thrombosis of the lower limbs (17 subjects versus 7, p<0.0001), varicose veins (14 vs 24, p=0.51), obesity (13 vs 18, p=0.21), malignancy (6 vs 8, p=0.25), chronic obstructive lung disease (5 vs 6, p=0.24), prolonged immobilization (1 vs 7, p=0.21), major surgery (1 vs 1, p=0.54), stroke (0 vs 3, p=0.62), family history of deep venous thrombosis, immobilizing plaster cast, and congestive heart failure (0 vs 1, p=0.54). Location of thrombi in patients in groups A and B was as follows: 18 patients in group A vs 25 subjects in group B on the left side and 13 patients in group A vs 20 patients in group B on the right side (p=0.02). Conclusion: Post-thrombotic syndrome correlated with personal history of deep venous thrombosis and previous deep venous thrombosis located in the left lower limb.

Endovascular Management of Chronic Disabling Ilio-caval Obstructive Lesions: Long-Term Results

Objective: To report the long-term results of stenting for chronic ilio-caval obstructive lesions. Material and methods: From January 1996 to January 2008, 89 patients (72 women, 17 men; median age 43 years) were admitted for endovascular treatment of chronic disabling non-malignant obstructive ilio-caval lesions. Patients were classified as C2 in 15 cases, C3 in 59, C4 in seven, C5 in two and C6 in six. Median preoperative venous disability score (VDS) and venous clinical severity score (VCSS) were 2 and 9, respectively. Aetiology was primary in 52 patients, secondary in 35 and congenital in two. Lesions were bilateral in seven cases, eight patients had inferior vena cava (IVC) involvement and 18 had common femoral vein (CFV) obstructive lesions. Complete occlusion was found in 30 cases. Results: Technical success was achieved in 98%. The median hospital stay was 2 days. During a median follow-up of 38 months (range: 1–144 months), one patient died and five cases of thromboses occurred. Iterative stenting was performed for restenosis in six cases. Primary, assisted-primary and secondary patency rates, in terms of intention to treat, were 83%, 89% and 93%, respectively, at 3 and 10 years, with a median VDS of 1. Univariate analysis found that significant factors affecting patency were CFV involvement for primary patency and history of deep venous thrombosis (DVT) and CFV involvement for secondary patency. The last 46 patients had statistically more severe lesions than the first 43 (higher VDS, more secondary lesions, more occlusions, more stented segments, higher length of stented vein), and in spite of which patency rates are not different. Conclusion: Endovenous angioplasty, combined with stenting, is a sure, safe, effective and very minimally invasive technique which provides good long-term patency rates. Currently, it is recognised as the technique of choice for the treatment of ilio-caval obstructive lesions. Surgery should be proposed only in case of failure.

Aortic Valve Vegetation Without Endocarditis

We present a 30-year-old man with an acute middle cerebral artery territory infarction. A transesophageal echocardiogram showed a large, highly mobile mass attached to the patient's aortic valve. We discuss the differential diagnosis of a cardiac mass that includes infection, tumor, and thrombus. A complete workup showed no evidence of systemic infection but did reveal the presence of antiphospholipid antibodies. The patient also had a history of a right lower extremity deep venous thrombosis. Anticoagulation therapy was started, and follow-up showed complete resolution of the aortic valve lesion. This case highlights that when a valvular vegetation is encountered in a clinical setting that does not suggest infectious endocarditis, the diagnosis of antiphospholipid antibody syndrome should be considered. This case and our review of the literature suggest that vegetations in antiphospholipid antibody syndrome, no matter how large and ominous in appearance, can be treated successfully with anticoagulation and vigilant observation.

Endovascular Management of Chronic Disabling Ilio-caval Obstructive Lesions: Long-Term Results

To report the long-term results of stenting for chronic ilio-caval obstructive lesions. From January 1996 to January 2008, 89 patients (72 women, 17 men; median age 43 years) were admitted for endovascular treatment of chronic disabling non-malignant obstructive ilio-caval lesions. Patients were classified as C2 in 15 cases, C3 in 59, C4 in seven, C5 in two and C6 in six. Median preoperative venous disability score (VDS) and venous clinical severity score (VCSS) were 2 and 9, respectively. Aetiology was primary in 52 patients, secondary in 35 and congenital in two. Lesions were bilateral in seven cases, eight patients had inferior vena cava (IVC) involvement and 18 had common femoral vein (CFV) obstructive lesions. Complete occlusion was found in 30 cases. Technical success was achieved in 98%. The median hospital stay was 2 days. During a median follow-up of 38 months (range: 1-144 months), one patient died and five cases of thromboses occurred. Iterative stenting was performed for restenosis in six cases. Primary, assisted-primary and secondary patency rates, in terms of intention to treat, were 83%, 89% and 93%, respectively, at 3 and 10 years, with a median VDS of 1. Univariate analysis found that significant factors affecting patency were CFV involvement for primary patency and history of deep venous thrombosis (DVT) and CFV involvement for secondary patency. The last 46 patients had statistically more severe lesions than the first 43 (higher VDS, more secondary lesions, more occlusions, more stented segments, higher length of stented vein), and in spite of which patency rates are not different. Endovenous angioplasty, combined with stenting, is a sure, safe, effective and very minimally invasive technique which provides good long-term patency rates. Currently, it is recognised as the technique of choice for the treatment of ilio-caval obstructive lesions. Surgery should be proposed only in case of failure.

The safety of radiofrequency ablation of the great saphenous vein in patients with previous venous thrombosis

The safety of radiofrequency ablation (RFA) of the great saphenous vein (GSV) in patients with previous history of deep venous thrombosis (DVT) has not been determined. From April 2003 to June 2006, 274 patients (68% women; mean age, 60 years +/- 15 years) underwent 293 consecutive RFA procedures. In the first 15 months, the temperature probe was maintained at 85 degrees C, with a pullback rate of 2 cm/min (85 limbs, 30%); we subsequently changed the protocol to 90 degrees C and a pullback rate of 2 to 3 cm/min (205 limbs, 70%). We identified 29 patients (10%) with a history of DVT or duplex scan evidence of post-thrombotic venous disease; these were compared with the remaining 264 (90%). Postprocedural acute thrombotic (AT) events were analyzed. By the CEAP classification, 204 limbs (70%) were C(2) to C(4), and 89 (30%) were C(5) to C(6). Thirty-seven patients (13%) had a history of superficial thrombophlebitis (SVT). Proximal mean GSV diameter was 0.95 +/- 0.29 cm (range, 0.4-2.3 cm). Concomitant procedures included avulsion phlebectomy in 88 limbs (30%) and perforator vein surgery in 4 (1%). AT events after RFA were detected in 38 limbs (13%), including thrombus protrusion into the sapheno-femoral junction (SFJ) in 24 (8%), common femoral vein in 7 (2.5%), and calf vein DVT in 7 (2.5%). Overall incidence of AT events in limbs with and without evidence of previous DVT was 7% (2 of 29) and 14% (36 of 264), respectively (P = .36). Variables significantly associated with AT events were previous SVT (10 of 37 [27%] vs 28 of 256 [11%], P = .01), a larger GSV diameter (mean 1.1 +/- .39 vs 0.93 +/- 0.27, P < .01), and first protocol (catheter temperature of 85 degrees C with a slower pullback rate in 18 of 88 [20%] vs 20 of 205 [9.7%], P = .02). Concomitant venous operations were associated with an increase in AT events (23% vs 9%; P < .002). By multivariate analysis, larger proximal GSV diameter and previous SVT remained independently statistically significant (P = .049 and P = .0135, respectively). All AT patients were successfully treated with standard anticoagulation. No pulmonary emboli occurred. RFA of the GSV in patients with previous venous thromboembolic events is safe and should be offered as an alternative to surgical procedures. These data demonstrate that AT events increase when larger-diameter GSVs are treated.

Quelle thromboprophylaxie après transplantation rénale ? Enquête sur la prévention des thromboses du greffon en France

Graft thrombosis is a major complication of transplantation. However, there are no recommendation on immediate postoperative thromboprophylaxis after kidney transplantation. We recorded clinical practices in France. In 29 transplantation centres, four case studies were submitted to the medical kidney transplantation referent (compatible graft from cadaveric donor, without perioperative complication). N(o) 1: Man, 27-years-old, IgA glomerulonephritis, without history of hypercoagulability or cardiovascular risk factor. Hemodialysis since 12months. N(o) 2: Man, 53-years-old, with history of deep venous thrombosis after cholecystectomy 15years before. Membranous nephropathy. Hemodialysis since 10months. N(o) 3: Man, 58-years-old, with history of myocardial infarction. On aspirin therapy. Nephroangiosclerosis and diabetic nephropathy. Peritoneal dialysis since 6months. N(o) 4: Woman, 63-years-old. Atrial fibrillation on vitamin K antagonists therapy. Lupus nephritis without antiphospholipid syndrome. Hemodialysis since 12months. N(o) 1: No anticoagulation therapy (62%), calcium heparin at prophylactic doses (34.5%). N(o) 2: No anticoagulation therapy (38%), calcium heparin at prophylactic doses (44.8%). N(o) 3: 62% interrupted aspirin of whom 22% without any immediate anticoagulation and 55% replaced aspirin with calcium heparin at prophylactic doses. Thirty-eight percent carried on with aspirin of whom 63.6% without other prophylaxis and 27.3% in association with calcium heparin at prophylactic doses. N(o) 4: Unfractionned heparin at curative dose (62%), unfractionned heparin at prophylactic doses (17.2%), calcium heparin at prophylactic doses (13.8%). Postoperative anticoagulation after renal transplantation is established as a local dogma rather than evidence-based medicine. Guideline recommendations and standardized protocols for the use of anticoagulation after kidney transplantation should be developed.

Epidemiology of deep venous thrombosis during pregnancy and puerperium in Sudanese women

Deep venous thrombosis (DVT) and venous thromboembolism (VTE) is a major health problem with high mortality worldwide. Patients at risk must be identified and given appropriate prophylaxis in order to decrease the mortality. To investigate the prevalence of DVT in pregnancy and the puerperium and to identify risk factors for DVT. Khartoum and Khartoum North Teaching hospitals, Sudan. Case-control study. During the study period (April 2007-March 2008), 65 patients presented with DVT as confirmed by Doppler ultrasound. A total of 14,490 deliveries occurred during the study period. The rate was 448 DVT per 100,000 births/year. Only four of these 65 patients were pregnant and the rest presented at postpartum. DVT occurred in the left lower extremity in 51 (78.4%), in the right in 13 (20.0%), and in one (1.5%) woman in both legs. In univarite and multivariate analyses, family history of DVT, primigravidae and cesarean section deliveries showed an higher risk of DVT. The study showed a high prevalence of DVT, most of these events occurred in the postpartum period. Primiparae, family history of DVT and cesarean section deliveries were important risk factors and these groups are candidate for prophylaxis measures against DVT.

Thrombophilias in adolescents: the past, present and future

In the past 10 years, clinicians have become more suspect regarding thromboembolic events and potential thrombosis in children at risk. Although adolescents are not typically considered to be a high-risk group, they are the main seekers of contraception in our society today, thereby placing them at some risk due to exogenous estrogen administration. Certain thrombophilic states increase the risk of thromboembolism significantly. Because estrogen-containing hormonal contraceptives also increase the risk of thrombosis, inherited thrombophilias are a contraindication to the use of these contraceptives. Current guidelines support laboratory screening for inherited and acquired thrombophilias when personal history of deep venous thrombosis exists, unexplained spontaneous thrombosis occurs, recurrent thrombosis arises, there is a family history of thrombosis, or thrombosis in unusual sites, such as central nervous system, abdominal veins or upper limbs. Prophylactic anticoagulation is not necessary in the setting of certain thrombophilias; however, consultation with a hematologist may be helpful when making decisions on acute and long-term management of these patients. Although some thrombophilic conditions are a contraindication to combined hormonal contraception, not all thrombophilias maintain the same level of risk. Routine history-taking to assess the risk of an inherited thrombophilia on the basis of family history is important prior to prescribing oral contraceptives and should be documented in a patient's chart. Laboratory screening is recommended in specific risk scenarios; however, routine screening is not presently recommended prior to oral contraceptive initiation.

Superficial femoral artery thrombosis as a cause for distal embolism in primary antiphospholipid syndrome

Antiphospholipid syndrome is a diagnosis with the clinical manifestations of thromboses in the presence of an antiphospholipid antibody. A 25-year-old man with a history of deep venous thrombosis, pulmonary emboli, and myocardial infarction, and receiving long-term anticoagulation with warfarin, all due to primary antiphospholipid syndrome, presented with blue toe syndrome from a primary superficial femoral artery thrombus. He was anticoagulated with fondaparinux in addition to dipyridamole and aspirin perioperatively. The area of thrombus was resected and reconstructed using a cephalic vein interposition graft. This report reviews antiphospholipid syndrome and identifies potential questions and problems relating to a rare clinical presentation.

A Novel Approach to Resection of a Vaginal Septum

Background: We describe the resection of a vaginal septum using the Harmonic Scalpel®. The innovative method was utilized in order to minimize blood loss and operative time in a patient with a history of deep venous thrombosis and anti-thrombin III deficiency on thromboprophylactic doses of low molecular weight heparin.

Little Differences in Outcomes Between Sexes Using a Contemporary Total Knee System

We reviewed 1252 patients during a 5-year period undergoing TKA at a single center. Surgeries were done under regional anesthesia whenever possible. Patients with previous anticoagulation use or a history of deep venous thrombosis (DVT) or pulmonary embolism (PE) were excluded, but all others received the after anticoagulation protocol: shortened tourniquet times, early ambulation, TED stockings, SCDs and Aspirin 325 mg BID daily and for 6 weeks postoperative. Patients were only studied if they were clinically suspicious for DVT or PE. Sixteen such patients were studied. Two patients had superficial clots below the trifurcation. There were no proximal DVTs identified and no clinically evident PEs. No wound healing problems or hematomas required treatment. Gastritis developed in 2 patients who were treated with antacids. We concluded that aspirin, in addition to the aforementioned protocol, could provide adequate thromboprophylaxis among low-risk patients undergoing TKA.

Late results of surgical venous thrombectomy with iliocaval stenting

Iliac vein occlusive disease leads to 73% of rethrombosis that occurs after venous thrombectomy when left untreated. The goal of this study is to present our long-term results of stenting of iliocaval occlusive lesions persisting after surgical venous thrombectomy. From November 1995 to April 2007, 29 patients (19 women), with a median age of 38 years, had surgical venous thrombectomy with creation of an arteriovenous fistula and angioplasty and stenting. All were admitted for acute (<10 days) deep venous thrombosis (DVT) involving the iliocaval segment, of which eight had concomitant acute pulmonary embolism. Six patients had a history of DVT (2 with previous venous thrombectomy), two were pregnant, and three had postpartum DVT. No patients had short- or mid-term life-threatening factors. The underlying lesion was left iliocaval compression (May-Thurner syndrome) in 22 patients, chronic left common iliac vein occlusion in 3, residual clot in 3, and compression of the left external iliac vein by the left internal iliac artery in 1. Neither perioperative death nor pulmonary embolism occurred. Four early complications occurred after stenting (13.8%). Median hospital length of stay was 8 days (range, 5-22 days). Median follow-up was 63 months (range, 2-137 months). Three late complications occurred (10.3 %): one rethrombosis due to stent crushing during pregnancy and two restenosis, which were treated by iterative stenting. At the end of the follow-up, the median venous clinical severity score was 3 (range 1-12) and the venous disability score was 1 (range 0-2). Primary, assisted primary and secondary patency rates were, respectively, 79%, 86%, and 86% at 12, 60, and 120 months. Patients with patent iliocaval segments had significantly fewer infrainguinal obstructive lesions (4% vs 50%) and a higher rate of valvular competence (76% vs 0%) than those who experienced rethrombosis. Venous scores were also worse in patients with rethrombosis. Stenting is a safe, efficient, and durable technique to treat occlusive iliocaval disease after venous thrombectomy. Its use can prevent most of the rethrombosis that occurs after venous thrombectomy without major adverse effects.