Idiopathic Deep Vein Thrombosis Research Articles

“Role of D-Dimer in One Year Recurrence of Venous Thromboembolism after Completed Anticoagulation Treatment” Following A First Idiopathic Deep Vein Thrombosis

After oral anticoagulant therapy (OAT) withdrawal, the recurrence of risk is greatest in the first year and gradually diminishes, while the increased bleeding risk may offset the benefits of prolonged OAT. the benefits of extending anticoagulation should be balanced against the risk of bleeding . D-dimer assay and measurement of residual thrombosis on ultrasonography, so-called residual vein obstruction (RVO) were proposed to be effec- tive in selecting patients with idiopathic DVT Materials and methods: This single center prospective study was conducted in patients with a first episode of symptomatic proximal DVT, de - tected by compression ultrasonography (CUS), and who received OAT for at least 3 months. Follow-up was extended from Oct. 2011, to Aug. 2013. After enrollment, patients were re-evaluated at 1st, 6th and 12th months of their follow-up. At the first and 30-day visits, venous blood samples were taken for D-dimer test. All enrolled patients without RVT were stopped OAT. At each follow-up visit, we examined patients and inquired about health status, clinical symptoms or signs of recurrent VTE, bleeding, post-throm- botic manifestations, adherence to treatment, and concomitant analgesic or anti-inflammatory therapy. The end point outcomes were VTE recurrence or complete of this survey follow-ups. Results: A total of 68 eligible patients were enrolled. Four patients (two patients need to using long-term oral anticoagulation, and another two patients for lost to their first follow-up) were excluded. D-dimer and CUS at first was normal in 28 patients (44%) while the remaining 36 patients had abnormal D-dimer but normal CUS while both groups were not consuming their anticoagulant. Total follow-up was 52.5 patient-years. Median follow-up was 11 months (95% CI: 6-17 months). A minimum follow-up of 12 months was avail- able in 44 patients (68%). During follow-up, three recurrent events were recorded (4.6% of patients - 95% CI: 3-7%). All Recurrent events were ipsilateral DVT. Among these index cases, all had an abnormal D-dimer at either T0 and/or T1. The recurrence rate was higher in males than in females (8.6% vs. 2.2%) with an abnormal D-dimer at T0 and/or T1 with a multivariate hazard ratio of 2.1 (95% 1.2-7; p=0.04). Patients older than 65 years had a higher rate of events than younger patients (2/ 12: (16%); 95% CI: 4-24% Vs. 1/ 52: (2%); 95% CI: 0.05-3%) and hazard ratio was about 3.8; (95% CI: 1.95-8.4 p= 0.04). Patients with recurrences had higher mean D-dimer at both T0 and T1 when compared with those without recurrences but the difference was significant only for D-dimer at T1. During follow-up, two patients died (3%). Conclusion: In our cohort of DVT patients, the annual risk of recurrence with an abnormal D-dimer, either during or at one month after VKA withdrawal, was 4.6% which is much lower to the annual risk of recurrence in most studies with idiopathic and provoked VTE. The benefits of extending anticoagulation should be balanced against the risk of bleeding. So according to these results of D-Dimer assay before withdrawal of OAT, this test is helpful for OAT withdrawal decision making.

The diagnosis and treatment of venous thromboembolism

Venous thromboembolism (VTE) is a common condition that can lead to complications such as postphlebitic syndrome, chronic pulmonary artery hypertension, and death. The approach to the diagnosis of has evolved over the years and an algorithm strategy combining pretest probability, D-dimer testing, and diagnostic imaging now allows for safe, convenient, and cost-effective investigation of patients. Patients with low pretest probability and a negative D-dimer can have VTE excluded without the need for imaging. The mainstay of treatment of VTE is anticoagulation, whereas interventions such as thrombolysis and inferior vena cava filters are reserved for special situations. Low-molecular-weight heparin has allowed for outpatient management of most patients with deep vein thrombosis at a considerable cost savings to the health care system. Patients with malignancy-associated VTE benefit from decreased recurrent rates if treated with long-term low-molecular-weight heparin. The development of new oral anticoagulants further simplifies treatment. The duration of anticoagulation is primarily influenced by underlying cause of the VTE (whether provoked or not) and consideration of the risk for major hemorrhage. Testing for genetic and acquired thrombophilia may provide insight as to the cause of a first idiopathic deep vein thrombosis, but the evidence linking most thrombophilias to an increased risk of recurrent thrombosis is limited.

Agenesis of the infrarenal inferior vena cava

A 71-year-old man presented to the emergency room with complaints of progressive dyspnoe and pain in both lower extremities. His medical history consisted of multiple idiopathic deep vein thrombosis, familial deafness and cholecystolithiasis. Clinical examination revealed large varicose veins in both lower extremities. A following electrocardiogram, echocardiography and radio graphy of the thorax were normal (not shown). D-dimeren had risen for which an angio CT of the thorax was performed. This showed no pulmonary embolism (not shown). A venous duplex of the lower extremities revealed insufficiency of both the superficial and deep venous system (not shown). An abdominal CT with intravenous contrast injection showed absence of the infrarenal inferior vena cava (Fig. A), absence of the common iliac veins, enlarged ascending lumbar veins (Fig. B) and prominent anterior paravertebral collateral veins (Fig. C) which lead to a prominent azygos vein (Fig. C). A complex venous collateral circulation was found infrarenally (Fig. A) as well as in the abdominal wall (Fig. D). The suprarenal IVC was normal (Fig. E), formed by confluence of the renal veins. Multiple calcifications in the enlarged internal and external iliac veins confirm a history of deep vein thrombosis (Fig. F).

The influence of factor V Leiden and G20210A prothrombin mutation on the presence of residual vein obstruction after idiopathic deep-vein thrombosis of the lower limbs

It was our aim to assess whether factor V Leiden (FVL) and G20210A prothrombin (FII) mutation are associated with the presence of residual vein obstruction (RVO) after a standard course of anticoagulation for a first episode of idiopathic proximal deep-vein thrombosis (DVT) of the lower limbs, with or without symptomatic pulmonary embolism (PE). Patients were enrolled in two prospective multicentre studies: PROLONG and PROLONG II. RVO was detected by compression ultrasonography according to the method of Prandoni on the day of anticoagulation withdrawal. Patients were also screened for FVL and FII mutation. The presence of FVL and/or FII mutation was determined in 872/963 (90.5%) patients, in 753 of whom RVO was assessed. FVL was significantly less frequent among subjects with isolated PE (7/176:4%) than among patients with either DVT and PE (15/133:11.3%; p=0.0018) or isolated DVT (89/563:15.8%; p<0.0001), confirming the FVL paradox. The rate of FII mutation was similar among patients with isolated PE (11/176:6.2%) and patients with either DVT and PE (12/133:9%) or isolated DVT (52/563:9.2%). FVL and FII mutation were not significantly associated with RVO at the multivariate analysis in all patients, although data suggest that FVL and FII mutation may have a differential effect on RVO in the subgroups of patients with DVT and DVT plus PE patients. Male sex and isolated DVT were significantly associated with RVO in all patients. In conclusion, male sex and isolated DVT are associated with RVO, while FVL and FII mutations are not significantly associated with RVO in this study.

Clinical profile and management of deep vein thrombosis of lower limb

Background: In India, the incidence of deep vein thrombosis (DVT) is not well highlighted and literature survey shows scanty works in this field. Most of the literature available in India is from the orthopaedic departments, overall incidence of DVT in general population is largely unknown. Materials and Methods: A 2 year prospective study to analyze the clinical profile and management of DVT of lower limb was conducted at Regional Institute of Medical Sciences, Imphal. Patients having limb pain, swelling with or without skin changes suspected of DVT were subjected to Doppler examination. Thirty-one patients with Positive test were admitted and treated with standard regimens of low molecular weight heparins (LMWH), oral warfarin, compressive stockings and supportive care. The risk factors, response to treatment, clinical course were documented using physical examination and relevant laboratory tests at regular intervals. The data was prospectively analyzed. Results: Majority of patients were less than 45 years old with no sex preponderance. No risk factors were identified in 45%, 26% had lower limb fractures, Seven percent were pregnancy related and cellulitis, electric burns, antecedent blunt Trauma, Systemic lupus erythematosis were observed in three percent of patients each. Ten percent of patients had history of immobilization due to medical illness. There was excellent response to LMWH in 93.54% of patients with two poorly responding patients requiring mechanical thrombectomy using Fogarty venous thrombectomy balloon catheter. No significant hemorrhagic complication or pulmonary embolism encountered clinically. No recurrent thrombosis or Malignancy noted during 6-16 months. Conclusion: Most of the DVTs are idiopathic and occur in less than 45 years age group. Irrespective of the etiology, LMWH and Warfarins are efficient, safety is well demonstrated, and domiciliary treatment is advisable with surveillance. Idiopathic DVTs require long term follow up to watch for recurrent thrombosis. Owing to small sample size the data cannot be extrapolated to general population to conclude the incidence. Further studies are necessary to stratify risks, and incidence in our Indian population.

Identification of genetic risk variants for deep vein thrombosis by multiplexed next-generation sequencing of 186 hemostatic/pro-inflammatory genes

BackgroundNext-generation DNA sequencing is opening new avenues for genetic association studies in common diseases that, like deep vein thrombosis (DVT), have a strong genetic predisposition still largely unexplained by currently identified risk variants. In order to develop sequencing and analytical pipelines for the application of next-generation sequencing to complex diseases, we conducted a pilot study sequencing the coding area of 186 hemostatic/proinflammatory genes in 10 Italian cases of idiopathic DVT and 12 healthy controls.ResultsA molecular-barcoding strategy was used to multiplex DNA target capture and sequencing, while retaining individual sequence information. Genomic libraries with barcode sequence-tags were pooled (in pools of 8 or 16 samples) and enriched for target DNA sequences. Sequencing was performed on ABI SOLiD-4 platforms. We produced > 12 gigabases of raw sequence data to sequence at high coverage (average: 42X) the 700-kilobase target area in 22 individuals. A total of 1876 high-quality genetic variants were identified (1778 single nucleotide substitutions and 98 insertions/deletions). Annotation on databases of genetic variation and human disease mutations revealed several novel, potentially deleterious mutations. We tested 576 common variants in a case-control association analysis, carrying the top-5 associations over to replication in up to 719 DVT cases and 719 controls. We also conducted an analysis of the burden of nonsynonymous variants in coagulation factor and anticoagulant genes. We found an excess of rare missense mutations in anticoagulant genes in DVT cases compared to controls and an association for a missense polymorphism of FGA (rs6050; p = 1.9 × 10-5, OR 1.45; 95% CI, 1.22-1.72; after replication in > 1400 individuals).ConclusionsWe implemented a barcode-based strategy to efficiently multiplex sequencing of hundreds of candidate genes in several individuals. In the relatively small dataset of our pilot study we were able to identify bona fide associations with DVT. Our study illustrates the potential of next-generation sequencing for the discovery of genetic variation predisposing to complex diseases.

Venous Thrombosis in Blacks

Case Presentation: A 42-year-old black woman is diagnosed with idiopathic (unprovoked) lower-extremity deep vein thrombosis (DVT) after presenting with leg swelling. She is treated with anticoagulation for 6 months without major complications and with stable international normalized ratios, and her lower-extremity symptoms completely resolve. She has sickle cell trait but no other chronic conditions. The patient's mother also had an idiopathic DVT at 53 years of age. Physical examination is notable only for obesity (body mass index 33 kg/m2) and absence of lower-extremity swelling, redness, and pain. D-dimer and follow-up lower-extremity Doppler ultrasound testing are negative. Testing for antiphospholipid antibodies was negative at the time the clot was diagnosed; further tests for thrombophilia have not been performed. She wants to know whether she should continue taking warfarin. In 2008, the US Surgeon General issued The Surgeon General's Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism , which highlighted the scope and impact of venous thromboembolism (VTE). In the United States alone, as many as 100 000 to 180 000 deaths occur annually due to DVT and pulmonary embolism (PE).1 Many of these events are preventable by implementation of standard prophylactic measures in certain high-risk populations (eg, hospitalized patients with reduced mobility); however, a large proportion of VTE events occur spontaneously, without clear inciting factors. Identification of novel risk factors for VTE might allow clinicians to better identify at-risk patients and modify both primary and secondary prevention strategies accordingly. The incidence of VTE depends on a complex interaction of inherited and environmental risk factors. The prevalence of inherited risk factors depends on the population being studied. To date, the genetics of VTE has been studied most frequently in patients with European …

HEEADSSS assessment for adolescents requiring anticoagulation therapy

The care of adolescents with complex chronic illness needs to be developmentally appropriate to encourage adherence, knowledge retention and self-management. There has been an increase in the number of adolescents...

Identification of DEEP Vein Thrombosis GENETIC RISK Variants by NEXT GENERATION Sequencing of Hemostatic Genes

Abstract 710Next-generation DNA sequencing is opening new avenues for genetic association studies in complex diseases that, like deep vein thrombosis (DVT), have a strong genetic basis only partially accounted for by currently identified risk variants. Using next-generation DNA sequencing, we resequenced the entire protein-coding area and intron-exon boundaries of ≈200 hemostatic/pro-inflammatory genes (including all coagulation factor and anticoagulant protein genes) in 26 Italian individuals with idiopathic DVT of the lower limbs and 28 age-, gender- and ethnicity-matched healthy controls.In order to enrich for genetic component, DVT patients were selected from a cohort of 730 cases of idiopathic DVT referred to the Angelo Bianchi Bonomi Hemophilia and Thrombosis Center (Milan, Italy) on the basis of the following criteria: (a) negative for anti-phospholipid autoantibodies, anticoagulant protein deficiencies, factor V Leiden and prothrombin G20210A, (b) age of onset <55 years. Genomic libraries with barcode sequence-tags were pooled (in pools of 8 or 16 samples) and enriched for target DNA sequences by capture on Roche NimbleGen HD2 2.1M-probe custom chips. Sequencing was performed on ABI SOLiD 4 platforms. After sequencing, reads with the barcodes were assigned to the corresponding sample and mapped to reference human genome, NCBI36/hg18, using BFAST software.We produced more than 18 gigabases of raw sequence data to sequence at high depth of coverage (>40X after duplicate read removal) the 700-kilobase target region. A total of 2351 single nucleotide variants (SNVs) and 121 short indels were identified. We developed a dedicated software in order to be able to run association analyses in our dataset using PLINK. A plain association analysis was used to compare the frequencies of common SNVs, whereas a gene-based analysis of restricted non-synonymous mutations was used to reveal potential associations of rare variants.Of 626 common SNVs tested for association, 32 SNVs from 13 genes were associated with p<0.01. These include 8 missense variants at 6 genes, 2 in genes already reported in association with DVT (FGA, ABO) and 6 in genes not previously reported (LPA, COL4A6, PLCG2 and KNG1). As a positive control we confirmed the association of rs6050 at FGA in ∼1400 Italian individuals (p=1.9 × 10−5, OR 1.45; 95% CI, 1.22–1.72). Replication of the other variants is ongoing. Gene-based analyses revealed an excess of private missense variants at anticoagulant protein genes (13 vs 3 variants; binomial probability, p=0.005) and at collagen 4 genes (14 vs 6 variants; binomial probability, p=0.02) in DVT cases compared to controls. We are currently expanding our investigations to 100 DVT cases and 100 controls.Although obtained in a relatively small number of patients and controls, our results illustrate the potential of next-generation sequencing for the discovery of genetic variation predisposing to complex diseases like DVT. Disclosures:No relevant conflicts of interest to declare.

Chest Radiography as a Method of Screening for Occult Cancer in Patients With Idiopathic Deep Vein Thrombosis

The occurrence of neoplasms in patients with idiopathic deep vein thrombosis (DVT) may result in a significant reduction in survival rates. The aim of our study was to assess the use of chest X-rays (CXRs) as a screening method of intrathoracic neoplasms in patients who with idiopathic DVT. In observational, cross-sectional study, the medical records of 99 patients with idiopathic DVT, who were submitted to CXR (during the hospital stay or within 30 days after discharge), were investigated. Of these patients, 15.1% had images suggestive of thoracic neoplasias (single or multiple pulmonary nodules and mediastinal widening). Neoplasms were diagnosed in 4 patients in the follow-up with CXR. The CXR is an option of early screening for thoracic neoplasms and other nonmalignant diseases in patients with idiopathic DVT.

Residual vein thrombosis for assessing duration of anticoagulation after unprovoked deep vein thrombosis of the lower limbs: The extended DACUS study

The safest duration of anticoagulation after idiopathic deep vein thrombosis (DVT) is unknown. We conducted a prospective study to assess the optimal duration of vitamin K antagonist (VKA) therapy considering the risk of recurrence of thrombosis according to residual vein thrombosis (RVT). Patients with a first unprovoked DVT were evaluated for the presence of RVT after 3 months of VKA administration; those without RVT suspended VKA, while those with RVT continued oral anticoagulation for up to 2 years. Recurrent thrombosis and/or bleeding events were recorded during treatment (RVT group) and 1 year after VKA withdrawal (both groups). Among 409 patients evaluated for unprovoked DVT, 33.2% (136 of 409 patients) did not have RVT and VKA was stopped. The remaining 273 (66.8%) patients with RVT received anticoagulants for an additional 21 months; during this period of treatment, recurrent venous thromboembolism and major bleeding occurred in 4.7% and 1.1% of patients, respectively. After VKA suspension, the rates of recurrent thrombotic events were 1.4% and 10.4% in the no-RVT and RVT groups, respectively (relative risk = 7.4; 95% confidence interval = 4.9-9.9). These results indicate that in patients without RVT, a short period of treatment with a VKA is sufficient; in those with persistent RVT, treatment extended to 2 years substantially reduces, but does not eliminate, the risk of recurrent thrombosis.

Superficial and Deep Vein Thrombosis Associated With Congenital Absence of the Infrahepatic Inferior Vena Cava in a Young Male Patient

Congenital absence of the inferior vena cava (AIVC) is a rare vascular anomaly that may be associated with deep vein thrombosis (DVT). It is underreported and may be present in up to 5% of young patients with DVT. We report a unique case of simultaneous thrombosis of both superficial and deep veins in a patient with AIVC. A 20-year-old man presented with a 2-week history of a swollen, painful, left lower limb. On examination, the left leg and thigh were found to be swollen and varicosities were present along the lower abdominal wall. Ultrasound showed extensive superficial and deep venous thrombosis of the entire left lower limb. Computed tomography venogram revealed an infrahepatic AIVC with lower limb drainage through enlarged intrathoracic continuations of the azygous and hemiazygous veins. The patient was put on oral anticoagulant therapy and was well at 6-month follow-up. The hypothesis for DVT in patients with AIVC is that venous drainage of the lower limbs is inadequate, leading to venous stasis and thrombosis. All young patients presenting with idiopathic DVT should be investigated for inferior vena cava anomalies with computed tomography if ultrasound does not visualize the inferior vena cava.

Recurrent deep venous thrombosis in a patient with agenesis of inferior vena cava

Background:Agenesis of the inferior vena cava (IVC) as a cause of recurrent deep vein thrombosis (DVT) is uncommon.Case:A 33-year-old male with no family history of thrombophilia, who had experienced multiple recurrent episodes of DVT over a 15-year period of unknown cause, was admitted into our hospital because of cellulitis in the right leg. Computer tomography with contrast of the abdomen showed an absence of IVC.Conclusion:Congenital absence of the IVC could be a rare risk factor for idiopathic DVT, especially in young individuals.

A local increase in red blood cell aggregation can trigger deep vein thrombosis: evidence based on quantitative cellular ultrasound imaging

Recurrent deep vein thrombosis (DVT) risk factors include a first idiopathic DVT, strongly suggesting the existence of undiagnosed and/or unidentified prothrombotic abnormalities. To evaluate the impact of locally increased red blood cell (RBC) aggregation on DVT pathogenesis in a rabbit model. DVT presence, flow and aggregation were measured in situ with ultrasound. Greatly enhanced aggregation was achieved by covalent linkage of Pluronic F98 to the RBC surface; coating with Pluronic F68, which very mildly enhances aggregation, was used as a coating control. On day 1, endothelial damage and a partial stenosis were surgically created on the left femoral vein whereas the right femoral vein was not manipulated. A thrombus was formed within 30 min in six out of seven left femoral veins of animals receiving a 30% volume blood exchange with F98-coated RBC, whereas a thrombus occurred in only one out of seven veins in F68-transfused controls. In vivo imaging using quantitative ultrasound confirmed increased aggregation in the thrombosed veins of the F98 group compared with the F68 group and the contralateral vessel. For each group, five animals were followed for 2 weeks before being killed. In F98-transfused animals, lysis of clots occurred and the presence of chronic thrombi totally occluding the vein in three out of five animals was confirmed by histology. Conversely, in the F68 group, a single disorganized blood clot was observed in one out of five animals. A marked increase in RBC aggregation promotes thrombosis in rabbit femoral veins, confirming a pathophysiological role of locally altered hemorheology in the onset of DVT.

A Potential Interaction between Warfarin and Atovaquone

To report a case of increased international normalized ratio (INR) in a patient established on warfarin therapy who was then initiated on atovaquone therapy. A 53-year-old African American male with HIV was prescribed warfarin 5 mg/day for 12 months after diagnosis of idiopathic deep vein thrombosis and bilateral pulmonary emboli (target INR 2.5 [range 2.0-3.0]). The patient required Pneumocystis jiroveci pneumonia prophylaxis and was prescribed atovaquone instead of trimethoprim/sulfamethoxazole therapy because of the latter drug's known interaction with warfarin. The patient's INR rose by greater than 50% (from 2.3 to 3.5) after 7 days of concomitant warfarin and atovaquone. In response, the patient's total weekly warfarin dose was decreased by 5%. Eight days later, the patient's INR was still supratherapeutic at 3.1. Approximately 4 weeks later, his INR was 4.2. One dose of warfarin was withheld and then the total weekly warfarin dosage was decreased by another 10%. Eight days later, the patient discontinued atovaquone therapy but continued on warfarin as prescribed. One day after atovaquone discontinuation, his INR decreased to 1.7. Due to this subtherapeutic INR level, 8 days later the total weekly warfarin dose was increased by 5%. Although a follow-up appointment was scheduled, no further INR values were obtained because the patient's 12-month course of anticoagulation therapy was completed and warfarin was discontinued. The patient did not report any adverse effects or signs or symptoms of hemorrhage while his INR values were supratherapeutic. Warfarin's potential for interactions with other highly protein-bound drugs, such as atovaquone, can result in displacement from protein binding sites and increased serum concentrations of warfarin. Based on a search of MEDLINE/PubMed, International Pharmaceutical Abstracts, and the Food and Drug Administration MedWatch Adverse Event Reporting Program (all through July 31, 2010), no cases were found of an interaction between atovaquone and warfarin. The Horn Drug Interaction Probability Scale calculated this to be a probable interaction between warfarin and atovaquone. Although current medication references do not report an interaction between atovaquone and warfarin, knowledge of their pharmacodynamic properties can enable practitioners to anticipate the consequences of a possible transient increase in warfarin serum concentration, such as that seen in our patient, when given concomitantly.

Gastric Carcinoma—A Rare Presentation

Over the last 10 years there has been increasing evidence of a strong association between Idiopathic Deep vein thrombosis (IDVT) and occult malignancy. A review of world literature puts this new clinical entity as 4 -25%10. This mandates screening all cases of IDVT for a hidden malignancy. We report a case of advanced gastric carcinoma presenting as upper limb DVT with pulmonary embolism.

Residual Vein Thrombosis and D-Dimer for Optimizing Duration of Anticoagulation in Idiopathic Deep Vein Thrombosis

Long-term anticoagulant treatment is highly effective in preventing recurrent Venous Thrombo-Embolism (VTE) in patients with idiopathic Deep Vein Thrombosis (DVT) of the lower limbs, though associated with an increased risk for major bleeding that may offset the benefits of anticoagulation. Accordingly to recent guidelines, patients with idiopathic DVT should be treated for at least 3 months and then should be evaluated for the risk-benefit ratio of long-term therapy. However, such 'time for decision' is often unclear and the optimal duration of VKA remains debatable. In recent studies, markers for the assessment of the individual risk for recurrent thrombosis have been proposed, which can be of help to establish the optimal duration of VKA treatment; among them, the D-dimer (D-d) assay and the Residual Vein Thrombosis (RVT) assessment by Compression Ultra-Sonography (CUS) were shown to be the most suitable. Studies' results showed that negative results of these parameters after 3 to 6 months of therapy, identify a group of patients at low-risk for recurrent thrombosis in whom VKA treatment can be withheld. In the present review we will discuss advantages and potential limits of using these individual markers for the management of patients with a first episode of DVT of the lower limbs.

Management of deep vein thrombosis to reduce the incidence of post-thrombotic syndrome

The post-thrombotic syndrome (PTS) is the major chronic sequel of deep vein thrombosis (DVT) of the leg, and is a major socioeconomic challenge. In addition to systematic prophylaxis of DVT in hospitalized patients, effective management of DVT is important to reduce the incidence of PTS. Thrombolysis and thrombectomy are not indicated routinely. Optimal anticoagulation, usually with heparins initially and then with oral warfarin, is important to prevent recurrent DVT, which is a major risk factor for PTS. Following a routine three-month period of anticoagulation, patients with proximal idiopathic DVT should be individually assessed for the benefits and risks of continued oral anticoagulation, including patient preferences. Risk factors for recurrent DVT include active cancer, pregnancy, continued use of oral oestrogens, male sex, obesity, recurrent thrombosis, established PTS, permanent inferior vena caval filters, residual DVT, high fibrin d-dimer and other thrombophilias. Early walking, continued high levels of physical activity and wearing compression stockings for up to two years may also reduce the risk of PTS.

Concomitant homozygosity for the prothrombin gene variant with mild deficiency of antithrombin III in a patient with multiple hepatic infarctions: a case report

IntroductionHereditary causes of visceral thrombosis or thrombosis should be sought among young patients. We present a case of a young man presenting with multiple hepatic infarctions resulting in portal hypertension due to homozygosity of the prothrombin gene mutation not previously described in literature.Case presentationA 42-year-old Caucasian man with a previous history of idiopathic deep vein thrombosis 11 years earlier presented with vague abdominal pains and mildly abnormal liver function tests. An ultrasound and computed tomography scan showed evidence of hepatic infarction and portal hypertension (splenic varices). A thrombophilia screen confirmed a homozygous mutation for the prothrombin gene mutation, with mildly reduced levels of anti-thrombin III (AT III). Subsequent testing of his father and brother revealed heterozygosity for the same gene mutation.ConclusionHepatic infarction is unusual due to the rich dual arterial and venous blood supply to the liver. In the absence of an arterial or haemodynamic insult causing hepatic infarction, a thrombophilia should be considered. To our knowledge, this is the first reported case of a hepatic infarction due to homozygosity of the prothrombin gene mutation. It is unclear whether homozygotes have a higher risk of thrombosis than heterozygotes. In someone presenting with a first thrombosis with this mutation, the case for life-long anticoagulation is unclear, but it may be necessary to prevent a second and more severe second thrombotic event, as occurred in this case.

Upperr extremity deep vein thrombosis in a 25 years old apparently healthy man

This case of upper extremity deep vein thrombosis is selected for case report as it is a rare form of deep vein thrombosis without a very well established treatment modality and prognosis. The objective of this study was to report the outcome of a 25 years old male patient with idiopathic upper extremity deep vein thrombosis treated conservatively with low molecular weight heparin (LMWH) and oral warfarin. The data sources used were patient interview, laboratory and radiology investigation results and patient charts. The patient had no apparent recurrence or complication for 3 years except the presence of occasional dull pain over the affected left upper extremity.