Major Thromboembolic Complications Research Articles

Treatment of patients with venous thromboembolism and malignant disease: Should vena cava filter placement be routine?

Purpose: It has been proposed that inferior vena cava filter placement should be the initial treatment of deep venous thrombosis (DVT) or pulmonary embolus (PE) in patients with coexisting malignant disease. We have chosen instead to selectively place filters only in patients with either a contraindication to anticoagulation therapy or a subsequent complication from anticoagulation therapy. The treatment efficacy and mortality rates in patients with concomitant malignant disease and venous thromboembolism using this approach was determined. Methods: We retrospectively reviewed all patients at our institution with malignant disease in whom venous thromboembolism developed between August 1991 through August 1996 and identified 166 patients with PE (n = 8), DVT (n = 147), and DVT/PE (n = 11). Of these patients, 138 (83.1%) were initially treated with anticoagulation therapy, and 28 (16.9%) had primary filter placement because of contraindications to anticoagulation therapy (10 for intracranial tumors, 11 for recent or upcoming operations, 6 for recent hemorrhage, and 1 for a malignant bloody pericardial effusion). Results: Thirty-two (23%) of the 138 patients who initially underwent anticoagulation therapy subsequently required a filter for the following reasons: bleeding (n = 15, 10.9%); recurrent thromboembolism (n = 6, 4.3%); heparin-induced thrombocytopenia (n = 1, 0.7%); and perceived high risk for bleeding with continued anticoagulation therapy (n = 11, 8%). Both bleeding and recurrent thromboembolism developed in 1 patient. Sixty patients (36%) received filters. No major technical complications occurred from filter placement. Major recurrent thromboembolic complications developed in 10 patients: DVT (n = 6, 10%), PE (n = 2, 3.3%), inferior vena cava thrombosis and phlegmasia cerulea dolens (n = 1, 1.7%), superior vena cava thrombosis (n = 1, 1.7%). Venous gangrene developed in 1 patient with DVT. The 1-year actuarial survival rates for patients treated with filter and anticoagulation therapy were 35% and 38%, respectively ( P = NS). Conclusion: In summary, our experience suggests that 64% of patients with malignant disease and venous thromboembolism are effectively treated with anticoagulation alone; 17% require primary filter placement for standard indications, and an additional 19% require subsequent filter placement because of complications (primarily bleeding) or failure of anticoagulation therapy. Although technical complications of filter placement are low, serious life-threatening or limb-threatening thromboembolic complications developed in 17% of patients. Survival was poor in all patients, regardless of treatment. These data support a conservative approach of routine anticoagulation therapy with selective filter placement. (J Vasc Surg 1998;28:800-7.)

Atrial Fibrillation and Thromboembolism

Atrial Fibrillation and Thromboembolism

Post-conference session: Experience with patient self-management of oral anticoagulation

Long-term oral anticoagulation requires careful patient monitoring in order to optimize results and to limit hemorrhagic or thromboembolic complications of treatment. For this reason, any improvement in anticoagulant control and management can be expected to have far-reaching consequences in extending longevity and decreasing complications in anticoagulated patients after heart valve surgery. Because one attractive means of improving anticoagulant management is to give patients a share of the responsibility, a program was designed to encourage patients to take an active role in monitoring their own prothrombin time (PT) and managing their own oral anticoagulation. During the period from August 1986 to February 1992, 600 patients requiring long-term anticoagulation, mainly after heart valve replacement, were trained to measure their own PT at the Cardiac Rehabilitation Center (Herz-Krauslauf-Klinik, Bad Berleburg, Germany) and to manage their own therapy: 216 patients could be followed with regard to their self-determined prothrombin times. The results were within the target range in 83.1% of the PT determinations (n=12,306 measurements) taken by the patients themselves. Neither major bleeding nor thromboembolic complications were observed in 205 patient-years of self-monitoring of PT and self-management of oral anticoagulation.

Proximity penetrating extremity trauma: the role of duplex ultrasound in the detection of occult venous injuries.

The diagnosis and management of occult vascular injuries caused by penetrating proximity extremity trauma (PPET) remains controversial. Over 18 months, we prospectively screened 37 patients (43 lower extremities) with PPET for occult arterial and venous injuries using noninvasive studies (physical examination, ankle-brachial indices, color-flow duplex ultrasonography (CFD)) and angiography (arteriography, venography). Eight isolated, occult venous injuries were detected (incidence, 22%). CFD detected seven of eight (88%) venous injuries. Venography was technically difficult to perform in this patient population and failed to detect four femoral-popliteal vein injuries. Major thromboembolic complications (pulmonary embolism, symptomatic deep vein thrombosis, venous claudication) occurred in 50% of the patients identified with femoral-popliteal vein injuries. Arterial injuries were detected in 4 of 42 (10%) extremities (arteriography, n = 3; CFD, n = 1) and were clinically benign. We conclude that following PPET, (1) isolated, occult venous injuries are common and are associated with significant complications and (2) CFD is useful for screening for occult venous injuries.

Peripartum cardiomyopathy: experiences at King Edward VIII Hospital, Durban, South Africa and a review of the literature.

The clinical profile of patients with peripartum cardiomyopathy (PP-CMO) seen in the patient population in Durban, South Africa, is documented. Parameters such as age, multiparity, time of presentation and the role of hypertension in PP-CMO were evaluated. The study comprised 97 patients seen over a 4 year period. Group 1 (n = 63), had a good outcome at follow-up and group II (n = 34), had an adverse outcome, namely: persistently severe symptoms New York Hospital Association, Class III/IV; major thromboembolic complications; or a fatal outcome. These results confirm that PP-CMO is more likely to occur in the older and multiparous female. Increasing age and multiparity did not adversely affect outcome. Eighteen per cent of the study group were primiparous, and a third of these had an adverse outcome. Late presentation of symptoms (after 1 month postpartum) tended to favour an adverse outcome (P = 0.06). Fifteen of the 19 patients with complete obstetric records had antenatal hypertension: in nine blood pressure levels were > or = 160/110 mmHg. We were unable to ascertain the prognostic value of hypertension in PP-CMO. In conclusion, this study showed a high incidence of PP-CMO in the local African population (1:1000 deliveries), and a high complication rate (35%): it suggests that early diagnosis and appropriate therapy may avert an adverse outcome.

The St. Jude medical prosthesis in the mitral position.

To study the long-term results of the St. Jude medical prosthesis in the mitral position, 520 patients were evaluated who had undergone mitral valve replacement with St. Jude medical (SJM) prosthesis. Eighteen patients or 3.5% died in the early postoperative period (within 30 days after operation). The total follow-up was 2872 patient-years and late deaths occurred in 23 cases. Postoperative cerebral embolism occurred in six, bleeding complication in five, and thrombosed valve in two patients. Postoperative anti-coagulant therapy was initiated with both dipyridamole (300 mg/day) and warfarin potassium. After discharge from our hospital the patients underwent routine examination of their thrombo-tests or prothrombin times at least every 2-3 months, and the major thromboembolic or bleeding complication rate was 0.45%/100 patient-years. In a period of 12 years, severe hemolysis following implantation was seen in seven patients. The cause of this hemolysis was perivalvular leakage in two patients but there were no leakages in the other five patients, although preoperative moderate to severe liver dysfunction was noted. Ninety-three percent of the patients were followed up, and their postoperative New York Heart Association functional classes were I or II in 88.6% of the cases. Their clinical results after mitral valve replacement with SJM prosthesis in the anti-anatomical position showed excellent durability and a low incidence of valve-related complications.

Home Prothrombin Time Monitoring after the Initiation of Warfarin Therapy

To evaluate the efficacy and accuracy of monitoring prothrombin times at home. Randomized, prospective cohort study. Outpatients discharged from a university hospital or a community hospital. Fifty patients started on warfarin for the first time who demonstrated an ability to use the monitor and who had not achieved a stable response to warfarin in the hospital. Oral anticoagulation therapy managed using a portable prothrombin time monitor compared with specialized anticoagulation clinic care. In the 46 patients who completed the 8-week study, the median percentage of time that patients in the home-monitor group (n = 23) were within a range equal to the target prothrombin ratio +/- 0.3, but always above 1.25, was 93%, compared with 75% for patients in the clinic group (n = 23) (P = 0.003). There was no significant difference between groups in the percentage of time above the therapeutic range; however, the percentage of time that patients were subtherapeutic was significantly greater in the clinic group (P less than 0.001). There were no major thromboembolic or hemorrhagic complications in either group. Differences between home monitor measurements and corresponding clinical laboratory measurements using blood samples drawn within 4 hours of the home test were comparable to differences observed between measurements using two different clinical laboratory instruments. Use of a portable prothrombin time monitor by patients at home is feasible and provides accurate measurements. Patients doing home monitoring achieve superior anticoagulation control compared with those receiving standard anticoagulation clinic care.

Thromboembolism from undersized Dacron grafts in the descending thoracic aorta

Three patients were referred to our institution for major thromboembolic complications secondary to the use of undersized Dacron grafts (14, 16, and 18 mm) in the descending thoracic aorta. The progressive accumulation of thrombotic material in the prosthesis caused recurrent coarctation in 1 patient and peripheral embolisms in the other 2. With a 9-mm Gott shunt providing distal perfusion, excision of the clotted graft and its replacement with a 22-mm Dacron prosthesis was successfully achieved in each patient.

Renal findings in rheumatoid arthritis: clinical aspects of 132 necropsies.

Renal abnormalities in 132 necropsied patients with rheumatoid arthritis were studied. Clinical findings before death included extra-articular manifestations of the disease (86% of patients), systemic vasculitis (6%), and uraemia (23%). Necropsy findings included nephrosclerosis (90%), systemic vasculitis (14%) with kidney involvement in 8%, amyloidosis (11%), membranous glomerulopathy (8%), and focal glomerular disease (8%). Association with clinical data suggests that both rheumatoid and non-rheumatoid disease may play a part in the cause of these abnormalities.

Role of intra-arterial streptokinase in treatment of arterial thromboembolism.

We treated 27 cases of arterial thromboembolism, including nine thrombosed grafts, with intra-arterial (IA) streptokinase. Complete lysis without significant residual lesions was achieved in eight (30%) of the cases, and partial lysis with sustained improvement was achieved in an additional six cases (22%). Partial lysis revealing inaccessible residual disease in runoff vessels occurred in four (15%) of the cases, and nine (33%) were primary failures. Surgery was completely avoided in 11 (41%) of the patients, lesser amputations were possible in three (11%), and 18 (67%) avoided major amputation. Grafts lysed faster (35 v 62 hours) and more frequently (seven [78%] of nine v 11 [61%] of 18) than native vessels, but had a higher rethrombosis rate (four [71%] of seven v two [11%] of 11) and a lower late patency rate (two [22%] of nine v nine [50%] of 18). Significant bleeding occurred in one (3.7%) of the patients, and major thromboembolic complications occurred in four (13.8%). None occurred in those treated with concomitant heparin sodium. Better patency and fewer complications were also observed in limbs that were not acutely threatened, when IA streptokinase infusion was completed within 48 hours, and when the occluded segment and runoff vessels were rendered widely patent by IA streptokinase, with the aid of balloon angioplasty when necessary (five [36%] of 14).

Coagulopathy of disseminated neuroblastoma

We performed coagulation studies in 16 patients with advanced neuroblastoma. Four of these patients had major hemorrhagic or thromboembolic complications. Abnormal coagulation screening tests were seen in all patients with active metastatic disease. We also measured plasma fibrinopeptide A, a sensitive measure of intravascular thrombin generation. Increased concentrations of fibrinopeptide A were found in each patient studied with active metastatic disease. Coagulopathy is a frequent finding in metastatic neuroblastoma and may cause severe morbidity. Laboratory studies suggesting either hyper- or hypocoagulability are frequent findings.

Management of major thromboembolic complications of umbilical artery catheters

Over the last 9 yr approximately 4000 infants have had physiologic monitoring with UAC at Vanderbilt University Medical Center. A larger number of them had minor ischemic complications prompting removal of the catheter, but 41 patients had major thromboembolic problems requiring varying degrees of surgical management. The place of surgery is clear in patients with catheter emboli or bleeding due to vascular avulsion related to catheter removal. Patients with arterial occlusion distal to the femoral artery may be treated expectantly although significant skin loss may occur. Occlusions at the femoral level allow limb survival, but the long-term outlook is not known; perhaps these patients may better be subjected to femoral thrombectomy in the future. Peripheral pulses are not normal early and Doppler studies suggest that collateral circulation is responsible for limb survival. Whether this will be sufficient to support adequate limb growth and function remains to be seen. Patients with signs of aortoiliac or mesenteric occlusion should be rapidly investigated and operated upon if survival is to be obtained. This study suggests that an aggressive surgical approach is in order. Computer-assisted radionuclide flow studies are helpful in diagnosing major aortic occlusion, as well as for followup.

Thromboembolic complications in myelomatosis.

Fourteen cases of myelomatosis associated with major thromboembolic complications are reported. Six patients died of pulmonary embolism, seven had deep-vein thrombosis as a presenting symptom, and three had evidence of amyloidosis. A preliminary estimate of the incidence of thromboembolism based on 376 patients admitted so far to the Medical Research Council's myelomatosis trial is about 3%, while pulmonary embolism accounted for about 3% of all deaths. Possibly a hypercoagulable state and the presence of amyloidosis may be important in the pathogenesis of this complication.