Management Of Deep Vein Thrombosis Research Articles

A Nomogram for Predicting the Risk of Deep Vein Thrombosis in Patients With Acute Ischemic Stroke During the COVID-19.

Deep vein thrombosis (DVT) is an important complication of stroke. As coronavirus disease 2019 (COVID-19) enters the stage of persistent and long-term management, the clinical management of DVT in stroke patients may require adjustment. The present study evaluated whether there was an increased risk of DVT in stroke patients during the COVID-19 period. Furthermore, we analyzed the possible risk factors and developed an easy-to-use nomogram to predict DVT in stroke patients during the long-term management of COVID-19. A total of 7087 stroke patients during the COVID-19 period and 14,174 patients with age, sex, and National Institutes of Health Stroke Scale (NIHSS) scores matched before the period from four centers were included. The incidence of DVT in stroke patients during the COVID-19 period (20.5%) was significantly higher than that before this period (15.9%, P < .001). Age, body mass index, smoking, D-dimer, physical activity level, NIHSS score, and intermittent pneumatic compression were significant predictors of DVT during the COVID-19 period (P < .05). A nomogram was constructed; internal and external validations showed high accuracy, and decision curve analysis showed excellent clinical applicability. This nomogram could evaluate the risk of DVT after stroke and assist in its early prevention during the long-term management of COVID-19.

Evaluation of preoperative coagulation function changes and deep vein thrombosis incidence in elderly patients with hip fractures.

This study involved an analysis of preoperative deep vein thrombosis (DVT) incidence and changes in coagulation function among elderly patients suffering from hip fractures. The objective was to offer guidance on the prevention and management of preoperative DVT in the lower extremities of elderly individuals with hip fractures. A total of 282 elderly individuals with a hip fracture were enrolled and divided into two groups based on the location of the fracture: femoral intertrochanteric fracture (FIF, 161 individuals) and femoral neck fracture (FNF, 121 individuals). The two groups were compared with respect to baseline characteristics, including gender, age, and comorbid chronic diseases. Furthermore, the analysis encompassed the incidence of preoperative DVT in both lower extremities, along with seven coagulation parameters and platelet count before the surgical procedure. There was no significant difference in baseline information between the two groups. The incidence of preoperative DVT in the FIF group was higher than that in the FNF group, along with a significantly higher percentage of patients exhibiting increased levels of D-dimer and fibrinogen/fibrin degradation products (FDPs). Preoperative hypercoagulability and a greater prevalence of DVT were observed in elderly individuals with FIF compared to individuals with FNF. This indicates that clinicians should pay attention to elderly patients with FIFs, especially those with increased D-dimer and FDP levels.

A Case Of Deep Vein Thrombosis With Pharmaco-Mechanical Catheter Directed Thrombolysis Therapy

Deep Vein Thrombosis (DVT) is a formation of blood clots condition in deep vein caused by multiple risk factor. The goals of acute phase of DVT management is prevent expansion of thrombus, limiting the progressivenes of leg swelling and also prevent venous dysfunction. In this case report, we present a case of DVT with Pharmaco-mechanical Catheter Directed Thrombolysis therapy which provides satisfactory outcomes during therapy and follow up.

Multimodal Approach for the Treatment of Extensive Bilateral Iliofemoral Deep Vein Thrombosis

Abstract Iliofemoral vein thrombosis is the primary cause of deep vein thrombosis (DVTs) in the lower extremities in around 25% of the cases. Restoration of venous outflow is the primary goal in the management of DVT which can be achieved by combined endovascular techniques such as balloon venoplasty and/or stenting, thrombectomy, and pharmacomechanical thrombolysis. At presently, percutaneous mechanical thrombectomy (PMT) devices, such as rheolytic thrombectomy device, are replacing conventional approaches for clot removal. Although the use of rheolytic thrombectomy device for DVT is associated with the risk of intravascular hemolysis, we report a safe and successful use of multimodal approach using rheolytic thrombolytic device for the management of a case of bilateral iliofemoral DVT. In our study, we noticed early relief in pain and reduced lower limb edema in a week with a reduced dose of thrombolytic agent and hospital stay in a 44-year-old male who was admitted with bilateral extensive iliofemoral DVT using a multimodal approach.

Predictive value of three kinds of thrombosis risk assessment scale for lower extremity deep vein thrombosis after hip fracture in elderly patients

To explore predictive value of Caprini score, Wells score and Autar score for lower extremity deep vein thrombosis (DVT) after hip fracture in elderly patients. A total of 310 elderly patients with hip fracture were selected from January 2018 to September 2022. According to the lower extremity color ultrasound examination results, 155 patients with DVT were divided into thrombosis group, included 42 males and 113 females, aged from 60 to 101 years old with an average of (80.58±8.84) years old; and 155 patients without DVT were divided into control group, included 58 males and 97 females, aged from 60 to 94 years old with an average of (79.01±8.99) years old. Caprini score, Wells score and Autar score immediately after admission were collected and compared between two groups. Receiver operating characteristic (ROC) curve was used to evaluate predictive value of three thrombus risk assessment tables for DVT after hip fracture in elderly patients. Caprini score, Wells score and Autar score in thrombus group were significantly higher than those in control group (P<0.001). ROC curve analysis results showed that the best cut-off value of Caprini score was 8.5 points, the sensitivity was 46.5%, the specificity was 99.4%, and area under the curve(AUC) was 0.763. The best cut-off value of Wells score was 1.5, the sensitivity was 100%, the specificity was 99.4%, and AUC was 0.998. The best cut-off value of Autar score was 10.5 points, the sensitivity was 58.1%, the specificity was 84.5%, and AUC was 0.717. Caprini scale, Wells scale and Autar scale all have good predictive efficacy for the risk of DVT in elderly patients with hip fracture, and could provide an important reference for clinical guidance for prevention, management and treatment of DVT after hip fracture in elderly patients, among which Wells scale has a higher predictive value.

Risk of Developing Post Thrombotic Syndrome after Deep Vein Thrombosis with Different Anticoagulant Regimens, a Systematic Review and Pooled Analysis

Background Post-thrombotic syndrome (PTS) is a chronic condition that arises in up to 20-50% of patients with deep vein thrombosis (DVT) of the lower extremity. Symptoms range from skin color changes and limb heaviness to edema, chronic pain and ulcers. PTS has a significant impact on patients' quality of life. Hence, it is important to optimize DVT management to minimize the incidence and severity of PTS. It is unclear if different anticoagulant therapies (e.g. vitamin K antagonists (VKA), direct oral anticoagulants (DOACs) or low molecular weight heparin (LMWH)) are associated with different risks of PTS. Objective We sought to assess the incidence rates of PTS development after a proximal DVT of the lower extremity managed with different anticoagulation regimens. Methods A systematic search of MEDLINE, EMBASE and PubMed as well as conference proceedings (inception to June 2023) was performed. Studies were screened and selected if they met the criteria for patients (age ≥18) receiving anticoagulation therapy for a minimum of 3 months after the diagnosis of a proximal DVT of the lower extremity. The primary outcome was development of PTS defined by the Villalta or PRV score of ≥ 5, or as defined by the individual studies. Incidence rates (overall and per type of anticoagulant regimens) were pooled using the random effects model and expressed as event per 100 patient-years with its associated 95% confidence intervals (CI) using R software. Results Out of the 2837 identified studies, 77 were reviewed in full text and 21 (n= 4342 patients) were included in the analysis (7 randomized controlled trials, 14 observational studies). There were 17 studies (2834 patients), 12 studies (1212 patients) and 2 studies (296 patients) reporting the outcomes for VKA, DOAC and LMWH, respectively. The crude incidence rates for PTS development are depicted in Figure 1. After adjusting for duration of anticoagulation, the overall incidence of PTS was 16.3 per 100 patient-years (95% CI: 11.1-24.12). The incidence of PTS was 15.1 per 100-patient-years (95% CI: 8.7-26.1), 18.2 per 100 patient-years (95% CI: 9.4-35.1), 24.6 per 100 patient-years (95% CI: 9.2-65.5) for VKA, DOAC and LMWH, respectively. The most used DOAC was rivaroxaban (incidence rate of 12.3 per 100 patient-years (95% CI: 1.6-96.4)). Conclusions PTS is a common complication among patients with proximal DVT of the lower extremity. Incidence of PTS development may differ based on the anticoagulant regimen. DOACs seems to be associated with lower incidence PTS development compared to VKA and LMWH. Future clinical trials are needed to confirm these findings.

PANCHAKARMA THERAPY WITH SPECIAL REFERENCE TO MANJISTADHI KSHARA BASTI IN “1A-3N KALA-BASTI PATTERN” IN THE MANAGEMENT OF DEEP VEIN THROMBOSIS (DVT): A CASE STUDY

Deep vein thrombosis (DVT) is the third most common vascular disease, after ischemic heart disease (IHD) and Stroke and it is a silent killer. It affects approximately 0.1% of total population per year. Various treatment mo-dalities and drugs of Western medicine such as Surgical interventions, Urokinase, Streptokinase or Tissue plas-minogen activators to dissolve the blood clots have their own limitations and side effects apart from being ex-pensive. The present case study deals with a 39-year-old male, cab driver by profession, who is used to long distance travel in car on daily basis and is obese in built, habituated to smoking 4-5 cigarettes a day, since 10-12 yrs., gradually developed pain and swelling of Right lower limb since 2months. On evaluation, Doppler Ultra-sonography of Right lower limb revealed Deep vein thrombosis of Right femoral vein (Upper and mid 1/3rd) &amp; long Sephanous vein (proximal 1/3rd). In Ayurveda, based on the Clinical picture and signs and symptoms, the condition can be correlated to “Kapha-Medavrutha Vataraktha”. This case study is about management of DVT with multi-modality treatment in the form of Panchakarma procedures such as Jaloukavacharana, Kashaya dhara, Alepana, Udwartana, Manjistadhi Kshara vasti along with oral medications. Treatment has shown re-markable result especially in reduction of symptoms such as swelling, pain and heaviness. Assessment was done on the basis of clinical examination, signs and symptoms before and after the treatment.

Deep Vein Thrombosis after COVID-19 mRNA Vaccination in a Young Man with Inferior Vena Cava Anomaly Leading to Recurrent Deep Vein Thrombosis

Severe side effects of adenoviral-vectored-DNA COVID-19 vaccines such as thrombosis have been reported. Herein, we report a case of sudden massive deep vein thrombosis (DVT) in a young man with inferior vena cava anomaly 20 hours after the second dose of the mRNA vaccine for COVID-19. There was recurrence of iliofemoral DVT after one year, despite complete resolution and administration of prophylactic anticoagulants. We suggest that the sudden episode was triggered by the vaccine rather than the venous anomaly, which can be associated with recurrence due to inadequate venous return through the small and tortuous infrarenal veins or increased venous pressure and stasis. There are no standard guidelines for the management of DVT following mRNA vaccination. However, we highlight the importance of initial workups, regular follow-ups, and standard treatment options, including the continuous administration of prophylactic anticoagulants which should be considered to prevent recurrence.

Catheter-Directed Interventions for the Treatment of Lower Extremity Deep Vein Thrombosis.

Lower extremity deep vein thrombosis (DVT) leads to significant morbidity including pain, swelling, and difficulty walking in the affected limb. If left untreated, DVT increases the risk of pulmonary embolism (PE), recurrent venous thromboembolism (VTE), and post thrombotic syndrome (PTS). The objective of this review was to identify catheter-directed interventions and their success rates for the treatment of lower extremity DVT. A comprehensive search of current and emerging catheter-directed interventions for lower extremity DVT treatment was conducted in PubMed and Google Scholar. Clinical trials, retrospective and prospective observational studies, and case reports were identified to classify percutaneous mechanical thrombectomy (PMT), catheter-directed thrombolysis (CDT), and pharmacomechanical CDT (PCDT) devices based on their mechanism of action and indication of use. Catheter-directed interventions such as PMT, CDT, and PCDT offer an alternative therapeutic strategy for DVT management, particularly in patients with limb-threatening conditions and absolute contraindications to anticoagulants. Currently, there are limited guidelines for the use of mechanical and pharmacomechanical devices because of the lack of clinical evidence available for their use in treatment. Future studies are required to determine the short and long-term effects of using catheter-directed interventions as well as their effectiveness in treating acute versus subacute and chronic DVT.

Acute Deep Vein Thrombosis Involving the Inferior Vena Cava: Interventional Perspectives

Extension of an iliofemoral thrombosis into the inferior vena cava (IVC), or from the IVC descending into the iliofemoral segments, can confer significant morbidity and mortality. Interventional management of acute deep vein thrombosis (DVT) has been controversial, but there is little doubt that certain subpopulations benefit, such as those with symptomatic IVC thrombosis. When considering an intervention, caval involvement introduces technical difficulties due to its larger diameter, high thrombus burden, bilateral limb clot extension and need for dual access. The frequent coexistence of an IVC filter increases the complexity even more. This review summarises the current indications and treatment modalities available for the management of acute DVT involving the vena cava.

MiR-513c-5p Suppression Aggravates Pyroptosis of Endothelial Cell in Deep Venous Thrombosis by Promoting Caspase-1.

Deep vein thrombosis (DVT) is a common peripheral vascular disease. Secondary pulmonary embolism (PE) caused by DVT leads to substantial patient death. Inflammation has been suggested as a key factor in the pathophysiology of DVT, however, involvement of pyroptosis-related inflammatory factors in DVT formation remains unclear. Here, we proposed that post-transcriptional modification of caspase-1 might be a crucial trigger for enhanced pyroptosis in vascular endothelial cells (VECs), and consequently contributed to severer symptoms in DVT patients. In order to explore the involvement of pyroptosis in DVT, peripheral blood mononuclear cells were collected from 30 DVT patients, and compared with the healthy controls, we found caspase-1 was increased both in mRNA and protein levels. miRNA microarray analysis demonstrated that down-regulated miR-513c-5p was significantly negatively correlated with the expression of caspase-1. In vitro assays suggested that miR-513c-5p overexpression could ameliorate the expression of caspase-1, and thus decreased the production of cleaved gasdermin D (GSDMD) and interleukin (IL)-1β and IL-18 in VECs. The dual-luciferase reporter assay identified direct binding between miR-513c-5p and the 3′ untranslated region of caspase-1 encoding gene. The administration of miR-513c-5p mimics through tail vein injection or caspase-1 inhibitor (vx-765) by intraperitoneal injection remarkably decreased the volume of blood clots in vivo, whereas miR-513c-5p inhibitor aggravated thrombosis formation and this effect was dramatically weakened when treated in combination with vx-765. Collectively, these results revealed that the pyroptosis of VECs induced by decreased miR-513c-5p was involved in DVT progression and indicated a potential therapeutic strategy of targeting the miR-513c-5p/caspase-1/GSDMD signal axis for DVT management.

British Lymphology Society's position paper for management of people with lymphoedema in presence of deep vein thrombosis: a summary.

There is some confusion surrounding the management of people with lymphoedema in the presence of deep vein thrombosis (DVT). This may be in relation to the suitability of commencing compression therapy or regarding the continuation of compression therapy in those who develop DVT. The purpose of this British Lymphology Society position paper is to support evidence-based practice and debunk the myths surrounding the management of DVT and lymphoedema.

Management of Proximal DVT: Clinical Benefit of Endovenous Intervention Is Still in Question

A recent systematic review by Ashrafi et al. aimed to compare various techniques for treating proximal and iliofemoral deep vein thrombosis (DVT).1 Sixty per cent of lower extremity DVTs are proximal, defined as those involving the popliteal and/or more proximal veins, thereby contributing to feared complications such as pulmonary embolism and post-thrombotic syndrome (PTS). PTS refers to the constellation of pain, oedema, ulceration, and limited mobility caused by venous insufficiency following DVT.

Ayurvedic Approach in the Management of Deep Vein Thrombosis (DVT): A Case Study

Venous Thrombosis (VT) of deep vein is a life-threatening condition. Deep vein thrombosis also known as Phlebothrombosis is a semisolid clot in vein which has got high tendency to develop pulmonary embolism and sudden death. It has an incidence of 1 per 1000 annually in adult population and is the third most common vascular disease, after Ischemic heart disease (IHD). DVT occurs most commonly in the lower extremities. The superficial femoral and popliteal veins in the thighs and the posterior tibial and peroneal veins in the calves are most commonly affected. Conventional treatment for DVT has some reported limitations and often requires expensive hospitalization. The present case study deals with a 49-year-old male, with a known history of heart attack 3 months before and lies in hospital bed for several days without sufficiently moving his legs, who noticed weakness, pain and swelling of bilateral lower limbs after discharge from hospital. In Doppler sonography it was found to have thrombosis of anterior and posterior tibial veins of right and left lower limbs. In Ayurveda the disease is not mentioned as it is but it can be correlated to Gambhira-vatarakta, Siragata-vata etc. This case study is about management of DVT with multi-modality treatment in the form of Panchakarma procedures such as Rooksha sweda, Rooksha vasti, Upanaha, Jaloukavacharana, Kashaya dhara, Kashaya vasti, Ksheeravasti along with oral medications. Treatment shown remarkable result especially in reducing swelling, pain and weakness. Assessment was done on the basis of signs and symptoms and doppler sonography. Venous doppler study showed normal superficial and deep venous system on both sides.

Improving Value in Emergency Department Management of Deep Vein Thrombosis

Background: Deep vein thrombosis (DVT) is a common diagnosis with a worldwide incidence of 10 million cases per year. The diagnosis requires treatment with anticoagulation that can have both high cost and high risk for bleeding and has traditionally been managed with an inpatient admission. Recent guideline updates from the American Society of Hematology have demonstrated that patients meeting certain criteria can be managed as an outpatient. A retrospective chart review of patients presenting for acute DVT in 2019 demonstrated 58.1% of patients who met criteria for outpatient management were admitted. In order to improve value of care for UF Health patients presenting to the Emergency Department (ED) for acute DVT, a multidisciplinary team consisting of physicians from the departments of Hematology and Emergency Medicine developed a step-by-step ED treatment pathway for the management of acute DVT based on evidenced-based guidelines. The project goal was to achieve less than a 25% admission rate for patient's meeting outpatient management criteria within 1 year.Methods: Recent American Society of Hematology anticoagulation management guidelines supporting outpatient management of DVT presented an opportunity to reduce cost to patients while maintaining safety and improving resource utilization and evidence-based practice. To identify patients that are safe for outpatient management, the HAS-BLED risk stratification tool was implemented. To improve both quality of outpatient treatment and patient compliance, recommended treatment options were updated to reflect current practice standards with an appropriate emphasis on direct oral anticoagulants (DOACs). Finally, a standard documentation template was created for patients being discharged to reduce variation in post-discharge recommendations. A cause-and-effect diagram and interviews were utilized to determine the reasons for patient management decisions including disposition and choice of anticoagulation. These quality improvement tools were added to the ED treatment pathway, which was published in the standard location for similar clinical tools for ED clinicians at our institution. Furthermore, lectures were given at the Emergency Medicine residency conference to educate clinicians on the updates and answer questions.We subsequently reviewed charts of applicable ED encounters. A run chart was utilized to monitor admission and discharge rates over time. ED encounters with assigned ICD codes for acute and acute-on-chronic lower extremity DVT were reviewed for data collection.Outcomes: Chart review of ED patient encounters for acute DVT in 2019 demonstrated 255 cases. Of those, 93 patients were identified as meeting criteria for outpatient management. Only 41.9% (n=39) of patients who met criteria for outpatient management were discharged. Unexpectedly, 92% of all encounters did not document bleeding risk. Review of data from January through October 2020 demonstrated an overall decreased incidence of encounters for acute DVT. This is likely a reflection of decreased ED encounters in the setting of the COVID-19 pandemic. Over a 10-month period, 38 patients met criteria for outpatient management. Of these, 76.3% (n=29) of patients meeting criteria for outpatient management for DVT were discharged and 23.7% (N=9) were admitted. This demonstrates a significant improvement in admission rates (59.2% relative reduction) compared to a 58.1% admission rate in 2019 and met our goal of less than 25% admission rate. Furthermore, 89.7% (N=26) of patients who were discharged were prescribed direct oral anticoagulants. Similar to 2019, bleeding risk was documented in only 6.9% of discharged patients. This was an unexpected finding and while not the primary objective of the project, certainly demonstrates a significant opportunity for further care improvements.Conclusions: The next PDSA cycle will focus on appropriate use of bleeding risk stratification tools and documentation of bleeding risk. Of note, 37.3% of admitted patients who did not meet outpatient management criteria were not discharged because of a concomitant pulmonary embolism. This may present an additional future opportunity for improving value of care for patients with different types of venous thromboembolism. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Pediatric May‐Thurner Syndrome—Systematic review and individual patient data meta‐analysis

BackgroundThe outcomes of deep vein thrombosis (DVT) in children with May‐Thurner Syndrome (MTS) remain unclear. ObjectivesThis systematic review and patient‐level meta‐analysis aims to describe the outcomes of children with MTS presenting with DVT. MethodsA systematic review of the published literature was performed. Data related to patients <18 years diagnosed with MTS and DVT was extracted. Risk of bias was assessed using the Murad criteria. Outcomes included vessel patency post‐treatment, DVT recurrence, and post‐thrombotic syndrome (PTS). Predictive and explanatory models were developed for these outcomes. ResultsIn total, 109 cases were identified (age range 4–17 years; 77 females) in 28 studies; 75% of patients had ≥1 additional risk factor for DVT. PTS was seen in 61% of patients, DVT recurrence in 38%, and complete vessel patency post‐treatment in 65%. The models developed to predict and explain PTS performed poorly overall. Recurrent thrombosis (adjusted for age and patency) predicted PTS (odds ratio [OR] 3.36, 95% confidence interval [CI] 1.28–8.82). DVT management strategies (adjusted for age and DVT characteristics) predicted vessel patency (OR 2.10, 95% CI 1.43–3.08). Lack of complete vessel patency (adjusted for age and thrombophilia) predicted recurrent DVT (OR 2.70, 95% CI 1.09–6.67). Sensitivity analyses showed the same direction of effects for all outcomes. ConclusionsPTS and DVT recurrence occur frequently in pediatric MTS. PTS prediction is complex and it was not possible to identify early predictors to guide clinical practice. Use of imaging‐guided therapy and thrombus burden predicted venous patency, and lack of patency predicted DVT recurrence.

Feasibility and safety of percutaneous hydrodynamic thrombolysis techniques in management of acute proximal lower limb deep vein thrombosis

Introduction Currently, there are different treatment options of deep vein thrombosis (DVT) available, and all of which have their own associated adverse effects. Pharmacomechanical thrombolysis (PMT) is a minimally invasive catheter-based intervention that uses a retrograde-directed saline jet under pressure to fragment, macerate, or disrupt the occlusive venous thrombus after lacing it with thrombolytic drugs followed by aspiration of the thrombus material. Patients and methods This is a prospective study examining the use of PMT in management of unilateral acute lower limb DVT for some cohort of patients with no contraindication to thrombolysis who presented to our vascular surgery units in the period from December 2019 to June 2020. Results A total of 25 patients with acute proximal lower limb DVT were selected for PMT, with an average age of 43.2 years (range: 27–53 years). There were 13 (52%) females and 12 (48%) males. PMT was found to be successful in 21 (84%) patients. The procedure time ranged from 28 to 55 min (average 45 min), and in all patients, the access was gained via the ipsilateral popliteal vein. At first month, the patency rate was found to be 84% (21/25) and 76% at the sixth month (19/25). Conclusion In selected group of patients with no contraindications to thrombolysis, PMT can be safely used with good results in terms of patency and lower incidence of developing postthrombotic limb symptoms.

Consensus document on anticoagulant management of deep vein thrombosis: A review

Deep-vein thrombosis (DVT) is encountered commonly in clinical practice. Recently, the European Society of Cardiology released guidelines on the diagnosis and management of venous thromboembolism. In this article, the authors reviewed the important aspects of DVT and advised on the clinical diagnosis and management of the same. Further, assessment of bleeding risk, risk of recurrences of DVT, and management of DVT in special situations is reviewed briefly. This will help physicians effectively diagnose and manage DVT in routine practice. Some of the essential clinical pearls include the following. Clinical risk prediction scores such as modified Wells score and Padua prediction score are effective tools used for screening DVT. Along with D-dimer assessment, venous ultrasound is helpful in confirming the DVT in “likely DVT” patients. Anticoagulation should be offered to all the patients diagnosed with DVT. Newer direct oral anticoagulants (DOACs) should be preferred. Among four commonly used DOACs, dabigatran and edoxaban use should be preceded by parenteral anticoagulants for at least 10 days without any drug overlap, whereas rivaroxaban and apixaban should be used as single-drug approach. Treatment duration should be 3–6 months and extended treatment should be based on the assessment of risk of bleeding and recurrences. Special situations such as DVT in upper extremity and in the elderly should be managed as recommended otherwise. For DVT pregnancy, low-molecular-weight heparin should be the anticoagulant of choice.

Outpatient management of patients presenting with venous thromboembolism: Retrospective cohort study at 11 community hospitals

A gap exists between clinical practice guidelines and real-world practice. We aim to investigate hospital admissions among patients presenting to emergency departments of 11 hospitals with venous thromboembolism (VTE). Eligible patients’ first emergency department VTE visit were retrospectively collected between 2013 and 2018 from electronic medical records (EMR). Patients were categorized at low risk of VTE complications if they were diagnosed with deep vein thrombosis (DVT) of the leg or if they were diagnosed with pulmonary embolism (PE) and had a PE score index < 85. Multivariable logistic regression models were constructed to measure the adjusted odds ratios (OR) and 95% confidence intervals (CI) of hospital admissions before and after clinical practice guidelines were updated to recommend outpatient management of DVT and PE with low risk of complications. A total of 13,677 patients were included in the analysis, of which 55% were diagnosed with DVT. Mean age was 65 ± 17 years, 54% were females, and 62% were Caucasian. Overall, 9281 patients were categorized at low risk VTE complications, of whom 77% were admitted for in-hospital management. The rate of in-hospital management declined from 81% in 2013 to 73% in 2018. Patients visiting emergency departments between 2016 and 2018 (post-guidelines) were equally likely to be admitted compared to patients visiting the emergency departments between 2013 and 2015 (pre-guidelines; OR = 0.99; 95% CI: 0.88, 1.11). Results from this real-world study indicate that most low-risk VTE patients are admitted for in-hospital management, despite recommendations in clinical practice guidelines.

THROMBOEMBOLISM-RISK-BASED ALGORITHM DECREASES ANTICOAGULATION RATES AND BLEEDING RISK AFTER LIVER TRANSPLANTATION

Introduction: There is scarce literature providing clinical guidance on deep vein thrombosis (DVT) management after liver transplantation (LT), where hemostatic disturbances are constantly changing as the synthetic capacity of the liver increases. We hypothesized that an anticoagulation algorithm based on thromboembolism risk would decrease anticoagulation rates and bleeding risk after LT. Materials and Methods: Ambispective, single center study. An algorithm for management of DVT after LT was developed based on thromboembolism risk according to DVT location.Data from patients who received a LT before implementation of the algorithm (control group: 2017) was collected retrospectively, and patients who received a LT during implementation of the algorithm (study group: 2018-2019) were followed prospectively. Primary endpoints included anticoagulation after diagnosis of DVT and bleeding (drop in hemoglobin ≥ 2 g/dL or transfusion of ≥2 units of blood). Safety outcomes included death, pulmonary embolism, return to OR and readmission within 30 days of LT. Univariate logistic regression analysis was performed to evaluate if implementation of the algorithm was associated with decreased odds of anticoagulation and bleeding, and to assess possible confounders. Results and Discussion: The study and control groups included 90 and 50 patients, respectively. There were no baseline differences on gender, age, or history of portal vein thrombosis, DVT or hypercoagulability disorders between groups.The study group had lower MELD scores. 16 (17.8%) patients from the study group and 5 (10%) controls developed DVT within 14 days (p=0.217). Of these, 2 (12.5%) study group and 4 (80%) control group patients received initial anticoagulation after DVT diagnosis (p=0.011). The study group had decreased odds of receiving initial anticoagulation after DVT (OR = 0.036, 95% CI: 0.003-0.503; p=0.014), and a tendency of decreased risk of bleeding (OR = 0.154, 95% CI: 0.017-1.369; p=0.093) compared to the historical cohort. MELD scores did not appear to have a significant association with DVT (OR = 1.023, 95% CI: 0.961-1.090; p=0.478), initial anticoagulation (OR = 1.089, 95% CI: 0.939-1.262; p=0.258), or bleeding (OR = 1.012, 95% CI: 0.882-1.162; p=0.860). No significant differences were observed on death, pulmonary embolism, return to OR and readmission within 30 days between groups.Conclusion: Implementation of a thromboembolism-risk-based algorithm for the management of DVT after LT decreases anticoagulation rates and may decrease bleeding risk. Use of this algorithm resulted in an increase of observation and US Doppler follow up. However, this increased surveillance balances favorably against the continuous laboratory monitoring and increased risk of bleeding associated with routine anticoagulation. Implementation of this algorithm does not seem to increase the rate of adverse events related to thromboembolism