Prevention Of Fatal Pulmonary Embolism Research Articles

Prevention of fatal pulmonary embolism in a patient with stomach cancer

A clinical case of a 71-year old patient with stomach cancer and concomitant lower extremity deep venous thrombosis diagnosed before the surgical treatment is presented. The patient was administered anticoagulants, and despite the treatment, a diagnosis of deep venous thrombosis with high risk for thromboembolism was set up. Considering high risk for pulmonary embolism, an inferior vena cava filter was implanted in infrarenal part of inferior vena cava at the first stage. On the second day after the cancer surgery (subtotal stomach resection with lymphadenectomy), clot detachment and its dislocation from the left common femoral vein to the area where the cava filter was implanted with further fixation were diagnosed. Accurate diagnosis of lower extremity deep venous thrombosis with high risk for thromboembolism set up by ultrasonography and timely inferior vena cava filter implantation saved the patient with cancer from developing pulmonary embolism.

Retrievable inferior vena cava filters for venous thromboembolism.

Inferior vena cava (IVC) filters are used as an alternative to anticoagulants for prevention of fatal pulmonary embolism (PE) in venous thromboembolic disorders. Retrievable IVC filters have become an increasingly attractive option due to the long-term risks of permanent filter placement. These devices are shown to be technically feasible in insertion and retrieval percutaneously while providing protection from PE. Nevertheless, there are complications and failed retrievals with these retrievable filters. The aim of the paper is to review the retrievable filters and their efficacy, safety, and retrievability.

Intrapartum placement of an inferior vena cava filter for a woman with hereditary antithrombin III deficiency: Its role in the prevention of fatal pulmonary embolism

We present a case of a pregnant woman with hereditary antithrombin III deficiency and deep vein thrombosis of the left lower extremity managed by perinatal unfractionated heparin injection with antithrombin III replacement as well as by intrapartum placement of a temporary inferior vena cava filter. A massive thrombus of the right common iliac vein occurred during the intrapartum period despite antithrombin III replacement. An inserted filter could prevent fatal pulmonary embolism in this patient. Hereditary antithrombin III deficiency increases risk of thrombosis during pregnancy. However, discussion on intrapartum management, when anticoagulants are contraindicated due to possible hemorrhage, is minimal. Our experience suggests that thrombosis can occur and develop during the intrapartum period in an antithrombin III deficient woman despite antithrombin III replacement. It may be advisable to manage deliveries with temporary inferior vena cava filters to prevent fatal pulmonary embolism.

Clinical outcome and complications of temporary inferior vena cava filter placement

We evaluated the current clinical experience of temporary inferior vena cava (IVC) filter placement and its related complications. From January 2000 to December 2005, we enrolled 33 patients (8 men and 25 women) who underwent percutaneous insertion of a temporary IVC filter in the Department of Vascular Surgery of Tokyo University Hospital. Deep vein thrombosis (DVT) was proven in 78.8% of the patients. The indications for filter insertion were contraindication to anticoagulation therapy (9.1%), thrombolytic therapy (12.1%), perioperative prophylactic implantation (84.8%), pregnancy with DVT (3.0%), and prophylactic implantation in the absence of DVT (15.2%). A Neuhaus Protect was used in 13 patients, and an Antheor was used in 20 patients. The mean +/- SD duration of filter placement was 10.6 +/- 7.0 days. There was no case of pulmonary embolism during filter protection and retraction. Filter thrombosis (capture of thrombus) was observed in four patients (12.1%), who then received additional thrombolytic therapy. Thrombi were dissolved by thrombolysis in three, one of whom had replacement with a permanent filter. The thrombus was not dissolved in one patient and was removed under venotomy at the insertion site. Major filter-related complications occurred in nine patients (27.3%), including filter dislocation in four patients (12.1%), catheter fracture in three (9.1%), and catheter-related infection in one (3.0%). In a patient with giant ovarian cancer, the IVC was nearly occluded with massive thrombus around the filter 2 days after operation, and the vena cava was then ligated under open laparotomy. No patients died during filter protection and retraction. Temporary IVC filters were effective for the prevention of fatal pulmonary embolism. However, our experience of a high incidence of complications related to temporary filters suggests that this device has limited indications and supports the need for innovative design of temporary filters.

Placement and Retrieval of a Gunther Tulip Filter in Patients with a Free Floating Thrombus in Inferior Vena Cava

Purpose: We wanted to assess the technical feasibility and clinical efficacy of the placement and retrieval of a Gunther Tulip filter for the prevention of fatal pulmonary embolism during the management of patients with a free floating thrombus in their inferior vena cava (IVC). Materials and Methods: Six patients having a free floating thrombus in their IVC (three patients with an isolated free floating thrombus in the IVC that resulted from immobilization due to traumatic liver injury or cerebral infarction, two patients with coexisting deep vein thrombosis in the left lower extremity that was caused by May-Thurner syndrome, and one patient with coexisting deep vein thrombosis in the right lower extremity that was due to nephrotic syndrome and immobilization after hip joint replacement) underwent placement and retrieval of a Gunther Tulip filter. The placement of the filter was performed through the right internal jugular vein to prevent the risk of detachment of the thrombus during the procedure. Retrieval of filter was performed after the free floating thrombus of the IVC had disappeared on follow-up CT because of anticoagulation therapy, aspiration thrombectomy or catheter directed Urokinase thrombolysis. Results: The Gunther Tulip filter was successfully placed in the IVC in all six patients and it was retrieved after the management of the free floating thrombus. The mean duration of the placement of the filter was 11 days (range: 7-25 days). Two patients underwent placement of an iliac vein stent for the management of May-Thurner syndrome. Detachment of the free floating thrombus in the IVC and the subsequent thrombus entrapment in the filter were documented during aspiration thrombectomy or Urokinase thrombolysis in four patients. Recurrent thrombus didn't occur during the follow-up period (range: 3-20 months) in five of the six patients. In one patient, a recurrent thrombus due to the discontinuance of anticoagulation therapy was identified at the filter detachment site of the IVC on the follow-up CT 10 days after the filter retrieval, but it disappeared 15 days after proper anticoagulation therapy was done. Conclusion: Temporary Gunther Tulip filter placement is technically feasible and efficacious for the prophylaxis of pulmonary embolism in those patients with a free floating thrombus in the IVC, and particularly in those patients who will have subsequent aspiration thrombectomy or catheter directed Urokinase thrombolyis performed.

Prevention of fatal pulmonary embolism and mortality in surgical patients

The incidences of fatal pulmonary embolism and death in surgical patients receiving low-molecular-weight heparin thromboprophylaxis have not been previously determined in large, adequately designed clinical trials and information on the relative efficacy and safety of unfractionated and low-molecular-weight heparin in preventing these clinical endpoints is not available. In a double-blind study, 23078 surgical patients randomly received the low-molecular-weight heparin, certoparin (3000 anti Xa IU) subcutaneously once-daily, or unfractionated heparin (5000 IU) subcutaneously three-times daily, for a minimum of 5 days. The primary outcome measure, autopsy-proven fatal pulmonary embolism recorded up to 14 days after the end of prophylaxis, occurred in 0.152% (95% confidence interval (CI) 0.10, 0.20%; 35 of 23078 patients) of cases, with no significant difference between the certoparin-treated patients (0.147% (95% CI 0.077, 0.217%; 17 of 11542 patients) and patients treated with unfractionated heparin (0.156% (95% CI 0.084, 0.228%; 18 of 11,536 patients, P=0.868). The autopsy rate was 70.2%. Comparing mortality, there was no significant difference between the groups (1 .44% [166 of 11542 certoparin patients] versus 1.27% [146 of 11536 unfractionated heparin patients]; P=0.279). The safety profiles of both treatment groups were similar. Once-daily certoparin and three-times daily unfractionated heparin are equally effective and safe in reducing fatal pulmonary embolism and death to low levels in surgical patients and mirror the findings of comparative efficacy studies using surrogate endpoints.

Low-dose heparin did not reduce fatal pulmonary embolism in patients hospitalized with infectious diseases

Source Citation Gardlund B, for the Heparin Prophylaxis Study Group. Randomised, controlled trial of low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases...

Low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases

Low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases

Randomised, controlled trial of low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases

SummaryBackground Fatal pulmonary embolism and other thromboembolic complications are common in hospital inpatients. However, there is little evidence on the routine use of pharmacological thromboprophylaxis in non-surgical patients. We assessed the efficacy and safety of low-dose heparin in the prevention of hospital-acquired, clinically relevant, fatal pulmonary embolism in patients with infectious diseases.Methods Our study used the postrandomisation consent design. 19 751 consecutive patients, aged 55 years or older, admitted to departments of infectious diseases in six Swedish hospitals, were screened for inclusion in the randomised, controlled, unblinded, multicentre trial. Of the eligible patients, 5776 were assigned subcutaneous standard heparin (5000 IU every 12 h) until hospital discharge or for a maximum of 3 weeks; 5917 were assigned no prophylactic treatment (control group). We sought consent only from the heparin group. Follow-up was for 3 weeks after discharge from hospital or for a maximum of 60 days from randomisation. The primary endpoint was necropsy-verified pulmonary embolism of predefined clinical relevance.Findings By intention-to-treat analysis mortality was similar in the heparin and control groups (5·3 vs 5·6%, p=0·39) and the median time from admission to death was 16 days in both groups (IQR 8-31 vs 6-28 days). Necropsy-verified pulmonary embolism occurred in 15 heparin-treated and 16 control-group patients. There was a significant difference between heparin and control groups in median time from randomisation to fatal pulmonary embolism (28 [24-36] vs 12·5 [10-20] days, p=0·007). This difference corresponds to the duration of heparin prophylaxis. Non-fatal thromboembolic complications occurred in more of the control than of the heparin group (116 vs 70, p=0·0012).Interpretation Our findings do not support the routine use of heparin prophylaxis for 3 weeks or less in large groups of non-surgical patients. Further studies are needed to investigate whether heparin prophylaxis of longer duration may prevent fatal pulmonary embolism.

Inferior Vena Cava Interruption for the Prevention of Pulmonary Emboli: Advantages, Disadvantages, and Complications

Pulmonary embolism (PE) in high-risk patients is minimized by inferior vena caval interruption by ligation, plication/clipping, intraluminal filters, or intralu minal balloons. Vena caval filter implantation is the least traumatic of all surgi cal implantation is the least traumatic of all surgical methods of preventing PE. These nonocclusive methods are preferred to minimize the possible sequelae of venous insufficiency. The prevention of septic emboli requires complete liga tion of the inferior vena cava (IVC). The transvenous approach to IVC inter ruption by intraluminal filter is particularly useful in severely ill patients. The Kim-Ray Greenfield filters are at present the most frequently used mo dalities for prevention of fatal PE when intervention is required. In a large ser ies of patients who have had the Greenfield filer implanted, there has been an operative mortality of less than 1%, with an incidence of recurrent emboli of less than 2%, and an incidence of venous stasis sequelae of approximately 20%. In general, this device has greater ease and flexibility of placement with lower mortality and morbidity rates.

Effectiveness and Safety of the Low-Molecular-Weight Heparin CY 216 in the Prevention of Fatal Pulmonary Embolism and Thromboembolic Death in General Surgery

Deep venous thrombosis is very frequent after general surgery, and its major complication, pulmonary embolism, is today the most frequent cause of postoperative death. The reduction of this cause of mortality is mainly based on its prevention rather than its therapy. This purpose was achieved by using physical and pharmacological means. During the past 15 years, low-dose heparin has been one of the most important means in the prevention of deep venous thrombosis, associated with early mobilization of surgical patients, but its actual efficacy against fatal pulmonary embolism was never statistically proved. In the early 80s new heparins became available, and their first experimental and clinical use demonstrated a longer half-life, a higher anti-Xa activity, and a lower haemorrhagic risk. On the basis of these data, we started a study in order to assess efficacy and tolerance of the new low-molecular-weight heparin CY 216 in preventing fatal pulmonary and thromboembolic death in patients undergoing general surgery. The study was designed as a multicentre, double-blind, randomized, controlled clinical trial versus placebo. A total of 4,498 patients, aged over 40 years undergoing general surgery, with anaesthesia lasting at least 45 min, were consecutively enrolled in the 18 centres which took part in the trial. 2,247 accounted for the CY-216-treated group and 2,251 for the placebo group. The patients received either subcutaneous injections of 0.3 ml of CY 216, equivalent to 7,500 anti-Xa units, or of 0.3 ml of a saline solution supplied in an identical form. The first dose was administered 2 h before surgery, the second 12 h later, and then once daily for at least 7 days. A post-mortem examination was carried out in every patient who died. The trial began in February 1986 and ended in June 1988. Statistical analysis showed that the two groups of patients were well matched for age, sex, type of disease, site and duration of operations, as well as for the incidence of risk factors which could predispose to the thromboembolic disease. Twenty-six deaths were recorded and validated. Eight (0.36%) belonged to the CY 216 group and 18 (0.80%) to the placebo group. In the CY 216 group, pulmonary embolism was the direct cause of death in 2 patients (0.09%), while the remaining 6 deaths could not be ascribed either directly or indirectly to thrombosis. In the placebo group, pulmonary embolism was the cause of death in 4 cases (0.18%; p less than 0.05) and contributed to death in 4.(ABSTRACT TRUNCATED AT 400 WORDS)

Prevention of fatal pulmonary embolism in patients with fractures of the neck of the femur

The Journal of Trauma: Injury, Infection, and Critical Care: April 1986 - Volume 26 - Issue 4 - p 405

Cost-Effectiveness of Primary and Secondary Prevention of Fatal Pulmonary Embolism in High-Risk Surgical Patients

Because death due to pulmonary embolism is relatively rare following general surgery, many question the need for prophylaxis. In addition, there has been reluctance to apply new interventions whose cost-effectiveness has not been adequately evaluated. A cost-effectiveness analysis based on over 1000 high-risk patients undergoing abdominothoracic surgery, with effectiveness measured in terms of numbers of deaths from pulmonary embolism averted, has shown subcutaneous administration of heparin in low doses starting 2 hours before the operation to be the most cost-effective of several active approaches to prophylaxis. It averted seven of the eight deaths expected without active prophylaxis per 1000 such patients and cost half as much as the traditional approach of intervening only when venous thromboembolism becomes clinically apparent. Intravenous administration of dextran, although effective, was expensive, and leg scanning with iodine-125-labelled fibrinogen was extremely expensive. Intermittent pneumatic compression of the legs was inexpensive, but, as with leg scanning, its effectiveness has not been determined in randomized trials.

Prevention Of Fatal Postoperative Pulmonary Embolism With Heparin-Dhe Or Dextran

Previous trials studying prevention of postoperative fatal pulmonary embolism (p.e.) concern elective general surgery. We have terminated a prospective, randomized multicentre trial comparing the effectiveness of s.c. heparindihydroergotamin (DHE) versus i.v. dextran in surgery of the musculoskeletal system including both emergency and elective cases. 14 Swiss hospitals participated. All adults operated upon were included and followed up for 6 weeks. 5000 IU heparin together with 0.5 mg DHE were given preoperatively and 12-hourly thereafter for at least one week. Patients in the dextran group received 6% dextran 70 in saline, a total of 3 × 500 ml. 8001 patients were admitted to the trial and 7413 fulfilled the criteria of the study. 5963 patients had been operated electively, 1450 as an emergency. 4368 patients had general anesthesia, 2259 were operated upon under epidural and 797 had other anesthetic procedures. 55 patients died during the first 6 postoperative weeks, the autopsy rate being 69%. 9 patients in the dextran group died of p.e. In 6 cases the pathologist decided the pulmonary embolus as being the only cause of death, in 3 the embolus was considered a contributory cause of death. In the heparin-DHE group 6 patients died of p.e. In 4 cases the embolus was the sole cause of death, in 2 it was contributory. These differences in the incidence of p.e. are statistically not significant. There were however significantly more bleeding and allergic complications in the dextran than in the heparin-DHE group.Conclusion: Both s.c. heparin-DHE and i.v. dextran are equally effective for the prevention of fatal pulmonary embolism. Heparin-DHE causes less bleeding complications.

The current status of low‐dose heparin in the prophylaxis of thrombophlebitis and pulmonary embolism

AbstractThe efficacy of low‐dose heparin in preventing postoperative venous thromboembolism has been well established in 27 clinical trials which have been published during the last 3 years. The largest study has been with patients undergoing general abdominal, thoracic, and urological operations. The incidences of isotopic deep vein thrombosis (25%) and extending thrombi likely to produce major pulmonary emboli (6.0%) in the control group have been reduced to 7% and 0.6%, respectively, in those who received heparin. The crucial question concerns the effect of low‐dose heparin in the prevention of fatal pulmonary embolism. This endpoint has been evaluated in a multicenter prospective randomized, controlled trial involving 4,121 patients; 2,076 of these were in the control group and 2,045 received heparin. Sixteen patients in the control group and only 2 in the heparin group were found to have died due to massive pulmonary embolism proved at autopsy. The difference was statistically significant (p<0.005). A careful objective analysis of operative and postoperative bleeding in 1,475 patients showed no statistically significant difference in the blood transfusion requirements or in the fall in the postoperative hemoglobin level either in the individual operative groups or in the group as a whole. However, the experience in patients undergoing total hip replacement demonstrates less evidence of benefit than in other groups of surgical patients. The published evidence and the clinical experience with low‐dose heparin prophylaxis should now be used to influence the practice habits of the profession for preventing fatal pulmonary embolism occurring after major surgery.