Previous Deep Venous Thrombosis Research Articles

Risk of deep venous thrombosis associated with peripherally inserted central catheter: A retrospective cohort study of 11.588 catheters in Brazil.

Deep Venous Thrombosis (DVT) due to Peripherally Inserted Central Catheter (PICC) is one of the most threatening complications after device insertion. To assess the rate of PICC-associated DVT and analyze the risk factors associated with this event in cancer and critically ill patients. We conducted a descriptive, retrospective cohort study with 11,588 PICCs from December 2014 to December 2019. Patients ≥ 18 years receiving a PICC were included. Pre-and post-puncture variables were collected and a logistic regression was used to identify the independent factors associated with the risk of DVT. The DVT prevalence was 1.8% (n = 213). The median length of PICC use was 15.3 days. The median age was 75 years (18; 107) and 52% were men, 53.5% were critically ill and 29.1% oncological patients. The most common indications for PICC's were intravenous antibiotics (79.1%). Notably, 91.5% of PICC showed a catheter-to-vein ratio of no more than 33%. The tip location method with intracavitary electrocardiogram was used in 43%. Most catheters (67.9%) were electively removed at the end of intravenous therapy. After adjusting for cancer profile ou chemotherapy, regression anaysis revealed that age (OR 1.011; 95% CI 1.002-1.020), previous DVT (OR 1.96; 95% CI 1.12-3.44) and obstruction of the device (OR 1.60; 95% CI 1.05-2.42) were independent factors associated with PICC-associated DVT, whereas the use of an anticoagulant regimen was a protective variable (OR 0.73; 95% CI 0.54-0.99). PICC is a safe and suitable intravenous device for medium and long-term therapy, with low rates of DVT even in a cohort of critically ill and cancer patients.

Evaluation of common femoral vein thickness as a diagnostic tool for Behçet's disease in a non-endemic area.

To evaluate common femoral vein thickness (CFVT) as a diagnostic tool in Brazilian patients with Behçet's disease (BD) and to analyse associations between increased CFVT and disease features. A cross-sectional study was performed including 100 BD patients and 100 controls. The CFVT and the diameters of great saphenous vein (GSV), and small saphenous vein (SSV) were measured by Doppler ultrasound. BD patients had higher right CFVT [0.600mm (0.500-0.700) vs. 0.525mm (0.450-0.637); p=0.012] and left CFVT [0.550mm (0.450-0.650) vs. 0.500mm (0.450-0.550); p=0.004] compared to controls. Vascular involvement of BD and previous deep venous thrombosis were associated with increased CFVT (p<0.05). The number of vascular events correlated with right and left CFVT (Rho = 0.475 p=0.030 and Rho = 0.429 p=0.052, respectively). The 0.575mm cut-off point of right and left CFVT had area under the curve (AUC) of 0.602; 95% confidence interval (95% CI): 0.524-0.680 and AUC: 0.615; 95% CI: 0.537-0.693, respectively. The right and left CFVT had a sensitivity for BD diagnosis of 52% and 43%, and a specificity of 64% and 77%, respectively. No significant differences were found between BD patients and controls regarding the GSV and SSV diameters in both legs (p>0.05). In this study, CFVT measurement was not shown to be a reliable diagnostic test for BD. CFVT was increased in BD patients presenting vascular involvement and correlated with the number of previous events.

Is Deep Vein Thrombosis Chemoprophylaxis Indicated After Spinal Irrigation and Débridement?

To (1) identify risk factors for the development of deep venous thrombosis (DVTs) in patients undergoing spinal irrigation and debridement for an infection with subsequent peripherally inserted central catheter (PICC) placement and to (2) determine if chemoprophylaxis mitigates the risk of developing DVTs. Patients with spinal infection and PICC placement at an academic medical center between 2009-2020 were retrospectively identified. Patients were grouped based on whether they had a postoperative DVT. Preoperative, intraoperative, and postoperative variables were compared to determine their association with postoperative DVT. A multivariate logistic regression model was developed to measure the effect of postoperative DVT chemoprophylaxis on the likelihood of DVT development. Of 335 patients included in the analysis, 48 (14.3%) developed a DVT and 287 (85.7%) did not. Patients who developed a DVT had a greater number of irrigation and debridement procedures (1.90 + 1.49 vs. 1.44 + 0.86, p=0.024). Multivariate logistic regression analysis identified a history of diabetes (odds ratio (OR)=2.23 [1.01-4.92], p=0.045), DVT/pulmonary embolism (OR=4.49 [1.93-10.34], p<0.001), and the number of irrigation and debridement procedures (OR=1.51 [1.13-2.06], p=0.006) as significant positive predictors of a postoperative DVT. Chemoprophylaxis (OR=0.68 [0.32-1.45], p=0.324) was not a significant negative predictor of postoperative DVT. Patients undergoing spinal debridement with subsequent PICC placement are at high risk for postoperative DVT. Multiple spine debridements, a history of diabetes, and previous DVTs are risk factors for a postoperative DVT. Chemoprophylaxis does not mitigate patients' risk for postoperative DVT.

Nurses' Knowledge and Practices Regarding the Prevention of Deep Vein Thrombosis in Saudi Arabia: Descriptive Cross-Sectional Study.

Deep venous thrombosis (DVT) is a prevalent fatal problem and a major cause of avoidable death among morbid hospitalized patients. It is estimated that up to 900,000 people in the United States are affected each year. Additionally, around 60,000 to 100,000 Americans die annually of DVT. To assess studied nurses' knowledge and practice regarding Deep venous thrombosis prevention. A descriptive cross-sectional research design was used in this study at King Fahad Hospital of the University in the Kingdom of Saudi Arabia, using a self-administered questionnaire. A total of 67 nurses from medical and surgical units were included in the study. Data were coded and analyzed using SPSS 23.0 version. According to the results, the knowledge and practice of nurses were found to be high. Total knowledge score regarding prevention of deep venous thrombosis (72.8±9.6), regarding studied nurses, score for each subcategory: general knowledge category (70.6±15.5), deep venous thrombosis risk factors category (66.5±13.1), and deep venous thrombosis prevention category (90.1±10.5). in addition, a statically significance association between nurses' years of experience (p=0.026), previous Deep venous thrombosis education (p=0.012), and total knowledge score regarding the prevention of deep venous thrombosis. Concerning the self-reported practice, the majority of the studied nurses have shown a very high practice score. Yet, there was no statically significant association between the sociodemographic characteristic and practice. Furthermore, a positive association between total knowledge and reported practice score but statically insignificant (p=0.075). Based on the result of the study, most of the studied nurses' level of knowledge and practice concerning the prevention of deep vein thrombosis ranged between high and very high.

Machine learning with D-dimer in the risk stratification for pulmonary embolism: a derivation and internal validation study.

To develop a machine learning model to predict the diagnosis of pulmonary embolism (PE). We undertook a derivation and internal validation study to develop a risk prediction model for use in patients being investigated for possible PE. The machine learning technique, generalized logistic regression using elastic net, was chosen following an assessment of seven machine learning techniques and on the basis that it optimized the area under the receiver operator characteristic curve (AUC) and Brier score. Models were developed both with and without the addition of D-dimer. A total of 3347 patients were included in the study of whom, 219 (6.5%) had PE. Four clinical variables (O2 saturation, previous deep venous thrombosis or PE, immobilization or surgery, and alternative diagnosis equal or more likely than PE) plus D-dimer contributed to the machine learning models. The addition of D-dimer improved the AUC by 0.16 (95% confidence interval 0.13-0.19), from 0.73 to 0.89 (0.87-0.91) and decreased the Brier score by 14% (10-18%). More could be ruled out with a higher positive likelihood ratio than by the Wells score combined with D-dimer, revised Geneva score combined with D-dimer, or the Pulmonary Embolism Rule-out Criteria score. Machine learning with D-dimer maintained a low-false-negative rate at a true-negative rate of nearly 53%, which was better performance than any of the other alternatives. A machine learning model outperformed traditional risk scores for the risk stratification of PE in the emergency department. However, external validation is needed.

ASAIO 2021 Annual Meeting Abstracts.

Study: Deep venous thrombosis (DVT) is said to be the most preventable cause of death in hospitals today (Centers for Disease Control, February 2020). This silent killer most frequently starts in the lower extremities as a small thrombus that initially forms in a valve pocket located behind a venous valve leaflet. Failure to initiate preventative measures to reduce the risk of DVT can result in the development of life-threatening pulmonary emboli (PE) and chronic venous insufficiency (CVI). These risks are currently exacerbated by the current SARS-CoV-2 pandemic that has increased the frequency of DVT formation and PE in patients through mechanisms that are not fully understood. The current study is using artificial intelligence (AI) and machine learning (ML) to evaluate changes in blood rheology, venous blood flow, and venous valve configuration that can lead to increased risk of DVT, PE, and CVI. Methods: In our model, AI/ML is used to evaluate previously recorded images of normal and abnormal cadaver veins and venous valves. Using these data, we can predict that previous DVT formation produced the observed leaflet damage and will increase the risk of CVI and future DVT formation. The contribution that changes in blood rheology could make to venous blood flow abnormality will also be assessed. We leverage the latest advances in image processing to quantify the valve leaflet geometry with respect to the susceptibility to recurrent DVT. Results: Based on this data, AI/ML will predict, on a patient-by-patient basis, the probability of deep venous thrombosis formation. This will allow healthcare professionals to determine when preventative measures are most appropriate. It will also allow physicians to assess whether a patient has an increased risk of developing a future DVT and/or CVI insufficiency. With this information patient care can be improved and the debilitating and life-threatening complications of DVT can be substantially reduced.

Prevalence and predictors of alternative diagnoses on whole-leg ultrasound negative for acute deep venous thrombosis

BackgroundTo investigate the prevalence, spectrum, and predictors of alternative diagnoses explaining leg symptoms in patients negative for suspected acute deep venous thrombosis (DVT), which can be detected with whole-leg ultrasound.MethodsWe retrospectively analyzed a cohort of 789 patients (median age 70 years, 50.6% women) evaluated with a whole-leg ultrasound examination for suspected acute DVT within one year. All findings in the radiology report were analyzed and electronic chart review was performed to collect clinical information.ResultsUltrasound was negative for acute DVT in 531 patients (67.3%). Among these, alternative diagnoses explaining leg symptoms were seen in 349 patients (65.7%). The most frequent alternative diagnoses were chronic venous insufficiency (147 patients, 27.7%), followed by lymphedema (48 patients, 9.0%) and chronic post-thrombotic changes (41 patients, 7.7%). Patients with alternative diagnoses were older (median 71 vs. 66 years, p = 0.0226), as well as more likely to present with leg swelling (39.5% vs. 23.1%, p = 0.0002), difference in leg circumference (25.5% vs. 14.8%, p = 0.0055) and redness (7.7% vs. 2.7%, p = 0.0213) than patients without alternative diagnosis. Independent predictors of finding alternative diagnoses on whole-leg ultrasound were older age (odds ratio 1.014 per year, p = 0.0119), leg swelling (OR 1.949, p = 0.0020) and history of previous DVT (OR 2.235, p = 0.0154).ConclusionsAlternative diagnoses explaining leg symptoms can be detected on whole-leg ultrasound in two thirds of patients with no evidence of acute DVT. Our data supports performing a comprehensive ultrasound evaluation beyond the venous system, particularly, in older patients, who present with leg swelling and a past history of DVT.

Common iliac vein obstruction in a symptomatic population is associated with previous deep venous thrombosis, and with chronic pelvic pain in females

ObjectiveThe objectives of this study were to determine the incidence of common iliac vein obstruction, gonadal vein incompetence, and renal vein compression/stenosis and to ascertain which referral reasons were associated with common iliac vein obstruction and gonadal vein incompetence in a population symptomatic for chronic venous insufficiency. MethodsData were obtained from patients, at least 18 years old, who were referred to a private vascular laboratory for venous duplex ultrasound examination between 2016 and 2017. Transabdominal ultrasound was used to assess the iliac, gonadal, and renal veins in a dedicated protocol. Demographic data, referral reasons (varicose veins, lower limb pain, lower limb edema, lower limb ulcers, chronic pelvic pain [CPP]) and history of previous deep venous thrombosis (DVT) were recorded. ResultsAmong 421 patients (78.6% female; 57.7 ± 16.7 years), 46.7% had iliac vein obstruction, 40.1% had gonadal vein incompetence, and 29.9% had renal vein compression/stenosis. Venous disorders were significantly more prevalent among female patients and on the left side. The most common referral reasons were varicose veins for both sexes, followed by lower limb pain for females and lower limb edema for males, none of which were associated with any venous obstruction or incompetence. Previous DVT was significantly associated with common iliac vein obstruction for all patients (β = .189; P = .001), despite its being a previous known diagnosis for only 11.4% of patients. Among females, CPP was also significantly associated with common iliac vein obstruction and gonadal vein incompetence (β = .246 [P < .001] and β = .201 [P = .012], respectively). Among those with CPP in this study, common iliac vein obstruction, with and without gonadal vein incompetence (33% and 35%, respectively), was more prevalent than gonadal vein incompetence alone (14%). ConclusionsHistory of DVT, as well as CPP among females warrants investigations of common iliac vein obstruction. Common iliac vein obstruction is likely to be a more significant contributor to CPP than gonadal vein incompetence.

Single- versus multiple-stage catheter-directed thrombolysis for acute iliofemoral deep venous thrombosis does not have an impact on iliac vein stent length or patency rates

BackgroundIncomplete venous thrombolysis and residual nonstented iliac vein disease are known predictors of recurrent deep venous thrombosis (DVT). Controversy exists as to whether the number of thrombolysis sessions affects total stent treatment length or stent patency. The goal of this study was to evaluate the outcomes of patients who underwent single vs multiple catheter-directed lysis sessions with regard to stent extent and patency. MethodsConsecutive patients who underwent thrombolysis and stenting for acute iliofemoral DVT between 2007 and 2018 were identified and divided into two groups on the basis of the number of treatments performed (one vs multiple sessions). Operative notes and venograms were reviewed to determine the number of lytic sessions performed and stent information, including size, location, total number, and length treated. End points included total stent length, 30-day and long-term patency, and post-thrombotic syndrome (Villalta score ≥5). The χ2 comparisons, logistic regression, and survival analysis were used to determine outcomes. ResultsThere were 79 patients who underwent lysis and stenting (6 bilateral interventions; mean age, 45.9 ± 17 years; 48 female). Ten patients (12 limbs) underwent single-stage treatment with pharmacomechanical thrombolysis, and the remaining 69 (73 limbs) had two to four operating room sessions combining pharmacomechanical and catheter-directed thrombolysis. Patients who underwent a single-stage procedure were older and more likely to have a malignant disease. These patients received less tissue plasminogen activator compared with the multiple-stage group (17.2 ± 2.2 mg vs 27.6 ± 11.6 mg; P = .008). Average stent length was 8.8 ± 5.2 cm for the single-stage group vs 9.2 ± 4.6 cm for the multiple-stage group (P = .764). Patients who underwent a single-stage procedure had no difference in average length of stay from that of patients who underwent multiple sessions (8.5 days vs 5.9 days; P = .269). The overall 30-day rethrombosis rate was 7.3%. Two-year patency was 72.2% and 74.7% for the single and multiple stages, respectively (P = .909). The major predictors for loss of primary patency were previous DVT (hazard ratio [HR], 5.99; P = .020) and incomplete lysis (HR, 5.39; P = .014) but not number of procedures (HR, 0.957; P = .966). The overall post-thrombotic syndrome rate was 28.4% at 5 years and was also not associated with the number of treatment sessions. ConclusionsSingle- vs multiple-stage thrombolysis for DVT is not associated with a difference in extent of stent coverage. Patency rates remain high for iliac stenting irrespective of the number of lytic sessions, provided lysis is complete and the diseased segments are appropriately stented.

Selecting Patients for Autologous Free Flap Breast Reconstruction in Body Mass Index &gt;35: Stratifying Surgical Risk Factors for Patient Inclusion or Exclusion

INTRODUCTION: Morbid obesity presents numerous challenges in autologous breast reconstruction. Along with considering other medical comorbidities, body mass index (BMI) alone can serve as an overall denominator in the decision-making process to offer or decline reconstruction. METHODS: Retrospective chart review was performed on N = 350 patients who underwent bilateral breast reconstruction using deep inferior epigastric perforator flaps (n = 654 flaps). Patients were divided into 2 groups: patients with BMI <35 (group 1; N1 = 273 patients; n1 = 508 flaps) and patients with BMI ≥35 (group 2; N2 = 77 patients; n2 = 146 flaps). Comorbidities including age, BMI, hypertension, diabetes mellitus, autoimmunity, smoking status, previous deep venous thrombosis (DVT)/PE, and previous abdominal surgery were tracked. Donor site complications including wounds, infection, seroma, hematoma, and DVT/PE and abdominal bulge were tracked. Flap losses and hospital stays were accounted. All data were collected using a centralized REDCap database. Analysis was performed with SPSS: continuous variables were analyzed with t tests, and binary variables were analyzed with chi-square, or Fischer’s exact test for subgroups with n < 5. RESULTS: Age, comorbidities, and medical histories were equivalent between groups, except for diabetes mellitus: group 2 (21%) had a significantly higher rate of diabetes mellitus than group 1 (7%; P < 0.01). Rates of infections requiring intravenous antibiotics (P = 0.056), seroma requiring operation (P = 0.750), hematoma requiring operation (P = 0.356), and DVT/PE (P = 0.512) were equivalent between groups. Rate of wound complications requiring operative repair was higher in group 2 (16%) than in group 1 (7%; P = 0.013). Surgical intensive care unit stay after flap procedure was equivalent between groups (group 1 = 2.22 days; group 2 = 2.32 days; P = 0.180). Total hospital stay was equivalent between groups (group 1 = 4.00 days; group 2 = 4.21 days; P = 0.091). Rates of abdominal bulge were equivalent between groups (group 1 = 4%; group 2 = 6%; P = 0.361). Umbilicus was sacrificed significantly more in group 2 (46%) than in group 1 (10%; P < 0.01). Flap loss was significantly higher in group 2 (4/146, 3%) than in group 1 (3/508, 0.6%; P = 0.026). Overall combined flap loss was 1%. DISCUSSION: In our study, offering deep inferior epigastric perforator flaps to patients with BMI >35 seems to have a 5-fold increase in flap loss. Despite attempting to decrease wound complications in higher BMI patients by sacrificing umbilicus, operative intervention for postoperative wound complications is still more than twice that of lesser BMI patients. This could be accounted by 3 times higher diabetes mellitus encountered in our higher BMI group. Based on individual practice patterns, patients with BMI >35 can be educated of their higher risks in consideration as a candidate for free flap breast reconstruction.

Le ulcere flebostatiche recidive degli arti inferiori: analisi di un’esperienza/Recurrent venous leg ulcers: clinical analysis of an experience

Nonostante i recenti progressi in tema di wound care, le ulcere varicose degli arti inferiori restano un problema frequente, con un alto tasso di recidiva. In questo lavoro abbiamo esaminato la storia clinica, la storia chirurgica e le patologie associate di 133 pazienti affetti da ulcera varicosa degli arti inferiori, di cui 56 da ulcera recidiva o plurirecidiva. L’analisi dei fattori di rischio potenziale per recidiva ha evidenziato come la presenza di varici recidive, una pregressa trombosi venosa profonda, problemi ortopedici, interventi ortopedici, l’obesità e un’età inferiore a 60 anni siano fattori di rischio potenziale per una recidiva dell’ulcera. La combinazione di uno più fattori di rischio assume significatività per la possibilità di una recidiva; si passa dal 22,7% in assenza di fattori di rischio al 33% per i pazienti che ne presentano due, fino al 57,5% in presenza di tre fattori di rischio e all’81,3% per quattro o più. L’ulcera varicosa richiede un follow-up stretto del paziente e una terapia elastocompressiva continua, che deve vedere una stretta collaborazione del paziente e un’attenzione specifica ai fattori di rischio.&#x0D; Despite recent advances in wound care, varicose ulcers of lower limbs remain frequent and display a high rate of recurrence. In this paper, we examined the clinical, surgical histories and associated diseases of 133 patients with venous ulcers of the lower limbs, which were recurrent in 56 cases. The analysis of potential risk factors for recurrence showed that the presence of recurrent varicose veins, a previous deep venous thrombosis, orthopedic problems, previous orthopedic procedures, obesity and age lower than 60 are potential risk factors for ulcer recurrence. Furthermore, the association of one or more risk factors increased the likelihood of relapse, from 22.7% with no risk factors to 33% with 2 risk factors, up to 57.5% with 3 risk factors, and up to 81.3% with 4 risk factors or more. Venous ulcers require close follow-up and continuous elastic compression, close collaboration by the patient and specific focus on risk factors.

A Study of Risk Factors of Chronic Venous Insufficiency and its Association with Features Suggestive of Preceding or Present Deep Venous Thrombosis.

Background:Deep venous thrombosis (DVT), even though resolved, may damage the valves and may lead to chronic venous insufficiency (CVI). We designed the present study to examine the thrombotic markers or other ultrasound features in the absence of active thrombosis in patients presenting with features suggestive of CVI.Materials and Methods:It was a cross-sectional study of 50 DVT patients. We collected a detailed history of presenting symptoms (onset, progression, and duration) and associated history of aggravating factors. After classifying the patients, color Doppler investigation for DVT and venous incompetence and blood investigations such as Factor V, D-Dimer, total cholesterol, total triglycerides, homocysteine, high-density lipoproteins, low-density lipoproteins (LDL), and very LDL were done.Results:We found a raised Factor V significantly more in patients classified as severe under clinical classification compared with nonsevere (19% and 0%; P = 0.05) and in patients with a high Venous Severity Clinical Score (VSCS) compared to those with a low VSCS score (17% and 0%; P = 0.03). We also found that perforators were significantly more in patients with a high VSCS score (88% and 58%; P = 0.02), in patients with a primary venous etiology compared with those without any venous etiology (97% and 1%; P < 0.0001), in patients with obstruction/reflux compared to those without any pathology (95% and 0%; P < 0.0001), and in patients with severe clinical classification compared with nonsevere patient (95% and 55%; P = 0.002).Conclusions:Clinical or subclinical DVT, an important cause of CVI, may not always be seen on ultrasound, especially after resolution. However, they may have the presence of blood parameters (Factor V and hyperhomocysteinemia) suggestive of DVT; these can be used as proxy markers for the current or previous DVT.

Surgical pulmonary embolectomy and catheter-directed thrombolysis for treatment of submassive pulmonary embolism.

Acute pulmonary embolism (PE) with preserved hemodynamics but right ventricular dysfunction, classified as submassive PE, carries a high risk of mortality. We report the results for patients who did not qualify for medical therapy and required treatment of submassive PE with surgical pulmonary embolectomy and catheter-directed thrombolysis (CDT). Between October 1999 and May 2015, 133 submassive PE patients underwent treatment with pulmonary embolectomy (71) and CDT (62). A multidisciplinary PE response team helped to determine the most appropriate treatment strategy on a case-by-case basis. The EkoSonic ultrasound-facilitated thrombolysis system (EKOS) was used for CDT, which was introduced in 2010. The mean age of submassive PE patients was 57.3 years, which included 36.8% females. PE risk factors included previous deep venous thrombosis (46.6%), immobility (36.1%), recent surgery (30.8%), and cancer (22.6%), P < 0.05. The most common indication for advanced treatment was right ventricular strain (42.9%), P = 0.03. The frequency of surgical pulmonary embolectomy remained stable even after incorporating the EKOS procedure into our treatment algorithm, with statistically similar operative mortality. Bleeding was observed in six CDT patients and one pulmonary embolectomy patient (P < 0.05). Follow-up echocardiography was available for 61% of the overall cohort, of whom 76.5% had no residual moderate or severe right ventricular dysfunction. Pulmonary embolectomy and CDT are important contemporary advanced treatment options for selected high-risk patients with submassive PE, who do not qualify for medical therapy.

Venous Ulcer: Could Endovenous Radiofrequency Ablation Improve Ulcer Healing? Preliminary Results of a Randomized Controlled Trial

Venous leg ulcers can take several weeks or months to heal and typically present with repeated cycles of ulceration, healing, and recurrence that result in high treatment costs and have a negative impact on patients’ quality of life. The multicomponent compression bandage system is still regarded as the “gold standard” to treat venous ulceration since previous randomized controlled trials failed to show improvement in ulcer healing rates by venous insufficiency surgical treatment despite decrease of ulcer recurrence risk. The current study was designed to investigate whether radiofrequency endovenous ablation of saphenous and perforating insufficient veins could increase venous ulcer healing rates. We did a prospective, controlled, randomized, open-label trial at a single center in Brazil. Participants had venous leg ulcer related to saphenous and perforating vein insufficiency with no sign of current or previous deep venous thrombosis. We randomly assigned participants to receive a weekly-changed two-layer compression bandage system alone or surgical radiofrequency ablation of insufficient saphenous and perforating veins before starting to receive the same compression system. Participants were stratified by ulcer duration (>6 months or <6 months) and ulcer area (>5 cm2 or <5 cm2). The primary end points were ulcer healing rates 6, 12, and 24 weeks after start of treatment. From January 2015 to August 2017, there were 77 patients considered eligible for the study, but 21 participants were excluded before randomization because of treatment abandonment, pretreatment wound healing, ultrasound evidence of previous unknown deep venous thrombosis, and clinical deterioration. The 56 remaining patients were randomly allocated to two treatment groups: 29 to multicomponent compression bandage alone and 27 to combined surgical and compressive treatment. The study is still ongoing, and 24 patients have been under intervention. We have therefore considered for analysis 15 participants from the surgical group and 17 participants from the isolated compressive treatment group. There are no statistically significant differences between groups in ulcer healing rates after 6 weeks. However, after 12 weeks, 73% of surgically treated patients have their ulcers healed vs 65% of compression alone-treated patients (hazard ratio, 4.968; 95% confidence interval, 1.053-23.42; P = .043). After 24 weeks, ulcer healing rate differences are even more evident (100% vs 76%), with the chance of healing greater for the surgical group (hazard ratio, 6.278; 95% confidence interval, 1.693-23.28; P = .006). Until now, 12- and 24-week venous ulcer healing rates were significantly greater in participants treated by endovenous radiofrequency ablation of saphenous and perforating veins plus two-layer compressive bandages than in patients who were treated with compression alone. We expect this difference to be maintained until the end of the study.

Deep venous thrombosis in elderly patients as a surgical emergency at King Abdulaziz University Hospital, Jeddah, Saudi Arabia.

BackgroundDeep venous thrombosis (DVT) is a condition that occurs frequently among surgical, as well as acutely ill hospitalized medical patients, and is responsible for significant morbidity and mortality in hospitalized patients. Risk factors include older age, surgery and immobilization (as with bed rest, orthopedic casts, and sitting on long flights.ObjectiveThis study was conducted to identify the frequency and factors associated with occurrence of DVT among elderly patients referred to King Abdulaziz University (KAU) Hospital, Jeddah, Kingdom of Saudi Arabia.MethodsThe current study is a hospital based cross sectional study. The emergency, inpatients and outpatients’ departments at KAU hospital were reviewed. We studied all the referred elderly subjects during the study period. All elderly patients (540) referred to or admitted to the hospital departments and who were clinically suspected to have DVT and subjected to Doppler examination were included in the study. Data were analyzed using descriptive statistics and Chi square test.ResultsBased on the results of Doppler examination, DVT was detected in 97 (18.0%) of the studied elderly population. There were no significant differences in gender between patients who developed DVT and those who were negative by Doppler examination (p=0.018). Other comorbidities as diabetes, IHD and hypertension were significantly associated with the occurrence of DVT among the participants (p=0.05, 0.05 and 0.04 respectively). Furthermore, the other investigated factors such as being bed ridden, cancer, orthopedic cast and previous DVT were not significantly associated with the development of DVT among the studied elderly patients (p=0.42, 0.16, 0.45 and 0.75 respectively).ConclusionDVT has high prevalence in Jeddah; KSA. Thrombophilia screening should be regular for elderly patients with diabetes, hypertension and bed-ridden patients with recurrent DVT or patients with other risk factors. Knowing the most common risk factors and their significance in developing DVT is essential for early detection of DVT to prevent unwanted complications for elderlies.

Deep venous thrombosis among diabetic patients in King Abdulaziz University (KAU) Hospital, Jeddah, Kingdom of Saudi Arabia.

BackgroundDeep venous thrombosis (DVT) is a major cause of morbidity and mortality among hospitalized patients worldwide and, simultaneously, the most preventable. Studies revealed several risk factors of deep venous thrombosis in hospitalized patients.Objectiveto identify frequency and factors associated with occurrence of deep venous thrombosis among diabetic patients referred to King Abdulaziz University (KAU) Hospital, Jeddah, Kingdom of Saudi Arabia.MethodsThis cross-sectional hospital-based study was conducted from June to December, 2016. All diabetic patients referred to the hospital departments and who were suspected to have deep venous thrombosis (DVT) and subjected to Doppler examination were included in the study. A questionnaire was designed to obtain data about deep venous thrombosis frequency among participants and factors associated with the development of deep venous thrombosis among them. Data was collected through face to face interviews with patients included in the study. We used SPSS version 16 for data analysis through descriptive statistics and Chi-square test.ResultsDVT was detected in 14.7 % of the examined patients. There were significant and positive associations between age and DVT (X2=10.13, p=0.03) and between ischemic heart disease and DVT (X2=1.628, p=0.043) with the development of deep venous thrombosis among the studied patients. On the other hand, gender, other comorbidities, history of previous DVT, being bed ridden and using orthopedic casting were not significantly associated with the occurrence of deep venous thrombosis among the participants.ConclusionDVT development rate among the participants was 14.7 %. Aging was significantly associated with DVT occurrence. Most of the studied factors and comorbidities had no significant role in DVT development among participants and only ischemic heart disease was significantly associated with DVT development.

Risk Stratification Model: Lower-Extremity Ultrasonography for Hospitalized Patients with Suspected Deep Vein Thrombosis

The Wells score for deep venous thrombosis (DVT) has a high failure rate and low efficiency among inpatients. To create and validate an inpatient-specific risk stratification model to help assess pre-test probability of DVT in hospitalized patients. Prospective cohort study of hospitalized patients undergoing lower-extremity ultrasonography studies (LEUS) for suspected DVT. Demographics, physical findings, medical history, medications, hospitalization, and laboratory and imaging results were collected. Samples were divided into model derivation (patients undergoing LEUS 11/1/2012-12/31/2013) and validation cohorts (LEUS 1/1/2014-5/31/2015). A DVT prediction rule was derived using the recursive partitioning algorithm (decision tree-type approach) and was then validated. Adult inpatients undergoing LEUS for suspected DVT from November 2012 to May 2015, excluding those with DVT in the prior 3months, at a 793-bed, urban academic quaternary-care hospital with ~50,000 admissions annually. The primary outcome was the presence of proximal DVT, and the secondary outcome was the presence of any DVT (proximal or distal). Model sensitivity and specificity for predicting DVT were calculated. Recursive partitioning yielded four variables (previous DVT, active cancer, hospitalization ≥ 6days, age≥46 years) that optimized the prediction of proximal DVT and yield in the derivation cohort. From this decision tree, we stratified a scoring system using the validation cohort, categorizing patients into low- and high-risk groups. The incidence rates of proximal DVT were 2.9% and 12.0%, and of any DVT were 5.2% and 21.0%, for the low- and high-risk groups, respectively. The AUC for the discriminatory accuracy of the Center for Evidence-Based Imaging (CEBI) score for risk of proximal DVT identified on LEUS was 0.73. Model sensitivity was 98.1% for proximal and 98.1% for any DVT. In hospitalized adults, specific factors can help clinicians predict risk of DVT, identifying those with low pre-test probability, in whom ultrasonography can be safely avoided.

Case report: primary osteonecrosis associated with thrombophilia-hypofibrinolysis and worsened by testosterone therapy

BackgroundFamilial and acquired thrombophilia are often etiologic for idiopathic hip and jaw osteonecrosis (ON), and testosterone therapy (TT) can interact with thrombophilia, worsening ON.Case presentationCase 1: A 62-year-old Caucasian male (previous deep venous thrombosis), on warfarin 1 year for atrial fibrillation (AF), had non-specific right hip-abdominal pain for 2 years. CT scan revealed bilateral femoral head ON without collapse. Coagulation studies revealed Factor V Leiden (FVL) heterozygosity, 4G/4G plasminogen activator inhibitor (PAI) homozygosity, high anti-cardiolipin (ACLA) IgM antibodies, and endothelial nitric oxide (NO) synthase (eNOS) T786C homozygosity (reduced conversion of L-arginine to NO, required for bone health). Apixaban 5 mg twice daily was substituted for warfarin; and L-arginine 9 g/day was started to increase NO. On Apixaban for 8 months, he became asymptomatic. Case 2: A 32-year-old hypogonadal Caucasian male had 10 years of unexplained tooth loss, progressing to primary jaw ON with cavitation 8 months after starting TT gel 50 mg/day. Coagulation studies revealed FVL heterozygosity, PAI 4G/4G homozygosity, and the lupus anticoagulant. TT was discontinued. Jaw pain was sharply reduced within 2 months.ConclusionsIdiopathic ON, often caused by thrombophilia-hypofibrinolysis, is worsened by TT, and its progression may be slowed or stopped by discontinuation of TT and, thereafter, anticoagulation. Recognition of thrombophilia-hypofibrinolysis before joint collapse facilitates anticoagulation which may stop ON, preserving joints.

Risk factors of deep venous thrombosis associated with peripherally inserted central venous catheter in upper extremity in ICU

To analyze the incidence and its risk factors of peripherally inserted central venous catheter related upper extremity deep venous thrombosis (PICC-UEDVT) in intensive care unit (ICU). Clinical data of the patients received PICCs in ICU of the First Affiliated Hospital of Nanchang University from August 2013 to August 2016 were retrospectively analysed. The inclusion criteria in the study included: the age > 18 years old, catheter indwelling time > 1 week and the complete relevant information. The gender, age, history of deep venous thrombosis (DVT) and PICC; number of illness involved organs; complicated with hypertension, diabetes, infection or not; and acute physiology and chronic health evaluation II (APACHE II), duration of mechanical ventilation; D-dimer, platelet count (PLT), and activated partial thromboplastin time (APTT) were recorded. According to the occurrence of PICC-UEDVT, univariate analysis was performed to identify the risk factors of PICC-UEDVT and variables with statistical difference were selected to do multivariate binary logistic regression analysis for the confirmable independence risk factors. Six patients of the 61 cases occurred PICC-UEDVT with the occurrence rate of 9.8%. Time of occurrence was 9 days, 14 days (2 cases), 22 days, 28 days, 62 days after inserted catheter respectively. Univariate analysis demonstrated that previous DVT, D-dimer and big diameter PICC were risk factors associated with PICC-UEDVT [the previous DVT: 50.00% vs. 7.27%, P = 0.017; D-dimer > 5 mg/L: 66.67% vs. 18.18%, P = 0.021; 5F catheter: 83.33% vs. 29.09%, P = 0.016]. It was shown by multivariate logistic regression analysis that the previous DVT [odds ratio (OR) = 20.539, 95% confidence interval (95%CI) = 1.733-243.875, P = 0.017] and increasing size of catheter (OR = 18.070, 95%CI = 1.317-247.875, P = 0.030) were independent risk factors associated with the development of PICC-UEDVT. For critical patients with a history of DVT and D-dimer > 5 mg/L, especially for those with the catheter placement over 14 days in ICU, clinical staffs should remain on high alert for the development of PICC-UEDVT and take early effective measures to prevent it. Meanwhile the patient's vascular conditions should be precisely assessed using ultrasound before insertion, and the appropriate catheter size be selected to reduce the incidence of PICC-UEDVT. Color Doppler ultrasonography should be used for dynamic monitoring during the indwelling of PICC, so that PICC-UEDVT can be found as early as possible.

Doppler sonographic evaluation of venogenic extremity swellings: Analysis of 170 patients from Kano, Nigeria.

Deep venous thrombosis (DVT) is a serious problem that can potentially lead to many complications including life-threatening pulmonary arterial thrombosis. Screening and confirmation of the diagnosis are critical in the care of this condition. The objective of this study was to evaluate the role of Doppler sonography in diagnosing DVT and to illustrate the pattern in 170 suspected cases from our local environment. This study was conducted at our department over 18 months. A total of 170 patients with clinical suspicion of limb DVT were recruited. The characteristics of the patients, risk factor for DVT, and the site of the lesion were documented. Sonographic examination was done using 7.5 MHz linear and 3.5 MHz convex transducers. Out of the 170 patients, there are 89 (52.35%) males and 81 (47.65%) females. Their mean age was 50.6 years (+17.9 years). The common risk factors for DVT include chronic medical illness (28.8%), long distance travel (15.3%), previous DVT (8.8%), stroke/paralysis (5.3%), neoplasms (5.9%), pregnancy (5.9%), and trauma/surgery (5.9%). About 55.8% (95) of them were confirmed to have DVT on ultrasound while 44.2% (75) had normal ultrasound findings. There was a female preponderance among the 95 cases of DVT, 58.9% of them were females while 41.1% of them were males. It was found that contiguous femoro-popliteal and ilio-femoro-popliteal segments were most commonly thrombosed. These lesions were predominantly left sided (59.5%). There was a predominance of females and femoro-popliteal segments in DVT. Doppler ultrasound is very useful in the evaluation of extremity DVT. All clinically suspected cases should be evaluated with this modality due to limited sensitivity of clinical evaluation in the diagnosis of DVT. Further correlative studies in comparison to venography and hematologic indices are also recommended.