Screening For Deep Venous Thrombosis Research Articles

超音波検査による深部静脈血栓症に伴う血行動態の検討

We observed lower extremity blood flow in deep venous thrombosis (DVT) patients using ultrasonography after orthopaedic hip joint operation. Between July 1999 and June 2000, four patients underwent total hip arthoplasty and hemi-surface arthroplasty was performed on one. We measured the flow volume of the femoral vein and the great saphenous vein using ultrasonography on all patients after venography. The patients consisted of one male and four females with a mean age of 67 years (age range: 47 to 74 years). Deep venous thrombosis was identified in two (40 percent) of the five patients. There was no significant difference in the flow volume of the femoral vein between the DVT (+) group and DVT (-) groups (129±33ml/m, 165±89ml/m). The flow volume of the great saphenous vein in the DVT (+) group increased significantly (189±108ml/m, 51±22ml/m p<0.01). Since measurement of the flow volume of the great saphenous vein was comparatively easy using ultrasonography, we concluded that it is useful for DVT screening.

The natural history of calf vein thrombosis: Lysis of thrombi and development of reflux

Purpose: Although the fact is well accepted that deep venous thrombosis (DVT) of the iliac, femoral, and popliteal veins can lead to the post-thrombotic (postphlebitic) syndrome, the significance of isolated calf DVT on the development of late venous sequelae and physiologic calf dysfunction is unknown. The purpose of this study was to review the outcome of 58 limbs with isolated calf DVT and report the clinical, physiologic, and imaging results up to 6 years after the onset of DVT. Methods: The study consisted of 58 limbs of 54 patients in whom isolated calf vein DVT was diagnosed between 1990 and 1995. Proximal propagation of clot, lysis of thrombi, and development of symptomatic pulmonary emboli were examined. Of the patients, 28 received anticoagulation therapy, and 26 did not, but they had follow-up with serial duplex scans. At late follow-up 1 to 6 years later (median, 3 years), 23 patients were examined for the post-thrombotic syndrome, and all 23 underwent clinical examination, color-flow duplex scanning, and air plethysmography. Results: Proximal propagation of DVT from the calf veins into the popliteal or thigh veins occurred in 2 of 49 cases (4%) within 2 weeks of diagnosis. No patient had clinically overt pulmonary emboli develop regardless of whether anticoagulation therapy was received or not. The most common site for calf DVT was the peroneal vein (71%). Complete lysis of calf thrombi was found in 88% of the cases by 3 months. At 3 years, 95% of the patients were either asymptomatic or mildly symptomatic, and 5% had discoloration of the limb. No ulcers occurred. By air plethysmography, physiologic abnormalities were found in 27% of the cases, which was not significantly different from normal controls. Valvular reflux by duplex scanning of the calf vein segment with DVT was found in 2 of 23 cases (9%). However, reflux in at least one venous segment not involved with DVT was found in 7 of 23 cases (30%), which was higher than, but not statistically different from, normal controls, with reflux occurring in 5 of 26 cases (19%). Conclusions: Isolated calf vein DVT leads to few early complications (ie, clot propagation, pulmonary emboli) and few adverse sequelae at 3 years. The peroneal vein is most commonly involved and should be a part of the routine screening for DVT. Lysis of clot usually occurs by 3 months. Although valvular reflux rarely is found in the affected calf vein at 3 years, reflux may be found in adjacent uninvolved veins in approximately 30% of the cases. The question of whether this will lead to future sequelae, such as ulceration, will require longer follow-up. (J Vasc Surg 1998;28:67-74.)

Low Molecular Weight Heparin Decreases Proximal and Distal Deep Venous Thrombosis Following Total Knee Arthroplasty

To assess the efficacy and safety of low molecular weight heparin (LMWH) as deep venous thrombosis (DVT) prophylaxis following total knee arthroplasty. Medline 1986 to June 1997, Embase, and manufacturers were used to identify randomized controlled trials. Trials included were randomized studies of LMWH with routine radiological screening for DVT. Placebo or active controls were included. Two reviewers independently screened trials for inclusion, and assessed their quality. Pooled relative risk estimates of DVT and proximal DVT rates were calculated using a DerSimonian and Laird random effects model. Sensitivity of the results to the type of control used and the quality of the trial was assessed. The relative risk of DVT for a patient given LMWH is 0.73 (95% CI 0.66 to 0.80) when compared with patients treated with adjusted dose heparin or warfarin controls. The relative risk for proximal DVT is 0.58 (95% CI 0.38 to 0.90). The relative risk of pulmonary emboli in the LMWH group was 0.55 (95% C.I. 0.20 to 1.57). No excess of bleeding was recorded in the LMWH group. Low molecular weight heparin is more efficacious than either adjusted dose heparin or adjusted dose warfarin, when used to prevent DVT and proximal DVT following total knee arthroplasty.

SCREENING FOR DEEP-VENOUS THROMBOSIS AFTER HIP AND KNEE REPLACEMENT WITHOUT PROPHYLAXIS

We performed routine venography after operation in a consecutive series of 252 patients with total joint arthroplasties in whom no form of routine chemical or mechanical prophylaxis had been used. The prevalence of deep-vein thrombosis (DVT) was 32% (16% distal, 16% proximal) after total hip replacement and 66% (50% distal, 16% proximal) after total knee replacement (p &lt; 0.001). We did not treat distal DVT. There were only two readmissions within three months of surgery because of thromboembolic disease. There were two deaths within this period, neither of which was due to pulmonary embolism.

Screening for deep-venous thrombosis after hip and knee replacement without prophylaxis.

We performed routine venography after operation in a consecutive series of 252 patients with total joint arthroplasties in whom no form of routine chemical or mechanical prophylaxis had been used. The prevalence of deep-vein thrombosis (DVT) was 32% (16% distal, 16% proximal) after total hip replacement and 66% (50% distal, 16% proximal) after total knee replacement (p < 0.001). We did not treat distal DVT. There were only two readmissions within three months of surgery because of thromboembolic disease. There were two deaths within this period, neither of which was due to pulmonary embolism.

The detection and management of proximal deep venous thrombosis in patients with acute acetabular fractures: a follow-up report.

To determine the efficacy of a thromboprophylaxis protocol that included deep venous thrombosis (DVT) prophylaxis (subcutaneous heparin), preoperative screening with magnetic resonance venography (MRV), and therapeutic management (vena caval interruption preoperatively, therapeutic heparin anticoagulation postoperatively) when indicated. Prospective, consecutive. Tertiary referral, teaching hospital in New York City. One hundred one patients with acutely displaced acetabular fractures. Preoperative MRV was performed to assess vascular structures. Patients with proximal DVT received vena caval filter interruption preoperatively and therapeutic warfarin postoperatively. Patients without proximal DVT received only subcutaneous heparin preoperatively and low-dose warfarin postoperatively. Forty-nine asymptomatic thrombi were identified in thirty-four of 101 patients (34 percent). Location of thrombi were in the popliteal vein in four of forty-nine patients (8 percent), superficial femoral vein in eight of forty-nine (16 percent), common femoral vein in thirteen of forty-nine (27 percent), external iliac vein in six of forty-nine (12 percent), internal iliac vein in fourteen of forty-nine (29 percent), and common iliac vein in four of forty-nine (8 percent). Thrombi were isolated to the injured extremity in twenty-six of thirty-four patients (76 percent), bilateral in four of thirty-four (12 percent), and isolated to the uninjured extremity in four of thirty-four (12 percent). Twenty-six of the thirty-four patients with proximal thrombi received preoperative vena caval filters. As a result of this protocol, only one patient (1 percent) developed a nonfatal pulmonary embolism. MRV is a sensitive screening examination that allows the placement of inferior vena caval filters based on documented proximal thrombosis. We anticipate that preoperative DVT screening with MRV will significantly decrease the incidence of fatal pulmonary embolism in this high-risk population.

Clinical results of Greenfield filter use in patients with cancer

The purpose of this report is to examine the outcomes for patients with an underlying diagnosis of malignancy who have had Greenfield vena caval filters placed for protection from pulmonary embolism, and to identify areas requiring further study. This was a retrospective review of data obtained from the Greenfield filter registry and the University of Michigan Tumor Registry for 166 patients treated at the University of Michigan Medical Center between January 1988 and June 1994. The 84 men and 82 women (mean age 57.8 years) had a mean survival time of 10 (range 1–68) months. This differs significantly from patients in the filter registry who do not have malignancy ( P<0.0001). Some 51% experienced recurrence of their malignancy at a mean of 20 months; this timing corresponds to development of new or recurrent thrombembolism and filter placement. Distant metastases were present in 72% of patients at the time of filter placement. In conclusion, as anticipated, filter patients with malignancy have a significantly shorter survival time than those with other concurrent diseases. A temporal association between the progression of the malignancy and the occurrence of thromboembolism is observed in this population and requires further study. Future studies regarding the use of vena caval filters in these patients and the role of diagnostic screening for deep venous thrombosis and occult recurrence of malignancy should focus on efficacy, safety, cost and patient quality of life rather than on survival. © 1997 The International Society for Cardiovascular Surgery.

Deep venous thrombosis: Incidence on admission to a brain injury rehabilitation program

Objective: To determine the incidence of deep venous thrombosis (DVT) in brain injured individuals at time of admission to a brain injury (BI) rehabilitation program. Design: Prospective study, sequential case series. Setting: University tertiary care BI rehabilitation center. Data Set: Eighty-two traumatic brain injury (TBI) and 71 atraumatic brain injury (ABI) patients were consecutively admitted to our BI unit over a 12-month period and screened within 24 hours of admission for a lower extremity DVT with color flow duplex Doppler ultrasonography. All patients had been prophylaxed with either subcutaneous heparin anticoagulation therapy or intermittent compression devices, and all patients were within 2 months of the original BI. Main Outcome Measure: Evidence of intrinsic venous occlusion by duplex Doppler. Results: DVTs were detected and treated prior to rehabilitation admission in three patients (2%), and these persisted at rehabilitation admission. New DVTs were detected at time of rehabilitation admission in 17 patients (11%). All were occult DVTs; none of the 17 patients had clinical findings indicative of acute DVT. No significant differences were noted in the TBI group when age, highest 24-hour Glasgow Coma Scale score, length of acute hospitalization, type of DVT prophylaxis, or presence of an extremity fracture were compared for individuals with and without DVT. No significant differences were noted in the ABI group when age, length of acute hospitalization, and type of DVT prophylaxis were compared for individuals with and without DVT. Conclusion: The overall incidence of DVTs was 13% and the incidence of occult DVT was 11%. Individuals with TBI had an overall incidence of DVTs of 20% and an occult DVT incidence of 18%. Individuals with ABI had an overall incidence of DVT's of 6% and an occult DVT incidence of 4%. These findings indicate the importance of baseline screening for DVT in this patient population.

A prospective study of the incidence of deep venous thrombosis in hospitalized children.

It is commonly believed that the incidence of deep venous thrombosis (DVT) in hospitalized children is less than in adults. However, it is possible that the disease is significantly underdiagnosed in children because the index of suspicion of pediatric practitioners is low, a substantial number of patients may have no symptoms, and DVT screening is not routinely performed. We therefore undertook a prospective study to define the incidence of DVT in hospitalized children with no symptoms. Patients included in the study were those younger than 18 years of age who were hospitalized for more than 72 hours and were identified to have two or more risk factors for the development of DVT and had at least one screening duplex scan. Risk factors for the development of DVT considered were a history of DVT or pulmonary embolism, recent operation, immobilization, trauma, stroke or acute neurologic deficit, the presence of cancer, sepsis, greater than 150% ideal body weight, a hypercoagulable state, and the presence of a femoral venous catheter. Over the 9-month period ending December 1994, 1997 patients 17 years of age and younger were admitted to the hospital, and 59 patients including 19 girls and 40 boys were enrolled in the study. The one patient with DVT was a 17-year-old boy hospitalized after a motor vehicle accident with blunt head trauma and a neurologic deficit who underwent multiple orthopedic and neurosurgical procedures. The development of acute DVT in children is unusual. As a result, DVT prophylaxis and screening is unnecessary in young children with only two risk factors for the development of the disease. Young age appears to be an important protective risk factor for the prevention of DVT.

Screening for deep venous thrombosis in asymptomatic postoperative orthopedic patients using color Doppler sonography: analysis of prevalence and risk factors.

The purpose of our study was to assess the prevalence and risk factors for sonographically detectable lower extremity deep venous thrombosis (DVT) in asymptomatic patients following major orthopedic surgery. We performed color Doppler sonography of the lower extremities in 474 asymptomatic patients following major hip or knee surgery. We determined the prevalence of lower extremity DVT and used stepwise logistic regression to identify factors predictive of DVT. All patients received routine prophylactic measures. The prevalence of DVT was 7%. Laterality of surgery, age, and gender were all independent predictors of DVT (p < or = .01): the odds of having DVT were 20 times higher in the leg that was operated upon than in the leg that was not; the odds of DVT rose by a factor of 1.5 per decade of life; and the odds of DVT were 3.4 times greater in men than in women. DVT was more common in patients who had received general rather than epidural anesthesia, with borderline significance (p = .06). The length of anesthesia and the joint involved (hip or knee) were not predictive of DVT (p > .10). Despite prophylaxis, DVT is a relatively common postoperative complication in patients who undergo major orthopedic procedures. Routine screening for DVT is warranted in asymptomatic patients who have undergone hip or knee surgery, and color Doppler sonography, despite its limitations, offers a reasonably accurate noninvasive method for screening these patients. Subsets of patients who are at particular risk include the elderly, male patients, and patients who have undergone general anesthesia. The low prevalence of DVT in limbs not operated upon suggests that routine screening may be limited to evaluating the affected limbs only, thus helping to minimize the cost of screening.

Cost-effectiveness of routine screening for proximal deep venous thrombosis in acquired brain injury patients admitted to rehabilitation

Objective: Determine the prevalence of proximal deep venous thrombosis (DVT) among acquired brain injury patients on admission to rehabilitation and assess cost-effectiveness of routine ultrasound screening for proximal DVT in those patients. Design: Prospective study, sequential case series. Setting: University tertiary care rehabilitation center. Data Set: One hundred sixteen traumatic brain injury patients (TBI) and 48 nontraumatic brain injury patients were admitted to our brain injury (BI) unit over a 21-month period and screened for a DVT on admission to rehabilitation utilizing real time, spectral Doppler, and color Doppler ultrasound. Patients with a previous clinically recognized and treated DVT were excluded. No patients had been treated with prophylactic anticoagulation or intermittent anticoagulation since their BI and all patients were within 4 months of the original injury. Results: Fourteen patients in total (8.5%) were found to have a DVT in the thigh or popliteal area, 9 of the 116 patients in the TBI group (7.8%), and 5 of the 48 patients in the nontraumatic BI group (10.4%). Statistically, there was no significant difference in the total number of detected proximal lower extremity DVT's between the TBI and the nontraumatic BI groups (Fisher's exact test). In the TBI group 22 patients had associated lower extremity or pelvic fractures, but this factor appeared not to be significant, because only 1 of the 22 patients was discovered to have a DVT. The average admission Glascow Coma Score (GCS) of the TBI group was 8.6 but there was no correlation with the GCS and the prevalence of DVT. The additional cost of screening for and treating the additional DVTs utilizing color Doppler ultrasound is conservatively estimated to be $674.84 per patient admitted to the BI rehabilitation unit. It can be estimated the cost of saving one life is $129,527.83. Conclusion: DVT screening in this patient population appears to be more cost-effective than mass screening programs for either breast cancer or colorectal cancer. The cost per year of life saved, estimated at only $2,977.65 ($129,527.83/43.5 years) for DVT screening for brain injury patients on admission to rehabilitation, is lower than those costs proposed for comparable programs with significant social support.

Diagnostic significance of thrombin-antithrombin III complex (TAT) and D-dimer in patients with deep venous thrombosis.

Thrombin-antithrombin III (TAT) and D-dimer were measured in 50 patients suspected of deep venous thrombosis (DVT) to assess the usefulness of these indicators in the diagnosis of DVT. DVT was diagnosed by ultrasonography (compression method and Doppler imaging). In patients who were negative for DVT (Group A), TAT was 3.8 +/- 2.36 micrograms/L (mean +/- SD) and D-dimer was 0.7 +/- 0.69 micrograms/ml, whereas in patients diagnosed with DVT (Group B), TAT was 20.4 +/- 19.10 micrograms/L (p < 0.001) and D-dimer was 9.0 +/- 9.21 micrograms/ml (p < 0.001). Thus, Group B had significantly higher levels of both markers. Moreover, 19 of the 23 cases in Group B had acute DVT, with symptoms appearing within 2 weeks of onset. When the cutoff for a positive diagnosis of DVT was set at TAT of 7.0 micrograms/L or more and D-dimer of 3.0 micrograms/ml or more, sensitivity was 84%, specificity was 96%, and accuracy was 90%. Based on these results, we concluded that TAT and D-dimer are extremely useful in screening for acute DVT.

Color Doppler Flow Imaging For Deep Venous Thrombosis Screening in Patients Undergoing Pelvic Lymphadenectomy and Radical Retropubic Prostatectomy for Prostatic Carcinoma

Patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy are traditionally considered to be at high risk for postoperative venous thromboembolic complications. A prospective deep venous thrombosis screening regimen was initiated at our medical center in 1990 following 2 cases of fatal pulmonary embolism that occurred after hospital discharge. During a 3-year period 245 consecutive patients undergoing radical retropubic prostatectomy for prostate cancer were screened postoperatively for lower extremity deep venous thrombosis using ultrasound duplex scanning with color Doppler flow imaging. The results were correlated only with the development of clinical deep venous thrombosis. No additional diagnostic modalities were used to confirm a normal venous system in asymptomatic patients. Venous thromboembolic complications were encountered in 9 of the 245 patients (3.6 percent). In 2 patients deep venous thrombosis was associated with nonfatal pulmonary embolism. Only 2 of the 9 cases of deep venous thrombosis were detected by color Doppler flow imaging screening. The striking decrease in the incidence of deep venous thrombosis following radical prostatectomy in the last decade and the low yield of screening at a single point in time may warrant reconsideration of the need for deep venous thrombosis screening among patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy for prostate cancer.

Duplex ultrasound screening for deep venous thrombosis in the puerperium.

Duplex ultrasound screening for deep venous thrombosis in the puerperium.

Ultrasonographic Screening of Deep Venous Thrombosis in Patients Undergoing Total Hip Replacement

The incidence of deep venous thrombosis (DVT) after total hip replacement is estimated to be up to 45%. Venography is widely accepted as the gold standard procedure for diagnosis of DVT. With the purpose of detecting the presence of DVT in asymptomatic patients operated on for primary hip replacement, we adopted Real-time B-Mode ultrasonography in order to evaluate its specificity and sensitivity in 68 patients. A venography was performed in all the cases in order to obtain a gold standard to compare with sonography. Sensitivity and specificity of sonography for femoral thrombosis were 71.4% and 97.6% respectively. Ultrasounds were not able to detect thrombosis of the calf veins but the risk of an evolution to worse pulmonary embolism is quite insignificant at this level. We suggest the use of B-mode ultrasonography for DVT screening of lower limbs in all the patients undergoing total hip replacement.

Postoperative deep venous thrombosis screening, monitoring and management utilizing duplex ultrasonography. A survey of 110 total hip arthroplasties

Postoperative deep venous thrombosis screening, monitoring and management utilizing duplex ultrasonography. A survey of 110 total hip arthroplasties

Vascular Ultrasonography for Deep Venous Thrombosis After Total Knee Arthroplasty

Screening vascular ultrasonography was performed postoperatively on 164 consecutive patients being treated with total knee arthroplasty (203 total knee prostheses). This consisted of examination of the femoral and popliteal veins of the operative extremity with color flow and duplex ultrasonography one week postoperatively. All patients received deep venous thrombosis (DVT) prophylaxis with sequential compressive pneumatic stockings, low-dose warfarin, continuous passive motion, and early mobilization. All patients were observed prospectively for thromboembolic sequelae for a minimum of six months postoperatively. The screening study was significantly limited in six (3%) of the 203 total knee prostheses. The overall incidence of sonographically detected proximal DVT or symptomatic calf vein thrombosis was 3% (6/203), and the incidence of symptomatic pulmonary embolism was 2% (4/203). Four of the ten thromboembolic complications occurred after hospital discharge. Results of this study suggest that duplex ultrasonography can be a useful screening method for identification of venous thrombosis after TKA. Patients with asymptomatic proximal DVT can be identified and appropriately treated before development of serious thromboembolic complications. Routine screening for DVT after TKA can avoid the considerable expense, inconvenience, and potential risk of complications associated with prolonged postoperative prophylactic anticoagulation. The combination of sequential compressive stockings, early mobilization, and low-dose warfarin appears to be a safe and effective prophylactic regimen against venous thromboembolic disease in these high-risk patients.

A computerised system of screening for deep venous thrombosis

We have developed a computer controlled system of strain gauge plethysmography for use as a screening tool for proximal segment venous thrombi which is simple to use, well tolerated by patients and extremely accurate. The computerised test was evaluated in 171 limbs of 163 symptomatic patients by comparison with subsequent ascending venography. Each of twenty occlusive proximal segment thrombi were identified, one non occlusive thrombus screened normal giving an overall sensitivity of 95.2%. The specificity of the test was 80% with a negative predictive value of 99.0%. The computerised system allows accurate screening for proximal segment venous thrombosis, and may permit more selective use of venography in the symptomatic post-operative limb.

Value of Liquid Crystal Contact Thermography and Plasma Level of D-Dimer for Screening of Deep Venous Thrombosis Following General Abdominal Surgery

Because the use of radioactive fibrinogen uptake test (FUT) has become questionable both for ethical (risk of virus transmission) and technical (lack of sensitivity) reasons, we investigated the potential value of two alternative methods for screening of asymptomatic deep venous thrombosis following elective digestive surgery: liquid crystal contact thermography (LCCT) and measurement of plasma concentration of D-dimer (DD), as compared with bilateral ascending phlebography. Out of 194 patients, 185 underwent phlebography on the 8th (0-19, median and range) postoperative day. Despite prophylaxis with low-molecular-weight heparin and elastic stockings, DVT was detected on phlebography in 58 legs of 45 patients. Sensitivity of LCCT with respect to the presence of DVT was 55% (n = 184 patients) or 28% (n = 368 legs) with a specificity of 67% and 82%, respectively. These poor performances were obtained despite a good interobserver agreement for the LCCT assessments (overall kappa coefficient of 0.66 between three experts). The most accurate cut-off of DD for discriminating patients with or without DVT was 3,000 micrograms/l, as determined by ROC curve analysis. Sensitivity of a DD level of more than 3,000 micrograms/l for the presence of phlebographically documented DVT on the 8th postoperative day was 89% for a specificity of 48%. Thus, LCCT cannot be used for screening of postoperative, mainly asymptomatic DVT following general surgery. On the other hand, measurement of plasma DD may be useful for initial screening, a negative result (level less than 3,000 micrograms/l) allowing to exclude DVT (negative predictive value of 93%) and a positive result (positive predictive value of 35%) requiring confirmation by phlebography.(ABSTRACT TRUNCATED AT 250 WORDS)

Post-operative thromboembolism in neurosurgery

This study compares the safety and effectiveness of two methods for the prophylaxis of post-operative thromboembolism in neurosurgical patients: A: low-dose heparin (5,000 IU X 2 s.c.) started preoperatively and continued daily for one week post-operatively, and B: per-operative electrical calf muscle stimulation with groups of impulses plus post-operative dextran infusions every other day for one week. Neurosurgical patients aged 40 years or more with normal laboratory coagulation values and operated under general anaesthesia were included. The 125:I-fibrinogen uptake test (FUT) was used for screening and phlebography for verification of deep venous thrombosis (DVT). 122 patients entered the study and 104 completed the prophylactic protocol, 58 in group A and 46 in group B. The two groups were comparable according to pre-operative data and distribution of diagnoses. 89 patients completed screening for post-operative DVT. We found an overall incidence of 5/49 (10 percent) DVT in group A and 5/40 (13 percent) in group B, compared to a frequency of 32-50 percent for controls without prophylaxis reported in the literature, In spite of prophylaxis our patients with intracranial neoplasms and intracranial vascular disease showed a relatively higher incidence of DVT, 4/23 (17 percent) and 4/14 (29 percent) respectively, compared to patients with spinal diagnoses 2/25 (8 percent). In combination with cranial diagnoses paretic lower limbs meant an apparent risk factor, 4/7 (57 percent). However, paretic limbs appearing in cases with spinal disorders did not predetermine an unsuccessful prophylaxis, 2/14 (14 percent). Blood loss, transfusion requirements and post-operative complications did not differ significantly between the two prophylactic groups.(ABSTRACT TRUNCATED AT 250 WORDS)