Superficial Vein Thrombosis Research Articles

Incidence of Thrombosis at Different Sites During the Follow-Up Period in Essential Thrombocythemia: A Systematic Review and Meta-Analysis.

Thrombotic events are the most frequent manifestations of essential thrombocythemia (ET). The objective of this study is to determine the incidence of thrombosis at different sites on follow-up in patients with ET. We searched PubMed, Web of Science, and The Cochrane Library databases and calculated the incidence of thrombosis by pooling and analyzing the extracted data using a random-effects model. A total of 70 studies (N = 25,805) were included in the analysis. The total and annual incidences of arterial thrombosis on follow-up were 13.4% and 2.0%, respectively. The total and annual incidences of the different manifestations of arterial thrombosis were as follows: stroke (5.3% and 0.8%), transient ischemic attack (5.1% and 1.2%), myocardial infarction (2.4% and 0.5%), unstable angina (0.9% and 0.2%), and peripheral arterial thrombosis (2.0% and 0.2%), respectively. In contrast, the total and annual incidences of arterial thrombosis in JAK2-positive patients were 18.4% and 2.7%, respectively. The total and annual incidences of arterial thrombosis in JAK2-negative patients were 5.9% and 0.8%, respectively. The total and annual incidences of venous thrombosis were 5.5% and 0.7%, respectively, and the incidences of the different manifestations of venous thrombosis at different sites were as follows: peripheral venous thrombosis (2.9% and 0.5%), superficial venous thrombosis (1.8% and 0.7%), deep venous thrombosis (1.6% and 0.3%), abdominal venous thrombosis (0.8% and 0.1%), pulmonary embolism (0.3% and 0.1%), and cerebral venous thrombosis (0.2% and 0%), respectively. The total and annual incidences of venous thrombosis in JAK2-positive patients were 7.4% and 1.2%, respectively. The total and annual incidences of venous thrombosis in JAK2-negative patients were 1.6% and 0.4%, respectively. The incidence of arterial thrombosis was higher than that of venous thrombosis in patients with ET. Arterial thrombosis manifested with cerebral arterial thrombosis, followed by cardiac thrombosis. Venous thrombosis events were mainly peripheral and superficial venous thrombosis. JAK2-positive patients have a higher incidence of arterial and venous thromboses than JAK2-negative patients, the sequence of thrombsis sites was similar to that of the overall patients.

Fondaparinux Sodium: Recent Advances in the Management of Thrombosis.

Fondaparinux sodium is a chemically synthesized selective factor Xa inhibitor approved for the prevention and treatment of venous thromboembolic events, that is, deep vein thrombosis, pulmonary embolism, and superficial vein thrombosis, in acutely ill (including those affected by COVID-19 or cancer patients) and those undergoing surgeries. Since its approval in 2002, the efficacy and safety of fondaparinux is well demonstrated by many clinical studies, establishing the value of fondaparinux in clinical practice. Some of the advantages with fondaparinux are its chemical nature of synthesis, minimal risk of contamination, 100% absolute bioavailability subcutaneously, instant onset of action, a long half-life, direct renal excretion, fewer adverse reactions when compared with direct oral anticoagulants, and being an ideal alternative in conditions where oral anticoagulants are not approved for use or in patients intolerant to low molecular weight heparins (LMWH). In the last decade, the real-world use of fondaparinux has been explored in other conditions such as acute coronary syndromes, bariatric surgery, in patients developing vaccine-induced immune thrombotic thrombocytopenia (VITT) and in pregnant women with heparin-induced thrombocytopenia (HIT), or those intolerant to LMWH. The emerging data from these studies have culminated in recent updates in the guidelines that recommend the use of fondaparinux under various conditions. This paper aims to review the recent data and the subsequent updates in the recommendations of various guidelines on the use of fondaparinux sodium.

Transient Ischemic Attack Following Foam Sclerotherapy for Chronic Venous Ulcer with No Cardiac Defect - A Rare Case Scenario

Abstract Chronic venous insufficiency (CVI) constitutes one of the main causes for lower limb ulceration. Foam sclerotherapy forms an important part of CVI treatment. It is used to treat truncal incompetence, perforating veins, and primary and secondary varicosities as well as reticular and spider veins. It is used either alone or in addition to the endovenous ablative techniques. Although usually done as an office procedure, it can cause serious complications which include allergic reaction, deep-vein thrombus formation, superficial vein thrombosis, and ulceration if extravasated into the subcutaneous plane and rarely can cause various neurological manifestations such as transient visual loss, migraine, transient ischemic attack, speech disturbances, and stroke. Neurological complications amount to only 0.90% among all the complications according to a systematic review by Tharsi Saravananthan et al. The neurological complications are usually transient and generally occur due to patent foramen ovale (PFO). There are very few case reports mentioned in the literature where the neurological symptoms occur without any evidence of cardiac defects. Herein, we report a case where foam sclerotherapy was given for chronic venous ulcer, and the patient developed speech disturbance in the immediate postprocedure period which resolved on its own. His preoperative echocardiography was normal without any structural heart defects. This is one of the few cases to be reported in the literature where sclerotherapy-induced neurological complication has occurred without any evidence of PFO.

Deep vein thrombosis: new developments and recommendations for the primary care physician

The management of deep vein thrombosis is becoming more specific in terms of diagnostic methods and drug treatments. The use of the dichotomous Wells' score is now established. The indications for direct oral anticoagulants have expanded. Prevention and management of the post-thrombotic syndrome are based on compression socks. Their use is individualized and needs repeated assessments in time. This article presents the latest developments and outlines principles involved in the management of superficial, distal and deep vein thrombosis in primary care.

PECULIARITIES OF THE COURSE OF PULMONARY EMBOLISM DURING THE COVID-19 PANDEMIC.

The aim: A comparative analysis of the course of pulmonary embolism during the COVID-19 pandemic and the era before pandemia. Materials and methods: 294 patients with pulmonary embolism (PE) , 1 group - 188 with PE before the pandemic, 2 group -106 during the pandemic. Two subgroups were distinguished in 2 group : 1- with laboratory-excluded coronavirus (acute and in anamnesis) and 2 - with a history of COVID-19. The diagnosis of PE was confirmed by CT. Echocardiography and ultrasound Doppler imaging of the veins of the lower extremities were performed. Results: In 1 group there was a more significant increase in pulmonary artery pressure (44.29 ± 17.04 vs 36.91 ± 16.6, p 0.0023) and a decrease in the E/A ratio of the right ventricle (0.80 ± 0,21 vs 1.28 ± 1.42, p 0.0202). In 2 subgroup of patients with COVID-19 had a significantly higher incidence of Diabetes mellitus (73.7% vs 13.3%, p 0.00001) and significantly lower signs of superficial venous thrombosis of the lower extremities (5.3% vs 33,3%, p 0,0175) and signs of proximal deep vein thrombosis (0% vs 56.7%, p 0.00001) and 3 times less often there was a high risk of adverse disease, right ventricular dysfunction were more pronounced (ratio E/A 0.87 ± 0.25 vs 1.13 ± 0.28, p 0.022). Conclusions: In patients with coronavirus infection, PE was significantly more common in the presence of diabetes mellitus , right ventricular diastole disorders were more common, and superficial and proximal deep vein thrombosis of the lower extremities were less common.

Superficial vein thrombosis in a child with methylene tetrahydrofolate reductase (MTHFR) heterozygous mutation: a case report

Methylene Tetrahydrofolate reductase (MTHFR) mutation leads to increased plasma homocysteine levels which is associated with increased risk of thrombosis. MTHFR mutation might be one of the unusual cause of thrombosis besides the usual risk factors like trauma, venous procedures, surgery, malignancy and immobility. We report a case of 13 years old male presenting with superficial venous thrombosis in bilateral forearm who later on evaluation was found to have heterozygous Methylene Tetrahydrofolate Reductase (MTHFR) mutation.

Lenalidomide treatment for recurrent adult T-cell leukemia/lymphoma after allogeneic hematopoietic cell transplantation.

Patients with recurrent adult T-cell leukemia/lymphoma (ATL) after allogeneic hematopoietic cell transplantation (allo-HCT) have a dismal prognosis. We retrospectively evaluated the safety and efficacy of lenalidomide (LEN)in 11 consecutive patients with recurrent ATL after allo-HCT. The median time from allo-HCT to ATL recurrence was 111days (range, 20-1476), and that from allo-HCT to the initiation of LEN was 162days (range, 43-1560). The median initial daily dose of LEN was 10mg (range, 5-25), and the median duration of LEN treatment was 37days (range, 3-1078). Three patients (27%) achieved complete response and two (18%) achieved partial response (PR). The rates of complete or PR according to the involved site were 57% for skin and 50% for nodal or extranodal lesions. With a median follow-up of 1033days (range, 601-1465) among survivors, the 1-year probability of overall survival (OS) after ATL recurrence was 55%. Grade ≥3 toxicities included cytopenia (n=4), superficial vein thrombosis (n=1), and deep vein thrombosis (n=1). Graft-versus-host disease (GVHD) newly developed in five patients (45%) and worsened in four patients (36%). The median duration from the initiation of LEN to GVHD onset or worsening was 5days (range, 1-9). GVHD was manageable in all patients. Seven patients received mogamulizumab (MOG) for recurrent ATL before LEN treatment. The overall response rates to LEN were 57% in patients who had previously received MOG and 25% in those who had not. The 1-year probabilities of OS after recurrent ATL were 71% in patients who had previously received MOG and 25% in those who had not. Although cytopenia and GVHD are common among patients with recurrent ATL after allo-HCT, LEN may improve survival. Administering MOG before LEN may augment treatment efficacy in the allo-HCT population.

Incidence and Risk Factors for Superficial and Deep Vein Thrombosis in Post-Craniotomy/Craniectomy Neurosurgical Patients.

Background Venous thromboembolism (VTE) is quite common among post-operative neurosurgical patients. This study aims to identify the incidence of deep vein thrombosis (DVT) and superficial vein thrombosis (SVT) among post-craniotomy/craniectomy patients and further evaluate established hypercoagulability risk factors such as trauma, tumors, and surgery. Methodology This single-center retrospective study investigated 197 patients who underwent a craniotomy/craniectomy. The incidences of DVT and SVT were compared, along with laterality and peripherally inserted central catheter (PICC) line involvement. A multivariate logistic regression analysis was conducted to identify risk factors for post-craniotomy/craniectomy VTE. This model included variables such as age, post-operative days before anticoagulant administration, female sex, indications for surgery such as tumor and trauma, presence of a PICC line, and anticoagulant administration. Results Among the 197 post-craniotomy/craniectomy patients (39.6% female; mean age 53.8±15.7 years), the incidences of DVT, SVT, and VTE were 4.6%, 9.6%, and 12.2%, respectively. The multivariate logistic regression analysis found that increasing the number of days between surgery and administration of anticoagulants significantly increased the risk of VTE incidence (odds ratio 1.183, 95% CI 1.068-1.311, p = 0.001). Conclusions Contrary to existing evidence, this study did not find trauma or the presence of tumors to be risk factors for VTE. Future prospective studies should assess VTE risk assessment models such as "3 Bucket" or "Caprini" to develop universal guidelines for administering anticoagulant therapy to post-craniotomy/craniectomy patients that consider the timing of post-operative therapy initiation.

Risk of recurrent thromboembolic events according to treatment duration in patients with superficial vein thrombosis treated with intermediate dose of tinzaparin.

To evaluate the risk of symptomatic venous thromboembolism (VTE) recurrence at 3months in relation to treatment duration, according to baseline risk factor profiles, in patients with superficial vein thrombosis (SVT) treated with intermediate dose of tinzaparin. We performed a pooled analysis on individual data from two prospective studies designed to assess the efficacy and safety of tinzaparin in intermediate dose (131IU/kg) in patients with SVT. Treatment duration was at the treating physician's discretion. All patients were followed up for at least 3months. A total of 956 patients (65% female, mean age 58.7 ± 13.7years) were included. The median treatment duration was 30days (range, 3-200days). History of deep vein thrombosis (DVT), location of SVT above the knee, and palpable induration were the only independent factors associated with prolonged treatment duration. During follow-up, 95.9% of patients were event free. Outcomes-related adverse events occurred in 39 (4.1%) patients and their median duration of treatment was 33days (range, 7-200days). Recurrent VTE events occurred in 33 patients, including 22 cases of SVT recurrence, 8 cases of DVT, and 1 case of pulmonary embolism. The median time to the event was 29 (6-113) days. Recurrent thromboembolic events were not related to treatment duration as occurred in 17 patients (51.5%) treated up to 30days and in 16 patients (48.8%) received prolong treatment (p = .46). Length of thrombus at the index event was significantly associated with higher risk for VTE recurrence. Intermediate dose of tinzaparin for 30days is an effective and safe treatment for SVT. The risk of recurrent VTE events may be higher in patients with greater amount of thrombus at index event.

Mondor's disease of the breast: A cutaneous thromboembolic manifestation of Covid-19?

BackgroundMondor's disease is a rare disorder characterised by thrombosis of superficial veins within the subcutaneous tissue of the breast and other organs. While factors such as trauma, infection, physical exertion, breast cancer and breast surgery have been implicated, in the majority no cause is identified. PatientsTwenty patients presented with a clinical diagnosis of Mondor's disease to the Edinburgh Breast Services in 2020. We present the etiopathogenic data as well as clinical and imaging diagnostic findings. ResultsDuring 2020, the annual incidence of Mondor's disease, in the UK's largest breast unit, increased five-fold compared to data from the previous year. This variation in the frequency of cases corresponded to trends in the frequency of Covid-19 infection during the pandemic. None of the patients had diagnosed COVID and few had any known etiopathogenic causes for their Mondor's. ConclusionSeveral recent studies have provided evidence for links between Covid-19 and thromboembolic events. Isolated reports have proposed a link between Covid-19 and Mondor's disease of the penis. Here we present data on a large series of Mondor's disease of the breast supporting a link between breast Mondor's and Covid-19.

Wegener\'s Granulomatosis: Are We Still Missing It?

We report the case of an 18-year-old female who was mis-diagnosed as a smear-negative pulmonary tuberculosis and advised standard antituberculosis treatment. She later presented with clinio-radiological worsening and thrombosis of superficial veins of the lower extremity. Cytoplasmic anti-neutrophil cytoplasmic antibody and computed tomography-guided lung biopsy confirmed the diagnosis of Wegener's granulomatosis. The rare association of superficial vein thrombosis with lung manifestation is highlighted here as also the need for a high index of clinical suspicion to avoid a missed or delayed diagnosis.

Risk of Venous Thromboembolism in Multiple Myeloma Patients Undergoing Autologous Hematopoietic Cell Transplant

Introduction: Venous thromboembolism (VTE) is a common complication that could affect multiple myeloma (MM) patients. Previous studies suggested the incidence of VTE in MM patients not on VTE prophylaxis to be as high as 10.7% in the peri-transplant period. Usage of antiplatelet or anticoagulant VTE prophylaxis is often a challenging clinical decision especially in patients with profound thrombocytopenia. Here, we aimed to explore the incidence and risk factors for VTE in MM patients undergoing AHCT. Methods: The electronic medical records of all MM patients who underwent AHCT at Cleveland Clinic between January 1st, 2011 and January 15th, 2021 were reviewed. We evaluated the incidence and type of venous thrombosis occurring in the immediate peri-transplant period, defined as extending from the start of stem cell apheresis up to 30 days post-AHCT. Baseline patient, demographic, disease, and transplant factors were evaluated to analyze risk factors for VTE occurrence within the studied period. Statistical Package for Social Sciences (SPSS) was used for statistical analysis. Results: A total of 493 patients with available records were included in our study. The median age was 61.4 years (range 33.1-77.7 years) at the time of AHCT with a male preponderance of 59%. Symptomatic VTE was recorded in 23 events involving 17 patients (3.5%) within the defined peri-transplant period, of which 34.8% of the events occurred between the start of stem cell apheresis and the date of transplant (i.e. day 0). Around 34.8% of VTE events, involving 6 (35.3%), patients occurred during hospitalization for the transplant procedure. All VTEs were non-catheter related, and most were lower extremity deep venous thromboses (DVT) (52.2%), followed by pulmonary emboli (17.4%), DVT of upper extremities (13%), internal jugular thromboses (13%) and superficial vein thrombosis (4.4%). Of the 17 VTE patients, 41% had history of previous VTE prior to the defined peri-transplant period, 88.2% were recently on immunomodulatory drugs (IMiD), 76.5% were on either antiplatelet (41.2%) or anticoagulant (53%) therapy or both (17.7%), while 23.5% were on none. Most of the VTE patients were never smokers (70.6%), while the rest (29.4%) were ex-smokers. Of note, 35.3% of VTE patients had thrombocytopenia (Platelets <150 x109/L) but median platelet count of 184 x109/L. Patients who developed VTE were of similar age (median 62.1 vs 61.4 years, P=0.9) but had a higher female preponderance (64.7 vs 40.1%, P=0.04) compared to those who did not. In addition, they had similar albumin levels at diagnosis (75 vs 71.7% ≥ 3.5 g/dL, P=0.8), similar cytogenetic risk categorization (high risk in 35.3 vs 25.8%, P=0.4), ISS stages (P=0.5), disease remission status prior to AHCT (P=0.3), mobilization regimens (G-CSF + Plerixafor in 88.2 vs 88.2%, P=0.1), and recent IMiD use (88.2 vs76.7, P=0.26) (Table 1). However, VTE patients were more likely to have IgG MM (70.6 vs 62%, P=0.06), Hematopoietic Cell Transplantation-specific Comorbidity Index (HCT-CI) ≥1 (100 vs 81.1%, P=0.05), infection at AHCT (12.5 vs 3.2%, P=0.05), longer length of AHCT hospital stay (median 17 vs 14.9 days, P<0.0001), and had higher prevalence of prior history of VTE (41.2 vs 11.6%, P<0.0001) (Table 1). With regards to prophylaxis therapy, VTE patients were less likely to be on antiplatelets (41.2 vs 65.6%, P=0.039), were on similar prophylactic anticoagulation (11.8 vs 19.5%, P=0.42), but were more likely to be on therapeutic anticoagulation (41 vs 14%, P=0.002) compared to non-VTE pts, suggesting a higher impact of a history of prior VTE than therapeutic anticoagulation on recurrence of VTE during the studied time period. Among patients with no history of previous VTE, non-VTE patients were more likely to be on either antiplatelet or prophylactic anticoagulation (82.6 vs 50%, P=0.02). Interestingly, no difference was seen in the incidence of VTE with antiplatelet vs prophylactic anticoagulation in patients without history of previous VTE (1.86 vs 0%, P=0.9). Moreover, among those with a history of previous VTE, the addition of antiplatelets to therapeutic anticoagulation did not significantly lower the risk of VTE recurrence in the studied time period (9 vs 16%, P=0.9). Conclusion: The use of VTE prophylaxis among MM patients undergoing AHCT may lower its incidence. The main risk factors for VTE are female sex, history of previous VTE, infections at AHCT, HCT-CI ≥1, and longer hospital stay. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Does Non-Alcoholic Steatohepatitis Independently Increase the Risk of Venous Thromboembolism?

Introduction: Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease. Studies have shown a strong association between NASH (non-alcoholic steatohepatitis) cirrhosis and portal vein thrombosis (PVT). Data is scarce on the association of NASH and venous thromboembolism (VTE), with one such study predicting a 2.5-fold increased risk for VTE in comparison to other liver diseases in hospitalized patients. The mechanism is believed to be hepatocellular injury causing a chronic inflammatory state leading to unregulated activation of procoagulant factors. There is no prior analysis of the degree of steatosis and fibrosis (measured on transient elastography, commonly known as Fibroscan®) in NASH patients and its association with VTE. We performed an analysis to study the risk of unexplained VTE in patients with NASH. Methods: In our case-control study, we included patients with a documented diagnosis of NASH and excluded patients with inherited thrombophilia, hemoglobinopathy, malignancy, alcohol use disorder, autoimmune hepatitis, and primary biliary cirrhosis. Collected data included age, tobacco use, recreational drug use, medical history, and vibration-controlled transient elastography (VCTE) scores. Venous thromboembolism specific data included location, type of anticoagulant, need for hospital stay, and history of VTE recurrence. Steatosis was categorized as S0-S1 (mild) and S2-S3 (moderate to severe) based on the controlled attenuation parameter (CAP) score. Fibrosis was classified based on the kilopascal(KPA) score and graded as F0-F1 (metavir stage), F2, F3, and F4(cirrhosis). Chi-square and Mann-Whitney U tests were used for qualitative and quantitative variable analysis, respectively. Furthermore, we computed logistic regression using VTE as a dependent variable. Results: A total of 415 patients were analyzed, and 386 met the inclusion criteria (Figure 1). Fifty-one patients were in the VTE group and 335 in the non-VTE group. Patients with VTE had a mean age of 60.63 years compared to 55.22 years in the non-VTE group (p=0.014). Patients with VTE had a higher body mass index (31.14 kg/m² vs. 29.30 kg/m²) and a higher prevalence of diabetes mellitus (29.4% vs. 13.1%, p=0.002). The history of NASH was significantly higher in the VTE group (45.1% vs. 30.4%, p=0.037). Further, moderate to severe steatosis was significantly higher in the VTE group (66.7% vs. 47.2%, p=0.009). Similarly, the F2-F4 fibrosis grade had a higher prevalence of 58.8 % in the VTE group compared to 38.5% in the non-VTE group (p=0.006) (Table 1). On logistic regression, using VTE as a dependent variable, diabetes mellitus type II had an OR =1.702 (p = 0.015) and F2-F4 fibrosis grade had an OR = 2.5 (p=0.033). In the VTE group, 58.8% had deep vein thrombosis (DVT), 17.6 % had superficial venous thrombosis (SVT), 13.7 % had pulmonary embolism (PE), 5.9% had portal vein thrombosis, and embolic stroke (3.9%). The most common location of VTE was the lower extremity (56.9%), followed by the upper extremity (19.6%). Right-sided VTE (66.7%) was more common and a majority of patients (74.5%) required hospital admission with 2% requiring ICU admission. Concerning anticoagulation 64.71% of patients were on direct oral anticoagulants (DOAC), 25.5% were on warfarin, and 84.3% of patients continued indefinite anticoagulation. Discussion: Our analysis shows that NASH is an independent risk factor for VTE, especially DVT. Demographics including gender, tobacco use, alcohol consumption, and ethnicity, were equally distributed between the two groups. There is a statistically significant association between the incidence of VTE and moderate to severe steatosis and fibrosis. The current management strategy for NASH includes abstinence from alcohol and intense lifestyle modification to lose weight. Newer medications like glucagon-like peptides (semaglutide) and bariatric surgery are other recommended modalities for weight loss. All hospitalized patients should be considered for medical thromboprophylaxis, particularly in those with NASH, where a high index of suspicion for VTE should be maintained even in the presence of thromboprophylaxis. Additional studies are needed to analyze the risk of bleeding in this patient population who continue indefinite anticoagulation. Another area of interest would be to determine the reversibility of VTE risk with appropriate management of NAFLD. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

LEAP Pilot: Low Molecular Weight Heparin Vs. Aspirin Postpartum

Background Expert opinion from the American Society for Hematology (ASH), the Royal College of Obstetricians and Gynecologists, UK, as well as the 'Society of Obstetricians and Gynecologists of Canada guidelines recommend a minimum of 6 weeks of prophylactic LMWH for patients with a history of venous thromboembolism (VTE) or high-risk thrombophilia. There are no randomized controlled trials (RCTs) determining the optimal duration of anticoagulation postpartum. A 2014 Cochrane review concluded that there is insufficient evidence on which to base thromboprophylaxis in the pregnancy postpartum setting, and high-quality randomized trials are warranted. Clinical trials and meta-analyses have suggested that ASA administered daily post-operatively may be non-inferior to LMWH for VTE prophylaxis; (RR 0.76; 95% CI, 0.37- 1.56 in one study), with a similar safety profile. Furthermore, in 2018 Anderson et al. demonstrated clinical safety and non-inferiority of a combination of 5 days of rivaroxaban followed by 81mg of ASA for 30 days after total hip arthroplasty and 9 days after total knee arthroplasty. The principal question to be addressed in a large definitive randomized controlled trial (RCT) is whether a combination of prophylactic LMWH for 3 weeks followed by low-dose ASA for the following 3 weeks is non-inferior to the standard of care of prophylactic LMWH for 6 weeks postpartum. This single-center pilot RCT addresses enrollment, adherence and feasibility required prior to conducting a definitive trial. Study Design and Methods Inclusion criteria: 1) Personal history of VTE prior to pregnancy and not prescribed therapeutic anticoagulation 2) Family history of VTE and antithrombin deficiency, protein C or protein S deficiency 3) Combined thrombophilia or homozygous for factor V Leiden mutation or prothrombin gene mutation, regardless of family history. Sample size: 50 patients, 25 patients treated according to each strategy. Primary outcomes: 1) Enrollment/consent rate 2) Adherence to study protocol 3) Loss to follow-up/missing data. Secondary outcomes: 1) VTE rate 2) Bleeding rate three months following delivery 3) Quality of life assessment (QoL) (Duke Anticoagulation Satisfaction Scale). Results The enrollment rate was 69.2%, with 18 of 26 patients agreeing to participate. Of the 18 recruited, one was randomized in error, one had an early pregnancy loss, and one developed a superficial vein thrombosis antenatally due to non-compliance with antepartum anticoagulation, leaving 15 patients satisfying inclusion criteria. 9 patients have completed their 3-month postpartum follow-up, with no patients lost to follow-up. The adherence to treatment at 3 weeks was 96.4% and 94.0% in Group A (LMWH and ASA) and B (LMWH), respectively (p=0.7). At 6 weeks postpartum, there was a trend toward greater treatment compliance in Group A vs Group B (98.2 vs 94.1%); however, this was not statistically significant (p=0.52). With regards to secondary outcomes, there was no VTE documented in either treatment group. One patient in each group reported mild gingival bleeding. No other bleeding events were reported. The QoL assessment score in Group A improved by 56% following the change from LMWH to ASA (39.5 to 16.8), whilst it deteriorated in Group B by 2% (24.5 vs 25.2). At 6 weeks postpartum, the QoL score improved by 33.3% in Group A vs Group B (P=0.01). Conclusion Our data shows promising enrollment, adherence, loss to follow-up and feasibility of our ongoing pilot trial. The results of this study will be used to design first a multicenter pilot study then a large definitive multicentered trial. Demonstration of non-inferiority of ASA and LMWH to LMWH will lead to a shorter course of LMWH postpartum, potentially reducing bleeding risk, need for subcutaneous injections, as well as cost, while improving quality of life. If the definitive trial does not show non-inferiority, the results will provide evidence that six weeks of postnatal thromboprophylaxis with LMWH is warranted.

Platelet in thrombo-inflammation: Unraveling new therapeutic targets.

In the broad range of human diseases, thrombo-inflammation appears as a clinical manifestation. Clinically, it is well characterized in context of superficial thrombophlebitis that is recognized as thrombosis and inflammation of superficial veins. However, it is more hazardous when developed in the microvasculature of injured/inflamed/infected tissues and organs. Several diseases like sepsis and ischemia-reperfusion can cause formation of microvascular thrombosis subsequently leading to thrombo-inflammation. Thrombo-inflammation can also occur in cases of antiphospholipid syndrome, preeclampsia, sickle cell disease, bacterial and viral infection. One of the major contributors to thrombo-inflammation is the loss of normal anti-thrombotic and anti-inflammatory potential of the endothelial cells of vasculature. This manifest itself in the form of dysregulation of the coagulation pathway and complement system, pathologic platelet activation, and increased recruitment of leukocyte within the microvasculature. The role of platelets in hemostasis and formation of thrombi under pathologic and non-pathologic conditions is well established. Platelets are anucleate cells known for their essential role in primary hemostasis and the coagulation pathway. In recent years, studies provide strong evidence for the critical involvement of platelets in inflammatory processes like acute ischemic stroke, and viral infections like Coronavirus disease 2019 (COVID-19). This has encouraged the researchers to investigate the contribution of platelets in the pathology of various thrombo-inflammatory diseases. The inhibition of platelet surface receptors or their intracellular signaling which mediate initial platelet activation and adhesion might prove to be suitable targets in thrombo-inflammatory disorders. Thus, the present review summarizes the concept and mechanism of platelet signaling and briefly discuss their role in sterile and non-sterile thrombo-inflammation, with the emphasis on role of platelets in COVID-19 induced thrombo-inflammation. The aim of this review is to summarize the recent developments in deciphering the role of the platelets in thrombo-inflammation and discuss their potential as pharmaceutical targets.

Clinical outcomes of cancer-associated isolated superficial vein thrombosis in daily practice

BackgroundDespite significant progress in the understanding of paraneoplastic deep vein thrombosis (DVT) and pulmonary embolism (PE), little is known about the outcomes of cancer-associated superficial vein thrombosis (SVT) in daily practice. MethodsINSIGHTS-SVT was a prospective observational study on patients with acute isolated SVT. Primary outcome measure was symptomatic venous thromboembolism (VTE), a composite of DVT, PE, and SVT extension/recurrence, at 3 months. Clinically relevant bleeding was also assessed. ResultsOf 1151 patients included, 6.7 % either had active cancer at baseline or were diagnosed with cancer during 12 months of follow-up. At 3 months, symptomatic VTE had occurred in 13.0 % and 5.4 % of cancer and non-cancer patients, respectively (HR 2.6, 95 % CI 1.3–5.0). Regarding secondary outcomes, cancer patients had increased risks of DVT and PE (HR 3.9, 95 % CI 1.3–11.8) and hospitalization due to VTE (HR 11.0, 95 % CI 2.5–49.0). The rate of clinically relevant bleeding was numerically higher in the cancer cohort (3.9 % vs 1.3 %, HR 3.1, 95 % CI 0.9–10.7). At 12 months, the primary composite outcome had occurred in 15.6 % and 11.9 % of cancer and non-cancer patients, respectively (HR 1.9, 95 % CI 1.0–3.5). After adjusting for additional risk factors, including age, history of DVT/PE and cardiovascular risk factors/diseases, the association of cancer with the primary outcome remained statistically significant. ConclusionCancer patients with isolated SVT are at significant risk of symptomatic VTE. While most events occur within 3 months, the VTE risk remains elevated up to one year of follow-up.ClinicalTrials.gov identifier: NCT02699151.

Early Adverse Effects of Foam Sclerotherapy for Varicose Veins: An Experience of 50 Sclerotherapy Sessions

Background: Foam injection sclerotherapy for treating varicose veins is a newly emerging and minimally invasive technique. Its safety profile needs to be investigated. Objective: We documented the adverse effects associated with foam injection sclerotherapy occurring in the first 24 hours and then at 2 and 4 weeks of follow up visits. Material and Methods: This cross-sectional study was conducted at Department of Surgery in Benazir Bhutto Hospital, affiliated with Rawalpindi Medical University, Rawalpindi from 1st July 2021 till 30th June 2022; on 50 patients of varicose veins. A duplex ultrasound was done in all patients. Varicose veins were classified using the CEAP system. Patients having C1 and/or C2 varicose disease with isolated GSV incompetence on duplex ultrasound were included. Results: Only minor complications were encountered and no serious complication was seen. The minor side effects included nausea, hyperpigmentation, matting, headache, vomiting, pruritus around injection site, vomiting and shortness of breath. Serious complications like anaphylactic shock, stroke, TIA, deep venous thrombosis, superficial venous thrombosis, tissue necrosis and skin necrosis were not encountered in any patient. Conclusion: Injection sclerotherapy with sodium tetra decyl sulphate in the foam form for the treatment of varicose veins is a safe modality; since only minor complications were encountered and no serious complication was seen. Keywords: Varicose veins; Foam sclerotherapy; Duplex ultrasound; Complications; Side effects

Тромбоз вен нижних конечностей и его последствия в восстановительном периоде инсульта

Post-stroke lower extremity vein thrombosis can be the reason behind complications of embolic nature and death. This study aimed to investigate the influence of provoking factors, frequency and localization of acute thrombosis, post-thrombotic changes in the lower extremity veins during stroke recovery period. The study involved 1315 patients, 885 (67.3%) male and 430 (32.7%) female, ages 18–94 years, mean age 59.23 ± 13.7 years. All participants underwent lower extremity venous duplex scanning in the early and late stages of stroke recovery period. We found no evidence of interconnections between presence of signs of thrombosis and/or its consequences and the pathogenetic variant of stroke the patient had. Acute deep vein thrombosis was diagnosed significantly more often (p &lt; 0.05) in the early stage of stroke recovery period. The frequency of acute lower extremity vein thrombosis was 7.8%, post-thrombotic changes — 5.6%. Isolated lesion of the lower leg veins was the most common complication associated with deep veins (49.6%). We have discovered a significant relationship between the side of lower extremity paresis (plegia) of and the side of deep vein thrombosis (p &lt; 0.001). No relationship was found between lower extremity superficial and deep vein thrombosis and use of anticoagulants and antiplatelet agents (p &gt; 0.05). Excess body weight was associated with damage to the lower extremity proximal veins (p &lt; 0.05). Women had lower extremity vein thrombosis significantly more often (p &lt; 0.05). Repeated lower extremity venous duplex scanning upon admission to the rehabilitation hospital allowed reducing the risk of venous thromboembolic complications that may develop during the stroke recovery period.

Case Report: Angio Behçet in a child

Behçet’s disease (BD) is rare in children. Herein, we report a case of 12-year-old male child with a history of left superficial femoral vein thrombosis and bilateral pulmonary embolism, admitted for multiple thrombosis located in the inferior vena cava, right atrium and ventricle associated with multiple pulmonary artery aneurisms and fissurations concomitant to oral aphthosis, which was suggestive of BD. Despite corticoids and immunosuppressive therapy, the child had a massive hemoptysis resulting in his death. The association between intracardiac thrombosis, pulmonary aneurism and venous thrombosis should raise suspicion of angio-Behçet, which could be lethal.

Complications and pitfalls of endovenous laser therapy for varicose veins of lower extremities.

Varicose veins of lower extremities are a common disorder affecting a significant proportion of adult population. Endovenous techniques have been used in clinical practice for more than 20 years for their radical treatment; of these, laser therapy is one of the most widely utilized options. However, this treatment modality, too, has its specific side effects and complications which can be divided into perioperative (difficult venous access, fiber or sheath damage, vasovagal reaction with a drop in blood pressure and bradycardia, cutaneous thermal injury), and postoperative (bruising and hematomas, exceptionally pain, superficial venous thrombosis (phlebitis) and fibrous cord formation or pigmentations). Paresthesias, infections, arteriovenous fistulas, deep venous thrombosis and pulmonary embolism are very rare. The introduction of new generators with higher wavelengths and fibers with radial emission of laser energy has substantially reduced the side effects and complications. Performing the surgery in the outpatient setting using tumescent local anesthesia and under perioperative ultrasound control is an essential condition of the procedure.