Symptomatic Deep Vein Thrombosis Research Articles

Two point-of-care test-based approaches for the exclusion of deep vein thrombosis in general practice: a cost-effectiveness analysis

BackgroundIn the diagnostic work-up of deep vein thrombosis (DVT), the use of point-of-care-test (POCT) D-dimer assays is emerging as a promising patient-friendly alternative to regular D-dimer assays, but their cost-effectiveness is unknown. We compared the cost-effectiveness of two POCT-based approaches to the most common, laboratory-based, situation.MethodsA patient-level simulation model was developed to simulate the diagnostic trajectory of patients presenting with symptoms of DVT at the general practitioner (GP). Three strategies were defined for further diagnostic work-up: one based on current guidelines (‘regular strategy’) and two alternative approaches where a POCT for D-dimer is implemented at the 1) phlebotomy service (‘DVT care pathway’) and 2) GP practice (‘fast-POCT strategy’). Probabilities, costs and health outcomes were obtained from the literature. Costs and effects were determined from a societal perspective over a time horizon of 6 months. Uncertainty in model outcomes was assessed with a one-way sensitivity analysis.ResultsThe Quality-Adjusted Life Years (QALYs) scores for the three DVT diagnostic work-up strategies were all around 0.43 across a 6 month-time horizon. Cost-savings of the two POCT-based strategies compared to the regular strategy were €103/patient for the DVT care pathway (95% CI: -€117–89), and €87/patient for the fast-POCT strategy (95% CI: -€113–67).ConclusionsPoint-of-care-based approaches result in similar health outcomes compared with regular strategy. Given their expected cost-savings and patient-friendly nature, we recommend implementing a D-dimer POCT device in the diagnostic DVT work-up.

Symptomatic Deep Vein Thrombosis Associated With Peripherally Inserted Central Catheters of Different Diameters: A Systematic Review and Meta-Analysis.

We assessed the relationship between peripherally inserted central catheter (PICC) diameters and symptomatic deep vein thrombosis (DVT) rates. We conducted a systematic search for articles published between 2010 and 2021 reporting DVT incidence by catheter diameter in patients who had a PICC, followed by meta-analyses for DVT risk in each diameter group. Pooled DVT rates were incorporated into an economic model. Of 1627 abstracts screened, 47 studies were included. The primary meta-analysis of 40 studies demonstrated the incidence of DVT was 0.89%, 3.26%, 5.46%, and 10.66% for 3, 4, 5, and 6 French (Fr) PICCs (P = .01 between 4 and 5 Fr). Rates of DVT were not significantly different between oncology and nononcology patients (P = .065 for 4 Fr and P = .99 for 5 Fr). The DVT rate was 5.08% for ICU patients and 4.58% for non-ICU patients (P = .65). The economic model demonstrated an annual, incremental cost savings of US$114 053 for every 5% absolute reduction in 6 Fr PICCs use. Using the smallest PICC that meets the patients' clinical needs may help to mitigate risks and confer savings.

Endovascular Thrombus Removal for Treating Post-Partum Iliofemoral Deep Vein Thrombosis: A Single-Centre Retrospective Cohort Study.

To evaluate the safety and efficacy of percutaneous thrombectomy for treating postpartum iliofemoral vein thrombosis. A retrospective analysis was performed on patients with continuous postpartum acute symptomatic iliofemoral deep vein thrombosis who were treated in our center, including all patients who underwent pharmacomechanical thrombolysis (PMT) or only catheter-directed thrombolysis (CDT) (study group), and patients that received simple anticoagulation treatment (control group). We evaluated the incidence of lower extremity postthrombotic syndrome, recanalization rate of lower extremity veins, and complications in the study and control groups. Overall, 72 postpartum women were included in this study, including the PMT combined with CDT group (14 cases, 15 limbs), CDT alone group (26 cases, 27 limbs), and anticoagulant therapy alone group (32 cases, 34 limbs). The thrombectomy group completed the treatment with a technical success rate of 100%, and no serious bleeding complications occurred. The patency rate of lower limb veins in the thrombectomy group was 85.09 ± 16.51% after treatment and 82.60 ± 21.45% after 1 year. At the 1-year follow-up, the Villalta score in the study group was lower (1.90 ± 2.45 vs 8.50 ± 5.33, P < .001), and the incidence of postthrombotic syndrome was significantly different between the groups (17.50% in the study group vs 68.75% in the anticoagulant group, P < .001). Lower extremity venous thrombectomy is a safe and effective treatment for postpartum iliofemoral venous thrombosis. It can improve the patency rate of lower extremity veins and reduce the incidence of postthrombotic syndrome compared with anticoagulation alone.

Noninvasive diagnostic work-up for suspected acute pulmonary embolism during pregnancy: a systematic review and meta-analysis of individual patient data

BackgroundFew studies evaluated the performance of noninvasive diagnostic strategies for suspected acute pulmonary embolism (PE) in pregnant women. ObjectivesThe aim of this study was to establish the safety and efficiency of the Wells rule with fixed and adapted D-dimer threshold, and the YEARS algorithm, combined with compression ultrasonography (CUS), in pregnant women with suspected PE in an individual patient data meta-analysis. MethodsWe performed a systematic review to identify prospective diagnostic management studies in pregnant women with suspected PE. Primary outcomes were safety, defined as the failure rate, ie, the 3-month venous thromboembolism (VTE) incidence after excluding PE without chest imaging, and efficiency, defined as the proportion of patients in whom chest imaging could be avoided. ResultsWe identified 2 relevant studies, of which individual patient-level data were analyzed in a fixed-effect meta-analysis, totaling 893 pregnant women. The Wells rule with fixed and adapted D-dimer threshold as well as the YEARS algorithm could safely rule out acute PE (failure rate, 0·37%-1·4%), but efficiency improved considerably when applying pretest probability-adapted D-dimer thresholds. The efficiency of bilateral CUS was limited (2·3% overall; number needed to test 43), especially in patients without symptoms of deep-vein thrombosis (efficiency 0·79%; number needed to test 127). ConclusionThis study supports the latest guideline recommendations (European Society of Cardiology 2019) to apply pretest probability assessment and D-dimer tests to rule out PE in pregnant women. From an efficiency perspective, the use of a strategy with pretest probability-adapted D-dimer threshold is preferred. The yield of CUS was very limited in patients without concomitant symptoms of deep-vein thrombosis.

Controversies in the management of proximal deep vein thrombosis.

Controversies in the management of proximal deep vein thrombosis.

Topical Tranexamic Acid Can Be Used Safely Even in High Risk Patients: Deep Vein Thrombosis Examination Using Routine Ultrasonography of 510 Patients.

Background and Objectives: Previous studies regarding tranexamic acid (TXA) in total knee arthroplasty (TKA) investigated only symptomatic deep vein thrombosis (DVT), or did not include high risk patients. The incidence of DVT including both symptomatic and asymptomatic complications after applying topical TXA has not been evaluated using ultrasonography. Materials and Methods: The medical records of 510 patients who underwent primary unilateral TKA between July 2014 and December 2017 were retrospectively reviewed. Because TXA was routinely applied through the topical route, those who had a history of venous thromboembolism, myocardial infarction, or cerebral vascular occlusive disease, were not excluded. Regardless of symptom manifestation, DVT was examined at 1 week postoperatively for all patients using ultrasonography, and the postoperative transfusion rate was investigated. The study population was divided according to the use of topical TXA. After the two groups were matched based on the propensity scores, the incidence of DVT and the transfusion rate were compared between the groups. Results: Of the 510 patients, comprising 298 patients in the TXA group and 212 patients in the control group, DVT was noted in 22 (4.3%) patients. Two patients had DVT proximal to the popliteal vein. After propensity score matching (PSM), 168 patients were allocated to each group. In all, 11 patients in the TXA group and seven patients in the control group were diagnosed with DVT, which did not show a significant difference (p = 0.721). However, the two groups differ significantly in the transfusion rate (p < 0.001, 50.0% in the TXA group, 91.7% in the control group). Conclusions: The incidence of DVT, whether symptomatic or asymptomatic, was not affected by the use of topical TXA. The postoperative transfusion rate was reduced in the TXA group. Topical TXA could be applied safely even in patients who had been known to be at high risk.

Real-life trends of anticoagulant prescribing practices for pulmonary embolism – results of a single-center study based on the experience of a multi-profile clinical hospital

Acute pulmonary embolism (APE) is one of the main causes of cardiovascular deaths and anticoagulant treatment plays a key role in preventing recurrent episodes, chronic thromboembolic pulmonary hypertension (CTEPH), and deaths. The aim of this study is to assess the real-life trends and to determine factors associated with the choice of anticoagulation therapy in patients with APE. This is a single center prospective open study. We followed 178 consecutive patients admitted to the tertiary clinical center with APE proven with computed tomography (CT) scan within period of 24 months. A total number of 178 patients with APE were enrolled in the study. 48.9% of subjects were hospitalized in cardiology department. As a prolonged anticoagulant therapy 35.7% of study cohort received direct oral anticoagulants (DOACs), 35.1% LMWH, and 29.2% vitamin K antagonists (VKA), respectively. No statistically significant differences were found between the departments regarding frequency of prescribing anticoagulants (p=0.15). The multivariable analysis showed that oral anti-coagulants (OACs) were less likely to be prescribed than LMWH in patients with malignancy, history of major bleeding, serious medical condition and altered mental status. OACs were preferred over LMWH in symptoms of deep vein thrombosis (DVT). VKA were significantly less likely to be chosen than DOACs in patients with history of orthopaedics procedure. After six months anticoagulation therapy was discontinued in 24.3% of patients. Concluding, the form of anticoagulant therapy was associated with the presence of chronic diseases. LMWH was prescribed in high bleeding risk patients more frequently.

Deep vein thrombosis symptoms and 30-day mortality in acute pulmonary embolism

BackgroundIn patients with acute symptomatic pulmonary embolism (PE), the presence of concomitant lower-limb deep vein thrombosis (DVT) has been associated with a higher mortality rate. The prognostic significance of DVT symptoms among these patients remains uncertain. MethodsWe used the RIETE (Registro Informatizado de Enfermedad TromboEmbólica) registry to compare the 30-day mortality rate in patients with PE and concomitant lower-limb DVT, according to the presence or absence of DVT symptoms. Primary outcomes were all-cause death and PE-related death within the first 30 days. ResultsSince March 2001 to June 2021, there were 17,742 patients with acute symptomatic PE and objectively proven concomitant lower-limb DVT. Of these, 11,984 (68%) had DVT symptoms. Most patients with or without DVT symptoms (82% vs. 81%) received low-molecular-weight heparin initially. Then, most (61% vs. 58%) switched to vitamin K antagonists. During the first 30 days of therapy, 497 patients with DVT symptoms (4.1%) and 164 (2.8%) with no DVT symptoms died (rate ratio [RR]: 1.48; 95%CI: 1.23-1.77). The rates of PE-related death were: 1.0% vs. 0.7%, respectively (RR: 1.50; 95%CI: 1.04-2.16). On multivariable analysis, patients with DVT symptoms were at increased risk for all-cause death (adjusted hazard ratio [aHR]: 1.49; 95%CI: 1.24-1.78), and PE-related death (aHR: 1.52; 95%CI: 1.05-2.20). ConclusionAmong patients with acute symptomatic PE and concomitant lower-limb DVT, those with DVT symptoms had an increased all-cause and PE-related mortality within 30 days. Assessment of DVT symptoms would assist with risk stratification of these patients.

Abstract 12175: A Migrated External Iliac Stent - To Retrieve or Not to Retrieve

Endovascular venous stenting has become a more favorable intervention for occlusive, symptomatic deep vein thromboses (DVTs), especially given its decreased complication rate and shorter recovery time than its predecessor, open venous bypass. Risks, however, still exist and can include stent fragmentation and dislodgement causing cardiopulmonary complications. A 57-year-old man with bilateral lower extremity DVTs status post left external ilio-femoral stent and inferior vena cava (IVC) filter placement presented with one month of atypical chest discomfort. CT chest showed migration of his 40cm iliac stent to the IVC and right atrium. Interventional radiology visualized both a patent stent and IVC, however, attempted endovascular removal from the distal margin failed with initial retrieval of fragments only. Other fragments subsequently embolized to the pulmonary and lower lobe arteries and right ventricles. Extraction of more distal fragments was deferred due to risks of structural damage, arrhythmias, and pulmonary vasculature perforation. Fragment analysis by pathology demonstrated evidence of clot, yet cardiothoracic surgical intervention was deferred.The patient continued to experience chest pain and underwent a repeat CT chest three months later that demonstrated the stent extending from the right atrial junction to the infrahepatic IVC. Fragmented portions of the filter in the right ventricle and multiple stent fragments retained in the right upper and bilateral lower pulmonary lobes remained as prior with no evidence of pulmonary embolism (PE), pericardial effusion, or tamponade. Although rare, stent removal complications can occur with increased risk of long-term sequelae. Stent fracturing and dislodgement can result in foreign bodies showering the pulmonary vasculature and cardiac chambers, ultimately placing patients at risk for arterial perforation or dissection, pulmonary hemorrhage, intracardiac damage, tamponade, PE, and chronic thromboembolic pulmonary hypertension (CTEPH). The consideration of such risks, in addition to early involvement of interdisciplinary teams and thorough risk-benefit discussions between patients and providers are essential when undergoing stent removal and related interventions.

Aspirin may not be effective in prevention of deep vein thrombosis after meniscus root repair: a retrospective cohort study

Background:Arthroscopic knee surgery has been associated with a low risk of symptomatic deep vein thrombosis (DVT), with previous studies demonstrating a risk of 0.12% to 3.7%. This risk of DVT and ideal prophylaxis in cases of meniscus root repair are unknown. The authors sought to determine the effectiveness of aspirin as DVT prophylaxis after meniscus root repair. The hypothesis was that there is no significant difference in the risk of symptomatic DVT after meniscus root repair with aspirin prophylaxis as compared with low molecular weight heparin (LMWH) or apixiban.Methods:Patients treated with repair of medial or lateral meniscus root tears over a 3 yr period were identified retrospectively. The risk of subsequent development of a symptomatic DVT was compared based on whether postoperative DVT prophylaxis was undertaken with aspirin or a stronger anticoagulant such as LMWH or apixiban.Results:Fifty-eight patients who underwent root repair (19 lateral and 39 medial) were identified. No symptomatic DVTs were identified in 42 patients (0%) who received LMWH or apixiban, but DVTs were identified in 3 of 16 patients (19%) who received aspirin (P=0.018). No significant differences in patient gender or body mass index, laterality of repair, associated procedures, or smoking history were noted between the groups. The aspirin group included older patients (mean age 49 yr) than those in the LMWH/apixiban group (mean age 39 yr).Conclusions:Aspirin alone may not be sufficient to prevent DVT after meniscus root repair. Additional work is required to clarify ideal DVT prophylaxis following this procedure.Level of Evidence:Level III.

A Case of Deep Vein Thrombosis After Recovery From COVID-19 and Its Association With Elevated D-dimers

The coronavirus disease 2019 (COVID-19) continues to be a devastating disease for the elderly population, especially in long-term care facilities, and it presents with varying clinical presentations. We have ample evidence that COVID-19 can predispose to deep vein thrombosis (DVT) and pulmonary embolism (PE) during an active infection. Still, very few cases of DVT have been reported after recovery from COVID-19. The imbalance of the coagulation cascade and the increased release of certain coagulation factors play an essential role in promoting hypercoagulability and vascular endothelial dysfunction. It leads to a rise in the level of fibrin degradation products, D-dimers, which can remain elevated for up to several weeks, even after recovery. It has been suggested that the risk of DVT occurring after recovering from COVID-19 remains high for up to three months. We report a case of a 77-year-old long-term care female resident at a nursing facility, ambulatory at baseline, who was noted to be COVID-19 positive upon routine facility-wide testing per department of health guidelines. She was asymptomatic during her 10-day quarantine period. D-dimer levels during routine labs were high (initial D-dimer level of 1.87 mg/L FEU {normal value: 0.19-0.52 mg/L FEU}), but the patient had no clinical signs and symptoms of DVT. Ultrasound of the bilateral legs was not performed due to low clinical suspicion. The patient received an enoxaparin DVT prophylaxis dose during the quarantine period. Follow-up D-dimer levels were done at frequent intervals after recovery, but D-dimer levels continued to remain elevated up till six weeks after her 10-day quarantine period ended.Based on previous experience with other long-term care residents who suffered from COVID-19, bilateral lower extremity ultrasound was performed, which showed bilateral DVT. Elevated D-dimer levels are a predictor of hypercoagulation complications in COVID-19. Patients with persistently elevated D-dimer levels after recovery from COVID-19 should be screened for thromboembolic complications, even if they are asymptomatic. DVT can occur up to three months post-recovery from COVID-19 infection.

Extended Thromboprophylaxis in Hospitalized Patients with Heart Failure: A Post Hoc Analysis of the MAGELLAN Study.

This post hoc subgroup analysis examined efficacy and safety outcomes with extended thromboprophylaxis rivaroxaban compared with in-hospital enoxaparin in 2,078 patients from the MAGELLAN study who had a hospitalization for heart failure or a history of heart failure and a lower risk of bleeding. A significant 36% reduction in the composite endpoint of asymptomatic proximal deep vein thrombosis (DVT) in the lower extremity, symptomatic DVT in the lower extremity (proximal or distal), symptomatic nonfatal pulmonary embolism, and venous thromboembolism-related death was observed with rivaroxaban. Major bleeding was low in both groups and not significantly increased with rivaroxaban.

Prophylactic Dose of Dalteparin in Pregnant Women With History of Venous Thromboembolisms and/or Thrombophilia: Real-World Data.

Women with a history of venous thromboembolisms (VTEs) and/or thrombophilia are at increased risk of VTE during pregnancy. We analysed our cohort of such women who were treated with a prophylactic doses of dalteparin. 152 pregnant women with 179 pregnancies were classified into 3 groups: (1) previous VTE without thrombophilia (122 pregnancies); (2) previous VTE with thrombophilia (26 pregnancies) and (3) thrombophilia only (31 pregnancies). They were treated with prophylactic dalteparin in the prepartum and postpartum periods or only in the postpartum period. Occurrences of symptomatic VTE and bleeding episodes were followed, as well as dalteparin discontinuation and anti-Xa activity. Symptomatic deep vein thrombosis occurred in 4 women (2.2%) with 2 episodes in group 1 (in the postpartum period) and 2 episodes in group 2 (one in the prepartum and another in the postpartum period). Seven episodes (3.9%) of minor bleeding occurred. Dalteparin was not stopped in any women. Anti-Xa levels were within the prophylactic range. Our real-world data show a low incidence of thrombosis and minor bleeding in pregnant women treated with prophylactic dalteparin. The incidence of recurrent VTE was lower than that reported in women with similar risk, but without prophylactic anticoagulation.

Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy.

Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy.

D-dimer and reduced-dose apixaban for extended treatment after unprovoked venous thromboembolism: the Apidulcis study

AbstractD-dimer assay is used to stratify patients with unprovoked venous thromboembolism (VTE) for the risk of recurrence. However, this approach was never evaluated since direct oral anticoagulants are available. With this multicenter, prospective cohort study, we aimed to assess the value of an algorithm incorporating serial D-dimer testing and administration of reduced-dose apixaban (2.5 mg twice daily) only to patients with a positive test. A total of 732 outpatients aged 18 to 74 years, anticoagulated for ≥12 months after a first unprovoked VTE, were included. Patients underwent D-dimer testing with commercial assays and preestablished cutoffs. If the baseline D-dimer during anticoagulation was negative, anticoagulation was stopped and testing repeated after 15, 30, and 60 days. Patients with serially negative results (286 [39.1%]) were left without anticoagulation. At the first positive result, the remaining 446 patients (60.9%) were given apixaban for 18 months. All patients underwent follow-up planned for 18 months. The study was interrupted after a planned interim analysis for the high rate of primary outcomes (7.3%; 95% confidence interval [CI], 4.5-11.2), including symptomatic proximal deep vein thrombosis (DVT) or pulmonary embolism (PE) recurrence, death for VTE, and major bleeding occurring in patients off anticoagulation vs that in those receiving apixaban (1.1%; 95% CI, 0.4-2.6; adjusted hazard ratio [HR], 8.2; 95% CI, 3.2-25.3). In conclusion, in patients anticoagulated for ≥1 year after a first unprovoked VTE, the decision to further extend anticoagulation should not be based on D-dimer testing. The results confirmed the high efficacy and safety of reduced-dose apixaban against recurrences. This trial was registered at www.clinicaltrials.gov as #NCT03678506.

Sıradışı Bir Olgu Sunumu: Sağ İliak Ve Femoral Ven Trombüsü

Aim: Abdominal pain is among the most common reasons for admission to the emergency department. Abdominal pain may be nonspecific, increasing the difficulty of accurately identifying the underlying cause. The classic symptoms of deep vein thrombosis are edema, redness, pain in the affected area, and tenderness on palpation. This case report aimed to demonstrate the thrombus observed in the right iliac and femoral vein in a young patient who applied to the ED with abdominal pain. Case: An 18-year-old female patient applied to the emergency department with the complaint of abdominal pain that had worsened for the last three days. Abdominal ultrasound was requested to exclude acute appendicitis and adnexal pathologies. Abdominal ultrasound did not detect any pathology. Doppler ultrasound performed during obstetric and gynecological examination of the patient showed a suspicious thrombus image in the right femoral vein and contrast-enhanced abdominal computed tomography was requested. The patient, who was found to have thrombus in the right iliac and femoral veins, was hospitalized due to venous thromboembolism. Conclusion: It is important for emergency physicians to keep venous thromboembolism in mind as a diagnosis in all patients (including young patients) presenting with abdominal pain.

Prognostic significance of symptomatic deep vein thrombosis in patients with acute symptomatic pulmonary embolism regarding the European Society of Cardiology mortality risk model.

Deep vein thrombosis (DVT) can be symptomatic or asymptomatic in patients with acute pulmonary embolism (PE). The prognostic value of the symptomatic DVT at the presentation regarding the prognosis of PE is unknown. Data were extracted from the REgional Pulmonary Embolism Registry (REPER) which enrolled 1604 hospitalized patients after multidetector computed tomography (MDCT) diagnosed symptomatic acute PE. According to the ESC risk model, patients were classified into four subgroups. Patients who had leg edema with or without pain, and patients with leg pain and DVT confirmed by compression ultrasound were considered to have symptomatic DVT. This study aimed to compare all-cause hospital mortality between patients with symptomatic DVT and patients without symptoms or signs of DVT across the PE risk stratums. All-cause mortality in patients with symptomatic DVT compared to those who had no symptoms or signs of DVT were 2/196 (1.0%) vs. 11/316 (3.5%), P=0.145, 4/129 (3.1%) vs. 17/228 (7.5%), P=0.106, 14/196 (7.1%) vs. 54/290 (18.6%), P<0.001 and 16/55 (29.1%) vs. 51/139 (36.7%), P=0.402 in patients with low, intermediate-low, intermediate-high and high-risk PE, respectively. In multivariate analysis symptomatic DVT was associated with decreased in-hospital mortality only in patients with intermediate-high PE (OR 0.320, 95%CI 0.164-0.627; P=0.001). Intermediate-high risk PE patients with symptomatic DVT who were treated with thrombolysis had significantly lower hospital mortality than patients without symptoms or signs of DVT (2.2% vs. 11.4%, P=0.003). Intermediate-high risk PE patients with symptomatic DVT at presentation may benefit from thrombolysis and have lower hospital all-cause mortality in such circumstances.

Time to Venous Thromboembolism Events Following Total Hip Arthroplasty: A Comparison Between Aspirin and Warfarin.

The attitude and approach of orthopedic community for minimizing venous thromboembolism (VTE) has evolved over the last decade with the trend toward use of aspirin (and mechanical modalities) in lieu of aggressive anticoagulation. The optimal length of VTE prophylaxis following total hip arthroplasty (THA) still remains unknown. This study aimed to determine the timing of VTE in patients who received aspirin compared to warfarin, and determine if 30 days of prophylaxis remain adequate. This is a retrospective study of 18,003 patients undergoing primary and revision THA at a single institution between January 2008 and August 2020. During this time, our institution underwent a transition from the use of warfarin to aspirin as the main method for VTE prophylaxis. Symptomatic deep vein thrombosis and pulmonary embolism occurring within 90 days of surgery were identified from medical records and phone call logs. Aspirin and warfarin cohorts were matched to account for demographic and comorbidity differences. Timing of pulmonary embolism was determined based on either the date of diagnostic imaging or patient-provider phone calls confirming diagnosis. The cohorts included 46 patients in the warfarin group and 46 in the aspirin group. Time to VTE was significantly shorter in the warfarin group compared to aspirin (P= .021) with a median time to VTE of 3 days (interquartile range 2-14) and 10 days (interquartile range 4-19) respectively. Over 90% of the events occurred within 32 or 30 days of surgery in the warfarin and aspirin groups respectively. Based on the findings, a 30-day aspirin prophylaxis remains appropriate for patients undergoing THA.

Abstract No. 155 Single-procedure, 8Fr rheolytic pharmacomechanical iliofemoral deep venous thrombectomy: a retrospective study of efficacy, safety and durability

A multicenter randomized controlled trial demonstrated reduction in severity of post-thrombotic syndrome in patients with symptomatic iliofemoral deep vein thrombosis (DVT) following pharmacomechanical thrombectomy/thrombolysis. However, patients in this trial were treated with variable lysis durations, including overnight lytic infusion. Further, the primary thrombectomy device used consisted of a 6Fr rheolytic thrombectomy catheter. Since then, an 8Fr rheolytic system has been developed specifically for deep venous disease, which may improve procedural efficiency and obviate the need for overnight lytic infusion.

P273 MANAGEMENT OF ACUTE PULMONARY EMBOLISM IN GERIATRIC PATIENTS IN THE EMERGENCY ROOM: DOES ADHERENCE TO INTERNATIONAL GUIDELINES REDUCE IN ATYPICAL SYMPTOMS?

Abstract Purpose of the Study Evaluate if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the presence of atypical symptoms. We understood dyspnoea, chest pain, signs and symptoms of deep vein thrombosis and syncope as typical symptoms. As atypical symptoms all the others (low–grade fever, vertigo …) Methods Single–center retrospective observational study on all geriatric patients (&amp;gt;75 y) who entered our ED, where they received a diagnosis of acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic/therapeutic algorithm, both for the risk of PE (Wells, Geneva and YEARS), and for the presentation of the risk of mortality at 30 days (sPESI). We then analyzed adherence to the guidelines in three decision turning points: 1 Correct application of the decision scores examined, which classify the patient at low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct administration of therapy starting from ED as suggested by the guidelines; 3 Any observation in the care area of medium intensity with careful monitoring for the subpopulation of patients with evidence of right ventricular dilation or myocardial enzyme elevation (considered to be at high risk of shock and short–term mortality). Results We enrolled 248 patients, with a mean age of 83 years with female prevalence (F = 63%). Of these, only 17 with atypical symptoms and 231 with typical symptoms. The vital signs were comparable in the two groups with no statistically significant difference (p &amp;gt; 0.05). Long–term outcomes such as mortality, need for hospitalization, hospitalization in intensive care and length of stay in hospital are also comparable results with no statistically significant difference (p &amp;gt; 0.05). However, adherence to international guidelines was statistically significantly lower in patients with atypical symptoms (33%) than in patients with typical symptoms (59%) (p &amp;lt; 0.05). Conclusions The study suggests that patients with atypical symptoms are more likely to have reduced adherence to international guidelines, most likely due to diagnostic delay.