Symptomatic Deep Vein Thrombosis Research Articles

Efficacy and safety of systemic tranexamic acid administration in total knee arthroplasty: A case series

IntroductionTotal knee arthroplasty (TKA) are associated with significant postoperative blood loss. Tranexamic acid (TXA) is a potent agent with antifibrinolytic activity, that can be administered via the intravenous (IV) and/or topical (intra-articular, IA) route, which can possibly interrupt the cascade of events due to hemostatic irregularities close to the source of bleeding. However, the literature contains scarce scientific evidence related to IV only TXA usage in TKA. The current study aims to compare the outcome between patients who were administered IV TXA and a control group in terms of blood loss, transfusion rate, and incidence of deep vein thrombosis (DVT) and thromboembolism (TE). Methods110 patients, who underwent TKA were placed into two groups: 1) 34 patients who received IV TXA; and 2) 76 patients in the control group. In the TXA group, patients received an IV TXA dose of 1 g, 30 min before incision. Two drains were placed. ResultsUsage of IV TXA showed better results when compared to the control group in terms of mean blood transfusion (0.5 less transfusion during hospital stay), hemoglobin drop (10%). No cases of DVT or TE were noted among the two study groups. ConclusionUse of IV TXA provided significantly better results compared to no TXA use with respect to all variables related to postoperative blood loss in TKA. Moreover, TXA use is safe in terms of incidence of symptomatic DVT and TE.

Topical Injection of Tranexamic Acid via a Drain Plus Drain‐Clamping to Reduce Blood Loss in Degenerative Lumbar Scoliosis Surgery

ObjectiveThe aim of the present study was to investigate whether an innovative way of administering tranexamic acid (TXA), that is, injecting it retrogradely through the drain and clamping it for 1 h, can reduce postoperative bleeding after degenerative lumbar scoliosis surgery.MethodsSixty degenerative lumbar scoliosis patients who underwent posterior lumbar decompression with fusion of three or more levels were retrospectively enrolled and categorized into three groups (TXA, Gelfoam, and control groups). The demographic distribution, operative parameters, length and amount of Hemovac drainage, blood transfusion rate, length of stay, laboratory results (complete blood count and coagulogram), and the postoperative complications were collected and analyzed.ResultsThe age of patients in the Gelfoam group was significantly younger than in the TXA and control groups (59.75 ± 6.95 vs 66.10 ± 8.80, P = 0.016 and 59.75 ± 6.95 vs 67.90 ± 5.33, P = 0.000, respectively). There were no significant differences in sex, body mass index, comorbid medical status, and operation level between each of the two groups. The three groups did not differ significantly in estimated blood loss during surgery, the mean red blood cell transfusion requirement during hospitalization, and the entire perioperative allogenic blood transfusion rate. The postoperative total blood loss and total drainage were lower in the TXA group than in the control group (1027.14 ± 466.56 vs 1390.07 ± 314.85 mL, P = 0.006; 322.20 ± 187.32 vs 605.50 ± 184.70 mL, P = 0.000, respectively). The length of drainage retention in the TXA group was significantly shorter than in the Gelfoam and control groups (46.10 ± 9.00 vs 68.00 ± 12.31 h, P = 0.000 and 46.10 ± 9.00 vs 76.40 ± 10.97 h, P = 0.000, respectively). The TXA and Gelfoam groups also had significantly shorter hospital stays than the control group (7.50 ± 0.95 vs 9.80 ± 2.44 days, P = 0.000, and 7.90 ± 1.16 vs 9.80 ± 2.44 days, P = 0.003, respectively). At discharge, the mean hemoglobin and hematocrit level were significantly higher in the TXA group compared with the control group (11.77 ± 1.78 g/dL vs 10.67 ± 0.94 g/dL, P = 0.002; 34.82 ± 3.57% vs 31.79 ± 3.85%, P = 0.014). No significant difference was identified with respect to prothrombin time, activated partial thromboplastin time, and D‐dimmer among groups (P > 0.05). The three groups were comparable in wound problem incidences. Symptomatic deep vein thrombosis and pulmonary embolism were not observed in this study.ConclusionTopical injection of TXA retrogradely via a drain at the end of a degenerative lumbar scoliosis operation and clamping the drain for an hour can effectively decrease the postoperative blood loss and the length of hospitalization without increasing the complication rate.

Venous Thromboembolism Prophylaxis in Acute Medically Ill Patients: A Retrospective Cohort Study

Background and Aims Venous thromboembolism (VTE) is considered as a preventable cause of death for hospitalized patients. Current guidelines recommend pharmacologic prophylaxis for medical patients considered high risk for VTE, despite failure of studies to show reduction in mortality. We aimed to assess the benefit and safety of VTE prophylaxis in acutely ill medical patients hospitalized in internal medicine wards. Methods Retrospective cohort study of all patients admitted to the internal medicine and acute geriatric departments, with an admission lasting more than 48 hours, during 2012-2018. Patients who received pharmacologic prophylaxis were compared to those who did not. The primary outcome was 30-day mortality. Secondary outcomes were the 90 day incidence of pulmonary embolism (PE), symptomatic deep vein thrombosis (DVT), and major bleeding. Propensity-weighted logistic multivariable analysis was performed. Results A total of 18890 patient-unique episodes were included in the analysis. Of them 3206 (17%) received prophylaxis. A total of 1309 (6.9%) died. 540/1309 (41.3%) of those who received VTE prophylaxis died and 769/1309 (58.7%) of those who did not receive prophylaxis died. VTE Prophylaxis was not associated with a reduction in mortality, multivariate-adjusted OR 0.99 (95% CI 0.84-1.14). One hundred and forty two patients (0.7%) developed VTE. The frequency of VTE among patients who received VTE prophylaxis was 31% (44/142) compared with 69% (98/142) in patients who did not receive prophylaxis. The frequency of VTE in patients who had a Padua score ≥4 and received VTE prophylaxis, was 1.9% (30/1573) compared with 1.6% (44/2797) in those with a Padua score ≥4 who did not receive prophylaxis. 74/142 (52.1%) of patients with VTE had a Padua score ≥4, 44/1309 (1.4%) of those who received VTE prophylaxis and 98/15864 (0.6%) of those who did not. VTE Prophylaxis was not associated with reduction in VTE in the whole cohort, multivariable-adjusted OR 1.09 (95% CI 0.52-2.29). VTE prophylaxis was associated with an increase in major bleeding (multivariable-adjusted OR 1.24, 95% CI 1.04-1.48) Conclusion The current practice of routinely administering VTE prophylaxis to medically ill patients considered at high risk for VTE, resulted in a high risk for bleeding a without clear clinical benefit, and should be reassessed. Disclosures No relevant conflicts of interest to declare.

Thrombus stability explains the factor V Leiden paradox: a mouse model

AbstractHumans carrying the factor V Leiden (FVL) variant have a fivefold increased risk for venous thrombosis. However, incidence of deep vein thrombosis (DVT) is proportionally greater than that of pulmonary embolism (PE) in these individuals. This is known as the FVL paradox. We hypothesized that the rate of initial DVT development is similar in FVL and noncarriers, but thrombi in FVL carriers are more stable and develop into a clinically significant DVT more often than in noncarriers. To test this, we induced thrombi in the femoral vein of wild-type (WT), heterozygous (F5L/+), and FVL homozygous (F5L/L) mice. Using intravital microscopy, thrombus size and embolization were visualized and emboli in the lungs were quantified. Compared with WT, femoral vein thrombi in F5L/+ and F5L/L mice were larger and embolized less. Total and large embolic events, the percentage of thrombus that embolized, and PE burden were significantly decreased in F5L/L mice. This suggests that in noncarriers (reflected by WT), a minor injury initially resulting in a small DVT tends to remain small and asymptomatic because of the embolization of the otherwise growing thrombus. Alternatively, the same insult in people with FVL (reflected by F5L/L) leads to thrombus growth as a result of less embolization, and thus symptomatic DVT development.

Low prevalence of Post-thrombotic syndrome in patients treated with rivaroxaban

Post-thrombotic syndrome (PTS) is a complication of deep vein thrombosis (DVT). Residual vein thrombus (RVT) on Doppler Ultrasound can be associated with PTS. Limited data are available on the effect of direct oral anticoagulants (DOACs) on the long-term outcome of PTS. This study aimed to compare the prevalence of PTS and RVT, in patients with previous DVT treated with rivaroxaban or enoxaparin/warfarin. A total of 129 patients with previous proximal lower limb DVT and treated with rivaroxaban (n = 71) or enoxaparin/warfarin (n = 58) for at least 3 months were included. The Villalta scale for PTS was performed after treatment. The median duration of the DVT symptoms before anticoagulation was 7 days for both groups. The rate of PTS was 50.7% in the patients treated with rivaroxaban and 69% in the enoxaparin/warfarin group. Enoxaparin/warfarin showed an increased prevalence of PTS (P = .018). An analysis in 3 different models showed that the relative risk of PTS decreased by 76% with rivaroxaban use when compared with enoxaparin/warfarin treatment. In addition, 93 of the 129 patients were evaluated regarding the presence of RVT, of which, 11 (24.4%) and 31 (64.6%) presented with RVT for rivaroxaban and enoxaparin/warfarin, respectively (P < .0001). The RVT analysis excluded the possibility of RVT as a mediator of the association between type of treatment and PTS when comparing rivaroxaban with enoxaparin/warfarin (odds ratio (OR) = 0.14; 95% confidence interval (CI): 0.1–1.0, P = .051) with rivaroxaban compared with enoxaparin/warfarin. Rivaroxaban treatment was associated with a lower risk of PTS when compared to enoxaparin/warfarin; RVT however, was not a mediator in the association between PTS and type of treatment.

Low-Dose Aspirin Is Adequate for Venous Thromboembolism Prevention Following Total Joint Arthroplasty: A Systematic Review

BackgroundPatients undergoing total joint arthroplasty (TJA) are at risk of developing venous thromboembolism (VTE) without adequate prophylaxis. Since the American Academy of Orthopedic Surgeons issued guidelines in 2007 recommending aspirin 325 mg bis in die for 6 weeks, aspirin has been favored as the main VTE prophylaxis. However, the appropriate dose and duration of aspirin are not well-studied. This systematic review aims to identify any differences between high and low dose as well as duration for aspirin thromboprophylaxis after TJA as outlined by previous studies. MethodsA search was performed using Ovid MEDLINE, EMBASE, and PubMed, including articles up to July 2016. Studies were included if they contained at least 1 cohort that underwent TJA with aspirin as the sole chemoprophylaxis and reported either (1) symptomatic VTE or (2) secondary outcomes such as major bleeding or 90-day mortality. ResultsForty-five papers were included. There were no significant differences in symptomatic pulmonary embolism, symptomatic deep vein thrombosis, 90-day mortality, or major bleeding between patients receiving low-dose or high-dose aspirin. Patients treated with aspirin for <4 weeks had a higher risk of major bleeding (1.59%) vs patients treated for 4 weeks (0.15%), which may be attributed to premature cessation or differential reporting. Patients treated with aspirin for <4 weeks had a statistically higher 90-day mortality (1.95%) vs patients treated for 4 weeks (0.07%). There was no significant difference between incidence of pulmonary embolism or deep vein thrombosis and the durations of aspirin treatment. ConclusionThis review suggests that low-dose aspirin is not inferior to high-dose aspirin for VTE thromboprophylaxis in TJA patients. Additionally, patients treated with aspirin for less than 4 weeks may have a higher risk of major bleeding and 90-day mortality compared to patients treated for a longer duration.

OC4. Abstract Title: Thrombus Stability Explains the Factor V Leiden Paradox: A Mouse Model

<h3>Background</h3> Factor V Leiden (FVL) is an inherited autosomal dominant condition that is identified in 20%-50% of patients with venous thromboembolic diseases and 5-8% of the population in Canada. People with FVL are often called hypercoagulable, and have a five-fold increase in the risk of venous thrombosis. There is a low prevalence of FVL among patients with fatal pulmonary embolism (PE) and a higher incidence of deep vein thrombosis (DVT) than PE in patients with FVL. This has been referred to as the FVL paradox in thrombosis. We wished to test whether FVL and normal patients are at the same risk of initial thrombus formation, expect FVL patients present with symptomatic DVT while normal patients do not present, because the small asymptomatic DVT in normal patients embolizes to become an asymptomatic PE. <h3>Aim</h3> Therefore, to explain why patients with FVL are more likely to present with a DVT rather than a PE we will study DVT stability in FVL mice using a modification of our previously published mouse model of venous thrombus stability. <h3>Methods</h3> Platelets were fluorescently labeled using CD41 fab fragments conjugated to an Alexa Fluor 488. DVT was induced using a ferric chloride saturated filter paper on the femoral vein of female mice. We chose conditions such that only a small thrombus developed in wild type (WT) mice, and then compared them to thrombi in FVL heterozygous (F5L/+) and FVL homozygous (F5L/L) mice. Intravital videomicroscopy recorded embolic events leaving the thrombus and the thrombus sizes every 10 minutes for 2 hours. Lungs were harvested sectioned and stained for presence of PE. <h3>Results</h3> Although thrombus size remained small in WT mice, it significantly increased over time in F5L/+ and F5L/L mice. The number of total and large embolic events, and the percent of thrombus that embolized was significantly decreased in F5L/+ and F5L/L mice compared to WT mice. Previously we have correlated increased large embolic events with increased PE burden. FVL mice had significantly reduced PE burden compared to WT mice. Mice with F5L had higher F1.2 levels than in WT, consistent with increased thrombin generation. <h3>Conclusion</h3> This suggests that in noncarriers (reflected by WT), a minor insult initially resulting in a small DVT tends to remain small and asymptomatic, due to the embolization. Alternatively, the same insult in people with FVL (reflected by F5L/L) leads to thrombus growth due to less embolization and thus development of symptomatic DVT, but no PE.

Natural History of 321 Flatfoot Reconstruction Patients Over a 14 Year Period Performed at a Single Institution

Category:Midfoot/ForefootIntroduction/Purpose:Outcomes following surgical reconstruction for acquired flatfoot deformity secondary to posterior tibial tendon dysfunction have been well described. However, the majority of studies have a limited number of patients or short to mid- term follow-up. The purpose of this study was to report the natural history, demographics, and mechanisms of treatment failure for patients undergoing flatfoot reconstruction at a single institution by a single surgeon.Methods:With IRB approval, 321 consecutive patients undergoing flatfoot reconstruction during a 14-year period were included in this study (February 2002 through October 2016). All procedures were performed by a single surgeon (PJJ) at our institution. Demographic data, surgical data, clinic notes, and radiographs were available for review. Exclusion criteria included patients without electronic records or incomplete data. Failure was defined as a need to return to the operating room for revision surgery. Statistical analysis was performed.Results:321 consecutive patients underwent flatfoot reconstruction from 2002-2016. The majority of patients were female (83.2%) with left laterality (58.6%) & a body mass index classified as overweight (21.5%) or obese (56.4%). 13.7% of patients were diabetics, and 18.4% were current smokers. 54 patients (16.8%) experienced treatment failure. Painful calcaneal hardware requiring removal occurred in 11.8% of patients, conversion to triple arthrodesis occurred in 3.45%, and wound complications or infection requiring irrigation & debridement occurred in 1.87%. There were no mortalities reported within 90 days. There were 3 symptomatic deep vein thromboses, none requiring surgical intervention, & no pulmonary embolisms. A significant increase in relative risk of treatment failure was calculated for female gender, current cigarette use, & age under 60 (3.4 p=0.0005/1.9 p=0.0081/1.8 p=0.042).Conclusion:This study represents the largest series of patients undergoing flatfoot reconstruction by a single surgeon at a single institution. Although retrospective, the results provide valuable insight to the natural history of patients undergoing this procedure. The overall complication rate and treatment failure rates are low and similar to those previously reported in the literature. Patients with female gender or under 60 years of age should be notified of their increased relative risk of treatment failure & counseled accordingly. Smoking cessation is recommended to reduce the risk of treatment failure.

OC2. Abstract Title: Comparison of Two Clinical Scales to Assess the Post-Thrombotic Syndrome: Secondary Analysis of a Multicenter Randomized Trial of Pharmacomechanical Catheter-Directed Thrombolysis for Deep Vein Thrombosis

<h3>Background</h3> Post-thrombotic syndrome (PTS) occurs in 20-50% of patients following proximal deep vein thrombosis (DVT), despite anticoagulation treatment. The International Society on Thrombosis and Haemostasis recommends using the Villalta scale to standardize the diagnosis of PTS and to quantify its severity. However, many investigators use the Venous Clinical Severity Score (VCSS) to assess PTS. Different to the Villalta score, the VCSS was developed as a measure for chronic venous disease and not PTS specifically. The aim of the study was to determine which of Villalta and VCSS best captures clinically important PTS and PTS severity by analyzing the relationship of each to QoL scores in the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial study population. <h3>Methods</h3> A secondary analysis of the ATTRACT randomized controlled clinical trial was conducted. 621 ATTRACT patients with symptomatic proximal DVT are included in this analysis. Correlations of the Villalta and VCSS scores with QoL scores (Short-Form Health Survey-36 physical component score/mental component score [SF-36 PCS/MCS]; the Venous Insufficiency Epidemiological and Economic Study-QoL/Symptoms [VEINES-QoL/Sym] questionnaire) were examined at study visits. The correlation of the random intercept (mean scores) and random slope (rate of change of the scores) between the Villalta, VCSS and the VEINES-QoL/Sym scores was assessed using a multivariate longitudinal model. <h3>Results</h3> The mean age at enrolment was 51 years of age, 78% were white, 62% were male, the mean BMI was 32 kg/m2, 57% had iliofemoral DVT, 19% had a previous ipsilateral DVT and 93% were taking one or more anticoagulation therapies prior to randomization. The median (range) correlation coefficients across all follow-up visits for the Villalta scale and VEINES-QOL and the Villalta scale and VEINES-Sym were -0.73 (0.51, -0.73) and -0.75 (-0.50, -0.76), respectively. The median (range) correlation coefficients for the Villalta scale and the SF-36 PCS or the SF-36 MCS across all follow-up visits were -0.51 (-0.35, -0.54) and -0.31 (-0.21, -0.38), respectively. In all correlation analyses between the Villalta scale and QoL measures, correlations at baseline were the weakest, and then increased until 6 months, after which the correlation coefficients remained relatively constant. The median correlation coefficient (range) across all follow-up visits for VCSS and VEINES-QOL and for VCSS and VEINES-Sym were -0.39 (-0.37, -0.39) and -0.41 (-0.36, -0.41), respectively. The median correlation (range) between VCSS and SF-36 PCS and for VCSS and MCS were -0.32 (-0.31, -0.32) and -0.12 (-0.12, -0.14), respectively. The magnitude of the correlations remained relatively constant from 6 months to 24 months follow-up visits. The Villalta scale had a strong negative correlation with VEINES-QoL and VEINES-Sym, a moderate negative correlation with SF-36 PCS, and a weak negative correlation with SF-36 MCS. Conversely, the VCSS had a weak negative correlation with VEINES-QoL, VEINES-Sym and SF-36 PCS, and a very weak negative correlation with SF-36 MCS. Adjustment for age, sex, ethnicity, race, extent of DVT and previous ipsilateral DVT did not change our findings. Each pair of disease severity scales and QoL scales were analyzed as a multivariate outcome in a multivariate longitudinal model. A random intercept (mean scores) and random slope (rate of change of the scores) were present in all these multivariate longitudinal models. The impact of covariates (i.e. age, sex and BMI) was also examined. The Villalta score and VCSS score have a positive correlation between their random intercept and random slope. This suggests that patients with a higher average Villalta score also tend to have a higher average VCSS score (correlation is 0.74 and 0.69 if adjusted). Those that have a higher rate of change in Villalta score over time tend to have a higher rate of change in VCSS (correlation is 0.72 and 0.84 if adjusted). The impact from covariate adjustment by age, sex and BMI was minor. <h3>Conclusion</h3> For all measures, the Villalta scale has a substantially higher correlation with QOL than the VCSS. Our findings support the use of the Villalta scale to assess PTS in preference to VCSS, as it better captures the impact of PTS on patient reported QoL, a key consideration in patients with chronic PTS.

Use of Fondaparinux Following Elective Lumbar Spine Surgery Is Associated With a Reduction in Symptomatic Venous Thromboembolism

Study Design:Retrospective cohort study.Objective:To assess the impact of fondaparinux on venous thromboembolism (VTE) following elective lumbar spine surgery in high-risk patients.Methods:Matched patient cohorts who did or did not receive inpatient fondaparinux starting postoperative day 2 following elective lumbar spine surgery were compared. All patients received 1 month of acetyl salicylic acid 325 mg following discharge. The primary outcome was a symptomatic DVT (deep vein thrombosis) or PE (pulmonary embolus) within 30 days of surgery. Secondary outcomes included prolonged wound drainage, epidural hematoma, and transfusion.Results:A significantly higher number of DVTs were diagnosed in the group that did not receive inpatient VTE prophylaxis (3/102, 2.9%) compared with the fondaparinux group (0/275, 0%, P = .02). Increased wound drainage was seen in 18.5% of patients administered fondaparinux, compared with 25.5% of untreated patients (P = .15). Deep infections were equivalent (2.2% with fondaparinux vs 4.9% control, P = .18). No epidural hematomas were noted, and the number of transfusions after postoperative day 2 and 90-day return to operating room rates were equivalent.Conclusions:Patients receiving fondaparinux had lower rates of symptomatic DVT and PE and a favorable complication profile when compared with matched controls. The retrospective nature of this work limits the safety and efficacy claims that can be made about the use of fondaparinux to prevent VTE in elective lumbar spine surgery patients. Importantly, this work highlights the potential safety of this regimen, permitting future high-quality trials.

The rate of missed diagnosis of lower-limb DVT by ultrasound amounts to 50% or so in patients without symptoms of DVT: A meta-analysis.

Background:To assess whether the ultrasound (US) is a reliable approach in detecting lower-limb deep-vein thrombosis (DVT) in patients without symptoms of DVT.Methods:The research team performed a systematic search in PubMed, Ovid, Cochrane, and Web of Science without language or date restrictions. Full-text reports on prospective diagnostic studies involve the detection of lower-limb proximal and distal DVT in patients without symptoms of DVT using US and venography. A meta-analysis was performed using Meta-DiSc (version 1.4), providing the pooled sensitivity, specificity, positive (LR+) and negative (LR–) likelihood ratios of the detection accuracy of US. There were 4 different classes of subgroup analysis—the class of patients stratified by location of US exam (proximal, distal, whole leg), the class stratified by technique (color/doppler, compression, both modalities), the class stratified by kind of surgery (orthopedic, otherwise hospitalized) and the class stratified by era of publishing (1980s, 1990s, 2000s). The study quality and the risk of bias were evaluated using QUADAS-2, with heterogeneity was assessed and quantified by the Q score and I2 statistics, respectively.Results:The meta-analysis included 26 articles containing 41 individual studies with a total of 3951 patients without symptoms of DVT. Using venography as the gold standard, US for proximal DVT had a pooled sensitivity of 59% (95% confidence interval (CI) = 51%–66%) and a pooled specificity of 98% (95% CI = 97%–98%), US for distal DVT had a poor sensitivity of 43% (95% CI = 38%–48%) and a pooled specificity of 95% (95% CI = 94%–96%), US for whole-leg DVT had a pooled sensitivity of 59% (95% CI = 54%–64%) and a pooled specificity of 95% (95% CI = 94%–96%), US for post-major orthopedic surgery patients had a pooled sensitivity of 52% (95% CI = 49%–55%), and US for other types of patients had a pooled sensitivity of 58% (95% CI = 43%–72%). Pure compression technique for DVT had a poor sensitivity of 43% (95% CI = 39%–48%), pure color/doppler technique for DVT had a pooled sensitivity of 58% (95% CI = 53%–63%), compression and color/doppler technique for DVT had a pooled sensitivity of 61% (95% CI = 48%–74%).Conclusion:US could be a useful tool for diagnosing DVT, but it has a lower positive rate and a higher false negative rate. The rate of missed diagnosis of lower-limb DVT by US amounts to 50% or so in the patients without symptoms of DVT. The negative results do not preclude the possibility of DVT and if appropriate heightened surveillance and continued monitoring or try a more accurate inspection method is warranted. The whole leg evaluation and color/doppler technique should be the preferred approach.

Рецидивирующее течение тромбозов глубоких вен у детей с заболеваниями крови. Результаты моноцентрового исследования

Введение. Тромбозы глубоких вен (ТГВ) являются нередким осложнением течения и лечения у детей с заболеваниями крови и требуют проведения антитромботической терапии и профилактики для снижения количества повторных тромботических эпизодов. Цель исследования: анализ частоты и определение факторов риска повторных ТГВ у детей, госпитализированных для лечения заболеваний крови. Материалы и методы. Проведен ретроспективный анализ электронной базы данных пациентов в возрасте от 0 до 17 лет включительно, которым проводили стационарное лечение гемобластозов и синдромов костномозговой недостаточности в период 01.0.2012 по 31.12.2017. В анализ вошли только те пациенты, у которых было зарегистрировано более 1 случая тромбоза. Результаты. Рецидивы тромбозов наблюдали у 13,3 детей с асимптоматическими (аТГВ) и у 5,4 с симптоматическими (сТГВ) ТГВ. Рецидивы аТГВ при остром лимфобластном лейкозе (ОЛЛ) выявлены у 14,5, при остром миелобластном лейкозе (ОМЛ) у 8,9, при лимфоме у 11,9. У детей с сТГВ рецидивы тромбоза выявлены при ОЛЛ у 8,2, при ОМЛ у 8,3, при лимфоме у 2,8 пациентов. Медиана возраста пациентов с единственным эпизодом сТГВ составила 10 лет, с рецидивом сТГВ 9 лет, при аТГВ 7 лет для пациентов с единственным эпизодом и 6 лет с рецидивом аТГВ. Некорректно проведенная терапия была зарегистрирована у 50 детей. Заключение. Рецидивирующее течение тромбоза у детей, госпитализированных для лечения заболеваний крови, уста новлено у 5,4 детей с сТГВ и у 13,3 детей с аТГВ, причем 1/3 часть сТГВ является потенциально жизнеугрожающей. Полученные данные подчеркивают необходимость проведения вторичной антитромботической профилактики у детей с ТГВ и ставят вопрос о необходимости и целесообразности проведения таковой у пациентов с аТГВ. Introduction. Deep vein thrombosis (DVT) remains a common complication of hematological diseases in children and requires antithrombotic therapy and prophylaxis of recurrent thrombotic events. Aim: to determine incidence and risk factors of recurrent DVT for hospitalized children with blood diseases. Materials and methods. Medical records of patients hospitalized with oncohematological diseases and bone marrow aplasia, aged from 0 to 17 years, were analyzed retrospectively. Only patients with more than one DVT were taken into this analysis. Results. Recurrent DVT was diagnosed in 13.27 children with asymptomatic DVT (aDVT) and in 5.41 with symptomatic DVT (sDVT). Recurrent DVT was found in 14.49 children with acute lymphoblastic leukemia (ALL), in 8.89 with acute myeloblastic leukaemia (AML), in 11.86 with lymphomas. Incidence of recurrent thrombosis in children with sDVT was 8.16 for ALL, 8.33 for AML, 2.78 for lymphomas. Age analysis of patients with the single episode and recurrent thrombosis showed that age median with single sDVT was 10 years, recurrent DVT 9 years, in case of single asymptomatic or incidental (aDVT) episode 7 years, recurrent DVT 6 years. Incorrect therapy was registered for 50 of children with recurrent sDVT. Conclusion. Recurrent DVT in hospitalized children with blood diseases occurred in 5.41 children with sDVT and in children 13.33 with aDVT 1/3 episodes of sDVT was lifethreatening. In conclusion, secondary prophylaxis is needed for children with DVT and future research should be done for prophylaxis in those with aDVT.

Oral Rivaroxaban in Symptomatic Deep Vein Thrombosis

To evaluate the efficacy of oral rivaroxaban compared to warfarin in patients with deep vein thrombosis (DVT). Open label randomized controlled study. Department of General Medicine, Pakistan Institute of Medical Sciences (PIMS), Islamabad from January 2016 to January 2018. Patients of both genders between 18 and 60 years of age with Doppler ultrasound-confirmed DVT were included in the study. Pregnant patients and those with advanced liver, renal disease, those with a previous history of DVT, malignancy, with a platelets count of less than 50000/ul were excluded from the study. Rivaroxaban was given in a dose of 15 mg twice daily for 21 days followed by 20 mg once daily. Patients in the warfarin group were given heparin for 3 to 5 days followed by warfarin for 3 to 6 months. The primary efficacy outcome was patency of the vessel at 3 and 6 months of treatment. The principal safety outcomes were major and minor bleeding during the study period. A total of 151 patients with acute symptomatic deep vein thrombosis were enrolled in the study. Half of the patients were given warfarin and the other half rivaroxaban for 6 months. At three months, there were no significant differences observed in vessel patency in the rivaroxaban group (22.4%) as compared to warfarin group (26.7%) but after 6 months of therapy, vessel patency was significantly more in the rivaroxaban group. Adverse events did not show any significant differences Conclusion: Rivaroxaban had an efficacy superior to warfarin in terms of vessel patency after six months of therapy but adverse events were similar in both the groups.

Does Tranexamic Acid Increase the Incidence of Thromboembolism After Spinal Fusion Surgery?

This was a retrospective analysis of prospectively collected data. To investigate the incidence of thromboembolism in patients who received tranexamic acid (TXA) after lumbar spine fusion and determine the diagnostic value of lower limb duplex sonography as a screening test. TXA is effective in reducing blood drainage in spine fusion surgery but some studies have reported increased incidence of venous thromboembolism associated with TXA. One hundred twenty-two patients who underwent lumbar fusion for degenerative spinal disease received intravenous TXA in doses equivalent to 10 mg/kg for 48 hours after surgery. As a control group, 85 patients received intravenous administration of the same amount of normal saline. D-dimer levels were checked on the day of admission and the seventh postoperative day (POD#7). All patients underwent duplex sonography on POD#7, and patients with abnormal results were further evaluated with computed tomography angiography and pulmonary arterial angiography. None of the patients showed symptoms of deep vein thrombosis (DVT). Suspicious signs of DVT were observed in 5 patients in the TXA group and 4 patients in the control group in lower limb duplex sonography. Finally, DVT was confirmed by computed tomography angiography in one of 122 patients (0.8%) in the TXA group and in one of 85 patients (1.2%) in the control group. D-dimer levels on POD#7 were higher in the patients with DVT than in patients without DVT. Average postoperative blood drain was 421.3±133.1 mL in the TXA group and 635.2±151.2 mL in the control group (P<0.001), which showed TXA was effective to reduce postoperative hemorrhage. The incidence of thromboembolism after using TXA in lumbar fusion surgery was 0.8%, as comparable as the incidence of thromboembolism in the control group. Lower limb duplex sonography is not recommended for screening test of DVT because of high false-positive rate. Level III.

Incidence of Symptomatic Pulmonary Embolus and Deep Vein Thrombosis After Knee Arthroscopy in the Pediatric and Adolescent Population.

The incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) after pediatric knee arthroscopy is unknown. The purpose of this study was to determine the incidence of venous thromboembolism (VTE) after knee arthroscopy in the pediatric and adolescent population in a high-volume center. Retrospective cohort study. Tertiary care children's hospital. All patients who underwent arthroscopy of the knee for a sports-related injury by 2 surgeons were reviewed. Chief complaint, past medical/surgical history, medications, procedure performed, intraoperative findings, intraoperative complications, and postoperative recovery were reviewed. The incidences of postoperative VTE within 30 days after the procedure were reviewed. Seven hundred forty-six (358 male and 388 female patients) knee arthroscopies performed from September 2011 to October 2016 by 2 pediatric orthopedic surgeons specializing in sports-related injuries were included. The average age was 15.2 ± 2.72 years. Five patients were suspected to have either DVT or PE postoperatively (0.67%). The overall incidence of symptomatic confirmed VTE after knee arthroscopic procedures was 0.27% (one DVT after a partial lateral meniscectomy and one PE after fixation of an osteochondral lesion). The incidence of VTE after pediatric sports medicine knee arthroscopies is low, 0.27%. Patients who present with calf swelling or pain, chest pain, or shortness of breath after arthroscopic surgery should be examined closely. Level III.

Features of etiology and pathogenesis of acute deep vein thrombosis in children of different age groups. Results of a prospective cohort study in parallel groups

Aim. To study the characteristics of the etiology and clinical picture of acute deep vein thrombosis in children of different age groups. &#x0D; Methods. The article analyzes the diagnosis and treatment of 77 children and adolescents with acute deep vein thrombosis. The features of the history of patients, previous fact of deep venous catheterization were studied. The fact of the presence and absence of clinical symptoms of thrombosis is registered. The results of ultrasound diagnostics are used. All patients underwent a course of anticoagulant therapy. The results of diagnosis and treatment were evaluated taking into account the age of the patients, the presence/absence of the history of catheterization of deep veins. &#x0D; Results. When comparing different age groups, their distinctive characteristics were revealed: predominant presence of asymptomatic catheter-associated thrombosis in the younger age group (newborns and infants) with symptomatic deep vein thrombosis of various origin in older children. Among the surveyed, the majority (75.3%) had asymptomatic thrombosis. Pain (2.6%), edema (3.9%) and a combination of pain and edema (18.2%) were more common among symptomatic patients with the symptoms of acute vein thrombosis. In some cases, a combination of two or more complaints was noted. Asymptomatic thrombosis in the catheter-associated thrombosis group amounted to 96.6%. All patients below 1 year had a predisposing factor in the history: 95% - preceding vein catheterization, 5% - postoperative period. With a history of venous catheterization, symptoms of thrombosis were detected 9.2 times less frequently than in children without vein catheterization. In the group of children older than a year, the ratio of thrombosis without a predisposing factor was 10.5%, and the ratio of children with symptoms of thrombosis was 1.38 times higher than among children younger than a year. The only fatal outcome: a 17-year-old patient with a history of thrombophilia, thrombosis of the left iliac vein, pulmonary embolism. &#x0D; Conclusion. Deep vein thrombosis in children of the first year of life in all cases was caused by a predisposing factor: in children during the first year of life in 95% of cases deep vein thrombosis was asymptomatic and was revealed by ultrasound examination.

Peripherally inserted central catheter-related thrombosis rate in modern vascular access era-when insertion technique matters: A systematic review and meta-analysis.

Technical factors at the moment of catheter insertion might have a role in peripherally inserted central catheter-related thrombotic risk. We performed a systematic review and meta-analysis to define the actual rate of peripherally inserted central catheter-related symptomatic deep vein thrombosis in patients in whom catheter insertion was performed according to ultrasound guidance, appropriate catheter size choice, and proper verification of tip location. We searched Medline, Embase, and Cochrane Library. Only prospective observational studies published in peer-reviewed journals after 2010 up to November 2018 reporting peripherally inserted central catheter-related deep vein thrombosis rate were included. All studies were of adult patients who underwent peripherally inserted central catheter insertion. Results were restricted to those studies which included in their methods ultrasound guidance for venipuncture, catheter tip location, and a catheter size selection strategy. Random-effect meta-analyses and arcsine transformation for binomial data were performed to pool deep vein thrombosis weighted frequencies. Of the 1441 studies identified, 15 studies involving 5420 patients and 5914 peripherally inserted central catheters fulfilled our inclusion criteria. The weighted frequency of peripherally inserted central catheter-related deep vein thrombosis was 2.4% (95% confidence interval = 1.5-3.3) and remained low in oncologic patients (2.2%, 95% confidence interval = 0.6-3.9). Thrombotic rate was higher in onco-hematologic patients (5.9%, 95% confidence interval = 1.2-10). Considerable heterogeneity (I2 = 74.9) was observed and all studies were considered at high risk of attrition bias. A proper technique is crucial at the moment of peripherally inserted central catheter insertion. Peripherally inserted central catheter-related deep vein thrombosis rate appears to be low when evidence-based technical factors are taken into consideration during the insertion procedure.

Developing an Appetite

Developing an Appetite

Clinical outcomes of manual aspiration thrombectomy for Ilio-femoral venous thrombosis in cancer patients.

e23145 Background: To determine the outcomes and feasibility of manual aspiration thrombectomy (MAT) for treatment of symptomatic ilio-femoral deep vein thrombosis (IFDVT) in cancer patients. Methods: In this retrospective study, one hundred and thirty-five consecutive patients (56 men; mean age, 63 years; 149 limbs) with acute (n = 113; 83.7%), subacute (n = 14; 10.4%), and chronic (n = 8; 5.9%) symptomatic IFDVT underwent MAT-based endovascular treatment, with adjunctive balloon angioplasty and stent placement performed in 94 patients. Degree of thrombus removal on venography and symptom improvement was assessed for evaluation of technical and clinical success, respectively. Results: Technical success (thrombus removal &gt; 50%) was achieved in 90.4%, and clinical success was observed in 71.5%. The primary patency rates were 88.1%, 81.6%, 76.0%, 74.1% and 69.1% at 1, 3, 6, 12, and 30 months, respectively. Recurrent IFDVT occurred in 19.3% of patients, 0.79 cases per patients-years of follow up. According to the analysis by causes of IFDVT, recurrent rate was 19.3%, 21.2%, and 14.3% in unknown, compression/invasion of the vein by cancerous mass, and May-Thurner syndrome groups, respectively (p = 0.798). No procedure-related complication developed. Conclusions: MAT is a feasible treatment option with favorable outcomes and minimal risk of complication in cancer patients with symptomatic IFDVT.

Postoperative Thromboprophylaxis With New Oral Anticoagulants is Superior to LMWH in Hip Arthroplasty Surgery: Findings from the Swedish Registry.

Although the use of thromboprophylaxis is well established, there is no consensus on the preferred thromboprophylaxis regimen after THA; large, population-based studies offer an opportunity to examine this problem in a robust way that can complement results from randomized trials. Using data from a large national registry, we asked: (1) Is there any difference between low-molecular weight heparin (LMWH) and new oral anticoagulants in preventing symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE), after THA? (2) Are there any differences in safety parameters, such as bleeding, reoperations and mortality, between LMWH and new oral anticoagulants? Between 2008 and 2012, 78,066 THAs were performed in Sweden. This study evaluated 32,663 (42%) of them, selected through the merger of several national registries. These patients underwent unilateral THA due to primary osteoarthritis. They had not experienced any venous thromboembolic events 5 years before the index operation and were not prescribed potent antithrombotic agents, of any type, in the 6 months before the index operation. Additionally, their postoperative thromboprophylaxis was confirmed in a national registry by purchase of prescribed medications. We divided the cohort into two groups: those patients who received new oral anticoagulants (5752, 18%) and those who received LMWH (26,881, 82%) as postoperative thromboprophylaxis. Our primary endpoints were the frequencies of symptomatic DVT and symptomatic PE within 3 months of surgery. Our secondary comparison was a between-group comparison of bleeding (by way of diagnostic coding), reoperation, and mortality within 3 months of surgery. Odds ratios (OR) are presented with 95% confidence intervals (CIs) as pooled results for the two groups after adjustment for duration of thromboprophylaxis (short or extended for at least 28 days), year of the index operation, Elixhauser comorbidity index, sex, age and previous treatment with platelet aggregation inhibitors. The risk of symptomatic DVT was lower in the group that received new oral anticoagulants than the group that received LMWH (0.3% versus 0.6%, OR, 0.47; 95% CI, 0.27-0.76; p = 0.026). The risk of symptomatic PE was lower in the group that received new oral anticoagulants than the group that received LMWH (0.1% versus 0.4%, OR, 0.36; 95% CI, 0.16-0.69; p = 0.005). There was no difference in the risk of bleeding (by way of diagnostic coding) (OR, 1.03; 95% CI, 0.82-1.28; p = 0.688), reoperation (OR, 1.02; 95% CI, 0.71-1.44; p = 0.860) or mortality (OR, 0.83; 95% CI, 0.31-1.88; p = 0.883) between groups. New oral anticoagulants were associated with a lower risk of symptomatic DVT and symptomatic PE in this large, registry study, and we observed no differences in the risk of bleeding, reoperation, or death between the groups. Although we were able to control for a number of potential confounding variables, we cannot ascertain the indications that drove the prescription decisions in this setting, and there were important between-group differences in terms of duration of thromboprophylaxis (new oral anticoagulants generally were used for a longer period of time after surgery). Future studies, preferably large randomized trials with pragmatic inclusion criteria, to analyze symptomatic DVT, symptomatic PE and death are needed to confirm or refute our findings. Level III, therapeutic study.