Symptomatic Deep Venous Thrombosis Research Articles

Thrombotic events following Covid-19 vaccines compared to Influenza vaccines

ImportanceThe actual risk of thrombotic events after Covid-19 vaccination is unknown. ObjectiveTo evaluate the risk of thrombotic events after Covid-19 vaccination. DesignRetrospective cohort study which included consecutive adult patients vaccinated with the first dose of Covid-19 vaccine between January 1 and May 30, 2021, and a historic control group, defined as consecutive patients vaccinated with influenza vaccine between March 1 and July 30, 2019. SettingHospital Italiano de Buenos Aires, a tertiary hospital in Argentina. ParticipantsNon-Hospitalized Adults vaccinated with the first dose of a Covid-19 vaccine. ExposureVaccination with Covid-19 vaccines available during the study period: Gam-COVID-Vac (Sputnik), ChAdOx1 nCoV-19 (AstraZeneca/Oxford or Covishield), BBIBP-CorV (Beijing Institute of Biological Products) (Sinopharm). Active comparator group exposure was Influenza vaccine. Main outcomePrimary endpoint was cumulative incidence of any symptomatic thrombotic event at 30 days, defined as the occurrence of at least one of the following: symptomatic acute deep venous thrombosis (DVT); symptomatic acute pulmonary embolism (PE); acute ischemic stroke (AIS); acute coronary syndrome (ACS) or arterial thrombosis. ResultsFrom a total of 29,985 adult patients who received at least a first dose of Covid-19 vaccine during study period and 24,777 who received Influenza vaccine in 2019, we excluded those who were vaccinated during hospitalization. We finally included 29,918 and 24,753 patients respectively. Median age was 73 years old (IQR 75–81) and 67% were females in both groups. Thirty six subjects in the Covid-19 vaccination group (36/29,918) and 15 patients in the Influenza vaccination group (15/24,753) presented at least one thrombotic event. The cumulative incidence of any thrombotic event at 30 days was 12 per 10,000 (95%CI 9–17) for Covid-19 group and 6 per 10,000 (95%CI 4–10) for Influenza group (p-value=0.022). Conclusions and relevanceThis study shows a significant increase in thrombotic events in subjects vaccinated with Covid-19 vaccines in comparison to a control group. The clinical implication of these findings should be interpreted with caution, in light of the high effectiveness of vaccination and the inherent risk of thrombosis from Covid-19 infection itself.

Percutaneous Mechanical Thrombectomy for Acute Symptomatic Iliofemoral Deep Venous Thrombosis Patients With Recent Aneurysmal Subarachnoid Hemorrhage

Purpose: To investigate the efficacy, safety, and mid-term outcomes of percutaneous mechanical thrombectomy (PMT) for acute symptomatic iliofemoral deep venous thrombosis (DVT) patients with recent (within 4 weeks) aneurysmal subarachnoid hemorrhage (aSAH). Materials and methods: From January 2016 to February 2020, 11 acute symptomatic iliofemoral DVT patients with a recent history of aSAH were enrolled in this study. All patients had a history of aneurysm ligation or clipping previously, computed tomography (CT) scans revealed ventricular hemorrhage had been absorbed obviously and no residual aneurysm. The mean time of DVT onset after aSAH ictus was 19.2±4.5 days, and the mean Glasgow score was 6.8 ± 0.7 (range, 6–8). These patients underwent PMT with an 8 French Aspirex®S device (Straub Medical AG, Wangs, Switzerland), subsequent stenting was performed to relieve the underlying stenosis, followed by anticoagulation alone. The procedure-related complications were assessed after intervention. The follow-ups were conducted up to 1 year, the patency was evaluated via duplex ultrasonography, and the incidence of post-thrombotic syndrome (PTS) was evaluated using the Villalta scale. Results: Grade III (>90%) clearance was achieved in all 11 patients. Stenting was performed in 7 patients (63.6%). There were no cerebral rebleeding events or other severe complications except 1 puncture site bleeding during treatment. A total of 90.9% (10 of 11) of patients were alive at the 12 month follow-up, and 7 patients achieved a good functional outcome. At the 1 year follow-up, there was 1 patient (10%) with mild PTS. The ultrasound showed that the patency of the iliofemoral veins was 100%, and femoral valvular incompetence was observed in 1 patient. Conclusion: Percutaneous mechanical thrombectomy seems to be a feasible and safe treatment for acute iliofemoral DVT in selected patients with recent aSAH, and it shows promising results in restoring patency and reducing the risk of PTS.

Equivalence of DOACS and LMWH for thromboprophylaxis after hip fracture surgery: Systematic review and meta-analysis

BackgroundPatients with hip fractures (HF) have an increased risk of venous thromboembolism (VTE). In elective orthopedic surgery direct oral anticoagulants (DOACs) have proven to be similarly or more effective compared to low molecular weight heparin (LMWH), but DOACs are not yet approved for thromboprophylaxis in trauma patients with HF. The aim of this study was to systematically review the literature comparing the effectiveness of DOACs and LMWH for thromboprophylaxis in trauma patients with surgically treated HF. Materials and MethodsWe searched PubMed, the Cochrane Library, Web of Science, and Embase. The primary outcome was the incidence of VTE (symptomatic and asymptomatic combined). Secondary outcomes were symptomatic VTE; a symptomatic VTE, symptomatic deep venous thrombosis (DVT); symptomatic pulmonary embolism (PE); major, clinically relevant non-major (CRNM), and minor bleeding. Meta-analysis was performed to compare the odds of VTE and secondary outcomes between DOACs and LMWH. ResultsThe search resulted in 738 titles. Five studies matched inclusion criteria. In total, 4748 hip fracture patients were analyzed (DOACs: 2276 patients, LMWH: 2472 patients). The pooled odds ratio for the risk of VTE for DOAC use was 0.52 (95% confidence interval 0.25–1.11, p = 0.09) compared to LMWH. No statistically significant differences between DOAC and LMWH were found for asymptomatic VTE, symptomatic DVT, PE, major or CRNM bleeding, and minor bleeding. ConclusionsMeta-analysis of the literature suggests that DOACs are associated with equivalent effectiveness and safety compared to LMWH.

Multimodal Thromboprophylaxis in Patients With a History of Venous Thromboembolism Undergoing Primary and Revision Knee Arthroplasty.

Background: Patients with a history of venous thromboembolism (VTE) undergoing total knee arthroplasty (TKA) are at a high risk of postoperative VTE. Purpose: In this high-risk population, we sought to evaluate the safety and efficacy of multimodal thromboprophylaxis. The regimen consisted of discontinuation of procoagulant medications, VTE risk stratification, regional anesthesia, rapid mobilization, perioperative use of pneumatic compression devices, vigorous ankle dorsiflexion during the recovery period, and chemoprophylaxis tailored to the patient's risk of VTE. Methods: We conducted a retrospective chart review of 141 consecutive patients with a history of VTE who underwent 177 elective TKA procedures between 2005 and 2019 by 2 arthroplasty surgeons at a single institution. The patients had a history of deep venous thrombosis (DVT) (n = 127; 72%), pulmonary embolism (PE) (n = 20; 11%), or both (n = 30; 17%). Postoperative chemoprophylaxis included aspirin (n = 20; 11%), anticoagulation (n = 135; 77%), or a combination of aspirin and anticoagulation (n = 21; 12%). Complications within 120 days, including VTE events, wound complications, bleeding, and unplanned readmissions, were recorded, as was 1-year mortality. Results: Five patients (2.8%) developed symptomatic DVT (3 distal, 2 proximal), and 4 patients (2.3%) developed symptomatic PE. The most common postdischarge complications were wound infection (n = 6; 3.4%) and stiffness requiring manipulation under anesthesia (n = 5; 2.8%). There was 1 emergency room visit and 13 unplanned readmissions; 3 patients developed intra-articular hematomas or prolonged wound drainage and recovered uneventfully. All patients were alive 1 year after surgery. Conclusion: The findings of this retrospective study suggest that multimodal prophylaxis may be safe and effective in patients with a history of VTE undergoing primary and revision TKA. More rigorous study is warranted.

Impact of Compliance on Elastic Compression Stockings Efficacy to Prevent Post-Thrombotic Syndrome: A Prespecified Analysis of the Celest Double-Blind Study

Introduction: Elastic compression stockings (ECS) are commonly used for the prevention of post-thrombotic syndrome (PTS) after deep venous thrombosis (DVT). However, their efficacy is controversial. While two open-label studies reported a 50% risk reduction of PTS in the ECS vs. no-ECS groups, a large double-blind study didn't find any benefit of ECS vs. placebo-ECS to prevent PTS. These opposite results could be explained either by a placebo effect in the open-label studies or to a lack of compliance to study ECS in the double-blind study. Additional data on the impact of compliance on ECS efficacy, obtained in a double-blind way, are therefore needed.Methods: We analyzed data from the French, CELEST, multicentre double-blind trial comparing 25mmHg ECS vs. 35mmHg ECS to prevent PTS at 2 years after a first symptomatic ipsilateral proximal DVT (NCT01578122). All CELEST patients who had complete data for primary outcome (i.e. PTS, defined as a Villalta score ≥5 on the DVT affected leg at the one- or 2-year follow up visit) were included. The objectives of this predefined analysis were to: i) compare the incidences of PTS at 2 years according to compliance to ECS (irrespective of allocated treatment group) during the first 3 months of treatment and during the 2-year follow-up; ii) assess independent predictors of PTS using a stepwise multivariable model including all of the following variables (baseline patients' and DVT characteristics, anticoagulant treatment and compliance to ECS) if they achieved a p value of 0.2 or less in univariate analysis as well as ECS strength allocation group; iii) build an induction tree algorithm to measure the impact in terms of incidence of PTS of each of the independent predictor of PTS. Compliance to ECS was defined as reasonable and optimal if the patient had worn the study ECS more than 50% and more than 80% of the time respectively and had a modified GIRERD score of 0-2.Results: 249 patients were eligible for this analysis. Mean baseline age was 57 years, 70% (n=174) were men, 20% (n=50) were obese, 21% (n=52) had previous VTE event, 7% (n=18) had a baseline Villalta score ≥5 and the most proximal extent of DVT was the iliac vein in 15% (n=37) of cases. In 80% (n=179) of cases patients were treated with anticoagulation for more than 6 months after DVT and a direct oral anticoagulant (DOAC) was used in 69% (n=164) of cases. 32 % (n=80) of patients developed PTS at 2 years. When patients wore study ECS>80% of the time (i.e optimal compliance), incidence of PTS over 2 years was 26.1% (n=31). Incidence of PTS was 25.0% (n=10) and 40.5% (n=34) in those patients who wore ECS 50-80% and <50% of the time, p=0.06. When comparing patients who never wore study ECS (compliance<50% during the whole study follow-up) to those who were reasonably compliant during the whole study follow-up, incidence of PTS was respectively 46.4% (n=13) vs. 25.3% (n=38), p=0.02. Results of the univariate and multivariate analyses are presented in Table 1 and induction tree algorithm is provided in Figure 1.Conclusions: In our double bling study assessing 25mmHg vs. 35mmHg ECS to prevent PTS, compliance to ECS was a significant independent predictor of PTS in our multivariable model. Impact of ECS use became apparent when patient used ECS at least 50% of the time without any strong benefit beyond. Wearing study ECS>50% of the time was associated with 2-fold decreased risk of developing PTS, which is consistent with the results from previous ‘positive’ open-label studies. It suggests that use of ECS influences the risk of developing PTS. Our induction tree algorithm evidences that being compliant with ECS seems particularly beneficial in - non-obese - patients with extensive DVT. [Display omitted] DisclosuresVerriere: Laboratoires Innothera: Current Employment.

Multimodal Peri-articular Injection with Tranexamic Acid can reduce postoperative blood loss versus Intravenous Tranexamic Acid in Total Knee Arthroplasty: A Randomized Controlled Trial

BackgroundTranexamic acid (TXA) has shown significant reductions in blood loss and transfusion rates in total knee arthroplasty (TKA). However, the optimal administration route continues to be debated. The aim of this trial was to compare the effectiveness of intravenous (IV) versus peri-articular injection (PAI) application of tranexamic acid in patients undergoing total knee arthroplasty.MethodsWe conducted a randomized controlled, double-blinded study. A total of 93 patients undergoing primary unilateral TKA were randomly distributed between 2 groups: the IV group (47 cases; 1 g TXA IV) and the PAI group (46 cases; 1 g TXA injected peri-articularly). The amount of total and hidden blood loss (HBL), drainage, transfusion rate, hemoglobin and hematocrit drift, and complications were recorded.ResultsPeri-articular injection of TXA reduced total blood loss (P < 0.001) and HBL more than IV use of TXA (P < 0.001). No patients in either group received a transfusion. No symptomatic deep venous thrombosis or other severe complications occurred.ConclusionPeri-articular injection of TXA significantly reduced total blood loss and hidden blood loss to a greater degree than IV injection in total knee arthroplasty without reduction of drainage volume.Trial registrationChinese Clinical Trial Registry, ChiCTR-INR-16010270. Date of registration: December 27, 2016.

Percutaneous Femoropopliteal Bypass: 2-Year Results of the DETOUR System

Purpose: This study investigated the 2-year safety and effectiveness of the PQ Bypass DETOUR system as a percutaneous femoropopliteal bypass. Materials and Methods: Seventy-eight patients with 82 long-segment femoropopliteal lesions were enrolled in this prospective, single-arm, multicenter study. The DETOUR system deployed Torus stent grafts directed through a transvenous route. Eligible patients included those with lesions of >10 cm and average of 371±55 mm. Key safety endpoints included major adverse events (MAEs) and symptomatic deep venous thrombosis in the target limb. Effectiveness endpoints included primary patency defined as freedom from ≥50% stenosis, occlusion, or clinically-driven target vessel revascularization (CD-TVR), primary assisted, and secondary patency. Results: Chronic total occlusions and severe calcium occurred in 96% and 67% of lesions, respectively. Core laboratory-assessed total lesion length averaged 371±51 mm with a mean occlusion length of 159±88 mm. The rates of technical and procedural success were 96%, with satisfactory delivery and deployment of the device without in-hospital MAEs in 79/82 limbs. The MAE rate was 22.0%, with 3 unrelated deaths (4%), 12 CD-TVRs (16%), and 1 major amputation (1%). Deep venous thrombosis developed in 2.8% of target limbs, and there were no reported pulmonary emboli. Primary, assisted primary, and secondary patency rates by the Kaplan–Meier analysis were 79±5%, 79±5%, and 86±4%, respectively. Conclusions: The PQ Bypass DETOUR system is a safe and effective percutaneous alternative to femoropopliteal open bypass with favorable results through 2 years. The DETOUR system provides a durable alternative to conventional endovascular modalities and open surgery for patients with long, severely calcified, or occluded femoropopliteal lesions.

The Natural History of Uterine Venous Plexus Thrombosis.

The management of incidental or unusual site venous thrombosis (VT) is challenging and is often extrapolated from studies on symptomatic deep venous thrombosis (DVT). There is a tendency to treat with anticoagulation, due to the theoretical risk of propagation and embolism; however, this is not without risk. Furthermore, there is little guidance on how to monitor incidental VT. The aim of this study was to describe the natural history of incidental uterine venous plexus thrombosis (UVPT) and provide a structured approach to its overall management. A prospective study was conducted in a university teaching hospital over a 16-month period. Women diagnosed with UVPT on transvaginal ultrasound (TVS) were followed up over a six-month period and managed based on an individualised risk assessments, in conjunction with haematologists. Fifty women were diagnosed with UVPT during the study period, of which 38 were managed expectantly. The resolution was documented in 70% of women. There were no cases of symptomatic DVT or pulmonary embolisms in either the expectant or treatment groups. Our study has shown that in a high proportion of women, incidental UVPT could be managed successfully without the need for anticoagulation. The overall management of UVPT should be based on individualised clinical risk assessments.

Risk factors for venous thromboembolism in patients with diabetes undergoing joint arthroplasty

BackgroundVenous thromboembolism (VTE) is a significant complication after joint arthroplasty. Diabetes is related to a few changes in coagulation and fibrinolysis that may lead to thrombophilia. We aimed to investigate the incidence of postoperative VTE and associated risk factors among patients with diabetes undergoing total hip (THA) or total knee anthroplasty (TKA) in a single centre in China.MethodsPatients with diabetes who underwent THA or TKA from January 2016 to December 2018 (n = 400) at Beijing Jishuitan Hospital were recruited in this study. Lower limb venous Doppler ultrasound was performed before and after surgery to confirm deep venous thrombosis (DVT). Computer tomography pulmonary angiography was done to confirm pulmonary embolism (PE) for those with new postoperative DVT and typical symptoms of PE. A multivariate logistic regression model was conducted to examine factors associated with the development of postoperative VTE.ResultsThe overall incidence of postoperative VTE in patients with diabetes after THA or TKA was 46.8 % (187 out of 400). Among the 187 VTE patients, 7.5 % (14 out of 187) had proximal vein thrombosis and 92.5 % (173 out of 187) had distal vein thrombosis. No PE occurred. Female patients and patients undergoing TKA had higher incidence of postoperative VTE. Patients who developed postoperative VTE were older, and had higher levels of preoperative D-Dimer and Caprini score. A high level of preoperative D-dimer (OR = 2.11, 95 %CI = 1.35–3.30) and the surgery of TKA (OR = 2.29, 95 %CI = 1.29–4.01) significantly increased the risk of developing postoperative VTE. Postoperative initiation of concomitant mechanical prophylaxis and low molecular weight heparin (LMWH) was protective for postoperative VTE (OR = 0.56, 95 %CI = 0.37–0.86).ConclusionsVTE is common in patients with diabetes undergoing joint arthroplasty. Patients undergoing TKA or with a high level of preoperative D-dimer are at a considerable risk of developing postoperative VTE. There may be a protective role of postoperative initiation of concomitant mechanical prophylaxis and LMWH for VTE.

Factors affecting D-dimer levels in patients with uncomplicated primary varicose veins.

Objectives The diagnosis of deep venous thrombosis (DVT) is hampered in patients with primary varicose veins due to similarity of symptoms of DVT and PVV and elevated levels of D-dimers. The purpose of this study was to analyze factors that influence the D-dimer concentration in patients with PVV in order to redefine its diagnostic value. Methods Forty- one patients with non-complicated PVV were enrolled in the study, in whom D-dimer level was determined by immunoturbidimetric assay. The influence of selected clinical factors on the concentration of D-dimers was determined with univariate and bivariate analysis. Besides descriptive statistics the D-dimers levels were compared to the age -adjusted cutoff values. Results The median concentration of D-dimer was 630.0 ng/ml (440.0-1140.0 ng/ml) and was above the age-adjusted level in 21 (52%) of patients. There was a positive correlation between the patient's age and and D-dimer concentration (p = 0.035, Spearman correlation coefficient rs=0,33. The bivariate analysis showed a significant interaction between age and weight p=0,02. Conclusions In patients with PVV the diagnostic value of D-dimers is limited especially in older and overweight subjects.

External validation of the IMPROVE-DD risk assessment model for venous thromboembolism among inpatients with COVID-19

There is a need to discriminate which COVID-19 inpatients are at higher risk for venous thromboembolism (VTE) to inform prophylaxis strategies. The IMPROVE-DD VTE risk assessment model (RAM) has previously demonstrated good discrimination in non-COVID populations. We aimed to externally validate the IMPROVE-DD VTE RAM in medical patients hospitalized with COVID-19. This retrospective cohort study evaluated the IMPROVE-DD VTE RAM in adult patients with COVID-19 admitted to one of thirteen Northwell Health hospitals in the New York metropolitan area between March 1, 2020 and April 27, 2020. VTE was defined as new-onset symptomatic deep venous thrombosis or pulmonary embolism. To assess the predictive value of the RAM, the receiver operating characteristic (ROC) curve was plotted and the area under the curve (AUC) was calculated. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Of 9407 patients who met study criteria, 274 patients developed VTE with a prevalence of 2.91%. The VTE rate was 0.41% for IMPROVE-DD score 0–1 (low risk), 1.21% for score 2–3 (moderate risk), and 5.30% for score ≥ 4 (high risk). Approximately 45.7% of patients were classified as high VTE risk, 33.3% moderate risk, and 21.0% low risk. Discrimination of low versus moderate-high VTE risk demonstrated sensitivity 0.971, specificity 0.215, PPV 0.036, and NPV 0.996. ROC AUC was 0.703. In this external validation study, the IMPROVE-DD VTE RAM demonstrated very good discrimination to identify hospitalized COVID-19 patients at low, moderate, and high VTE risk.

Compression treatment in acute symptomatic proximal deep venous thrombosis – Results of a worldwide survey

The aim of this study was to illustrate how compression is performed worldwide in proximal DVT and if compression management has changed recently. A global online survey, consisting of 36 questions, was used. The survey was solicited from membership lists of Union Internationale de Phlébologie (UIP) membership societies. For differences between the continents in comparison to Western Europe odds ratios and 95% Confidence Intervals (95%CI) where calculated. We received 626 answers from 41 countries. Compression is routinely used in proximal DVT in all regions (82.8%). 81.4% start compression immediately after diagnosis. In the acute phase of DVT reduction of pain and swelling (91.7%) and PTS prevention (66.2%) are the main reasons for compression. 33.2% recently changed their compression management with 43.5% starting compression earlier and 7.0% later. Compression is still used routinely in proximal DVT in addition to anticoagulation. The changes in international guidelines towards the non-routine use of compression in proximal DVT have not caused significant changes in DVT management.

Risk for deep venous thrombosis in pediatric cancer patients undergoing surgery

PurposeCancer is a well-established risk factor for deep venous thrombosis (DVT). We sought to assess the incidence of DVT in pediatric cancer patients undergoing select surgical procedures at our institution and to identify additional factors associated with DVT development. MethodsWe performed a retrospective review of cancer patients who underwent select surgical procedures and developed a DVT within 30 days of their operation from 2000 to 2018 at our institution. Catheter-associated DVTs were excluded from this analysis. Major oncologic operations were selected. ResultsFrom 2000 to 2018, 3031 major oncologic operations were performed following which 14 symptomatic DVTs occurred, for an overall incidence of 0.46%. Procedures associated with post-operative DVT included: mass biopsy (7), pulmonary wedge resection (2), inguinal lymph node excision (1), colectomy (1), nephrectomy (1), lower extremity limb-sparing revision (1), and femur resection (1). ConclusionsOur data suggest that surgery does not put children with cancer at significant risk for DVT. Given the low incidence of perioperative DVT, routine pharmacologic prophylaxis for children with cancer undergoing surgery does not seem warranted.Level of Evidence: II

Aspirin for Deep-Venous Thrombosis Prophylaxis After Anterior Cruciate Ligament Reconstruction.

To evaluate whether a daily full-dose aspirin regimen after anterior cruciate ligament (ACL) reconstruction reduces the risk of postoperative symptomatic deep-venous thrombosis (DVT). Single-center retrospective cohort study of patients who underwent ACL reconstruction from 2007 to 2016. One thousand two hundred thirty-three patients met inclusion criteria: 821 patients received no chemoprophylaxis and 412 patients received daily full-dose aspirin. A total of 10 patients, seven receiving no chemoprophylaxis and three using aspirin, sustained a postoperative symptomatic DVT. Calculated adjusted odds ratio for symptomatic postoperative DVT for aspirin versus no chemoprophylaxis was 0.928 (95% CI 0.237-3.629, P value = 0.91). Odds ratio for symptomatic postoperative DVT occurrence among tobacco users versus non-tobacco users was 3.76 (95% CI 1.077-13.124, P = 0.04). No statistically significant difference was observed in postoperative symptomatic DVT after ACL reconstruction in those who received full-dose aspirin chemoprophylaxis versus those with no chemoprophylaxis. Additionally, there was a significantly increased risk of postoperative symptomatic DVT with tobacco use.

A Retrospective Comparison of Catheter-Directed Thrombolysis versus Pharmacomechanical Thrombolysis for Treatment of Acute Lower Extremity Deep Venous Thrombosis

Pharmacomechanical thrombolysis (PMT) and catheter-directed thrombolysis (CDT) are frequently employed for treating deep venous thrombosis (DVT). However, there have been relatively few studies comparing PMT outcomes to those associated with CDT. The present study was thus designed to compare short- and mid-term PMT and CDT patient outcomes following the treatment of DVT of the lower extremities. This study was a retrospective analysis of 98 patients treated at the 3rd Affiliated Hospital of Shenzhen University (Shenzhen, China) and Beijing Chao Yang Hospital (Beijing, China). All patients had undergone treatment for symptomatic DVT of the lower legs via either CDT or PMT. Clinical records and outcome data between the patients in these 2 treatment groups were compared. Of the 98 patients analyzed in this retrospective study, 50 had been treated via CDT while 48 had undergone PMT. These PMT and CDT operations were associated with mean treatment durations of 0.97 ± 0.20 hr and 32.48 ± 7.46 hr, respectively (P < 0.0001). Complete lysis was achieved in 78 patients (42 and 36 in the PMT and CDT groups, respectively P = 0.057), while effective lysis was achieved in 96 patients (48 and 48 in the PMT and CDT groups, respectively P = 0.162), with lysis being ineffective in the 2 remaining patients. PMT was associated with a significantly decreased length of hospital stay, usage of UK dose, and treatment duration relative to CDT(P < 0.0001). No major complications or MACE incidence were noted in either group, although 18 patients in the PMT group suffered from bradyarrhythmia (P = 0.007). Clinical efficacy was achieved in 96 patients (48 in each treatment group) at time of discharge (P = 0.162). A Kaplan-Meier analysis revealed that 2-year primary patency rates did not differ significantly between these 2 groups (P = 0.442). PMT is an effective treatment modality in patients with symptomatic DVT. Relative to CDT it is associated with high treatment success rates, reduced treatment duration, and reduced hospitalization duration, although it is also associated with higher rates of systemic complications.

Clinical Risk Factors and Perioperative Hematological Characteristics of Early Postoperative Symptomatic Deep Vein Thrombosis in Posterior Lumbar Spinal Surgery.

A retrospective analysis (2015-2019) of data collected from patients who underwent posterior lumbar spinal surgery. This study aims to identify the incidence, perioperative hematological characteristics, potential prognostic indicators, and risk factors of deep venous thrombosis (DVT) in the lower limbs after posterior lumbar spinal surgery. Eliminating risk factors or taking measures against patients at risk may reduce the incidence of DVT. Deep venous thromboses have been extensively studied in other reconstructive surgeries. Present literatures provide limited evidence for determining the prognostic and risk factors for this complication after spinal surgery. Patients who underwent posterior lumbar spinal surgery with internal fixation in the Spine Surgery Center of Peking Union Medical College Hospital (PUMCH) were evaluated. The patient demographics, the number of operative segments, the hematological and biochemical parameters on baseline and postoperative day 1, and the presence of DVTs were obtained from all patients. The diagnosis of DVT was established by venous ultrasound when symptomatic. A multivariate logistic regression test was subsequently performed to determine the prognostic indicators and risk factors for DVT. A total of 2053 patients who received lumbar spine procedures were qualified and included. Patients were followed up for 12 weeks. Early symptomatic DVT occurred in 58 individuals (2.39%; 95% confidence interval [CI], 0.4-0.7%). Advanced age, higher preoperative serum D-dimer level, and lower serum potassium level were recognized as independent risk factors for symptomatic DVT. Multiple independent risk factors were identified for early symptomatic DVT after posterior lumbar spine surgery. Postoperative prophylactic anti-coagulation treatment might be warranted for patients with high D-dimer or low potassium levels before the procedure.Level of Evidence: 4.

Adjunctive techniques to minimize thrombotic complications following microfoam sclerotherapy of saphenous trunks and tributaries

ObjectiveThrombus extension into the deep venous system following superficial vein chemical ablation with Varithena polidocanol microfoam has been reported. The objective of this study was to assess the effect of intraoperative improved techniques during treatment for patients with symptomatic varicose veins and their impact on extension of thrombus into deep veins. MethodsA retrospective review of a prospectively maintained database was performed. All patients who underwent endovenous chemical ablation with polidocanol microfoam (Varithena, Boston Scientific, Marlborough, Mass) for symptomatic superficial axial and tributary vein reflux were identified. Patients had postoperative duplex (48-72 hours) scanning after the procedure; those who did not adhere to the recommended follow-up were excluded. Demographic data, CEAP Classification, Venous Clinical Severity Score, procedure details, and follow-up data were abstracted. ResultsBetween April 2018 and August 2020, 157 limbs in 122 patients were treated with Varithena microfoam; 129 limbs in 99 patients met our inclusion criteria. Veins treated included the great saphenous vein (n = 89), anterior accessory saphenous vein (n = 15), small saphenous vein (n = 14), and tributary veins (n = 56). Adjunctive techniques during treatment included intraoperative elevation of the limb to greater than 45°, ultrasound mapping and digital occlusion of large perforator veins, limitation of foam volume per session, injection of sterile saline before treatment, and compression of the limb in the elevated position. The preoperative Venous Clinical Severity Score was 11.4 and decreased after treatment to 9.7. The immediate closure rate was 95% with 81% overall symptomatic relief at last follow-up. The mean follow-up was 113.5 days for the entire cohort; two limbs (1.5%) required postoperative anticoagulation for thrombus extension into the deep venous system (common femoral vein n = 1; popliteal vein n = 1) postoperatively for a mean of 22 days. Both resolved with anticoagulation. One asymptomatic limb developed a femoral vein deep venous thrombosis and one symptomatic late deep venous thrombosis was noted 4 months after the procedure. Postoperative pain and phlebitis were reported in 15.6% and 14.8% of patients, respectively, and all had resolved at last follow-up. No pulmonary emboli were noted and no neurologic or visual adverse events were recorded. ConclusionsAdjunctive techniques during microfoam ablation decreased thrombotic complications in our series compared with those reported in earlier phase III clinical trials. Excellent early closure and symptomatic improvement were also noted. Endovenous microfoam ablation with Varithena is a safe and effective nontumescent, nonthermal alternative to laser and radiofrequency ablation.

PREvention of VENous Thromboembolism in Hemorrhagic Stroke Patients – PREVENTIHS Study: A Randomized Controlled Trial and a Systematic Review and Meta-Analysis

Background: In this randomized trial, currently utilized standard treatments were compared with enoxaparin for the prevention of venous thromboembolism (VTE) in patients with intracerebral hemorrhage (ICH). Methods: Enoxaparin (0.4 mg daily for 10 days) was started after 72 h from the onset of ICH. The primary outcome was symptomatic or asymptomatic deep venous thrombosis as assessed by ultrasound at the end of study treatment. The safety of enoxaparin was also assessed. We included the results of this study in a meta-analysis of all relevant studies comparing anticoagulants with standard treatments or placebo. Results: PREVENTIHS was prematurely stopped after the randomization of 73 patients, due to the low recruitment rate. The prevalence of any VTE at 10 days was 15.8% in the enoxaparin group and 20.0% in the control group (RR 0.79 [95% CI 0.29–2.12]); 2.6% of enoxaparin and 8.6% of standard therapy patients had severe bleedings (RR 0.31 [95% CI 0.03–2.82]). When these results were meta-analyzed with the results of the selected studies (4,609 patients; 194 from randomized trials), anticoagulants were associated with a nonsignificant reduction in any VTE (OR 0.81; 95% CI 0.43–1.51), in pulmonary embolism (OR 0.53; 95% CI, 0.17–1.60), and in mortality (OR 0.85; 95% CI 0.64–1.12) without increase in hematoma enlargement (OR 0.97; 95% CI, 0.31–3.04). Conclusions: In patients with acute ICH, the use of anticoagulants to prevent VTE was safe but the overall level of evidence was low due to the low number of patients included in randomized clinical trials.

A cut above? Inferior vena cava resection without reconstruction: a dual-centre experience

Objectives: To evaluate outcomes in our patients undergoing inferior vena cava (IVC) resection without reconstruction, as part of an adrenal/renal cell cancer (RCC) operation. Methods: British Association of Urological Surgeons (BAUS) Data and Audit System records were obtained for two operating surgeons, each at geographically separate urological cancer centres. Retrospectively reviewed case notes of patients who had undergone IVC resection without reconstruction as part of an adrenal/RCC operation, assessing operative parameters, length of stay, complications and follow-up status. Results: A total of Twenty-eight patients (20 right-sided tumours, 8 left sided) underwent IVC resection without reconstruction in May 2013–February 2017. No perioperative or early deaths occurred. Fourteen patients (50%) had complications: sepsis; pneumonia; congestive cardiac failure; acute kidney injury; symptomatic peripheral deep venous thrombosis; splenectomy; and significant chyle leak. At a median follow-up of 21 months (range 1–55 months) six patients (21.4%) have died and two patients (7.1%) progressed to metastatic disease, giving a 71.4% progression-free survival in this series. Conclusions: This case series illustrates our experience of IVC resection without reconstruction as an acceptably safe procedure. This should be considered as an alternative to graft reconstruction, particularly as minimal invasive approaches are being adopted. Level of Evidence: 3

La maladie thrombo-embolique veineuse au cours du purpura thrombotique thrombocytopénique autoimmun est associée à un traitement prolongé par échanges plasmatiques

IntroductionThrombotic thrombocytopenic purpura (TTP) is a devastating disease characterized by disseminated microvascular thrombosis. Despite pro-thrombotic predisposing conditions, the prevalence of macrovascular venous thrombosis event (VTE) in immune-mediated TTP (iTTP) has rarely been assessed. MethodsWe reviewed data of all iTTP patients of the French reference Center for thrombotic microangiopathies registry prospectively enrolled through a 10-year period, between 2008 and 2018. Venous thrombosis included either thrombosis of central venous catheter, symptomatic deep venous thrombosis of the limbs or pulmonary embolism. ResultsForty-eight (12.7%) VTE were diagnosed. VTE was diagnosed after a median time of 7 [IQR, 3–16] days following the first therapeutic plasma exchange (TPE) and consisted mainly in catheter-related thrombosis (73%), and to a lesser extend symptomatic deep venous thrombosis (16%), proximal pulmonary embolism (8%) and splanchnic vein thrombosis (2%). Cases with VTE (VTE+ cases), required more TPE to achieve remission (P < 0.01), and the total volume of plasma required to achieve remission was larger (P < 0.01) than for VTE- cases. There was also a trend for more rituximab use in the VTE+ cases as compared to the VTE- cases (47% vs 33%; respectively; P = 0.07). Curative anticoagulation was started in 38 cases (79%), while 6 VTE cases did not receive any antithrombotic agents, and catheter was systematically removed when catheter-related thrombosis was diagnosed. VTE+ cases had a higher number of inserted central venous catheters than VTE- cases (P < 0.05). ConclusionVTE is a frequent condition occurring during iTTP management and is observed when patients require a prolonged treatment with daily TPE and multiple catheter insertions. Therapeutic strategies aimed at reducing the duration of TPE treatment in iTTP should substantially reduce this complication.