Therapy For Deep Vein Thrombosis Research Articles

Deep Vein Thrombosis After Total Hip Arthroplasty and Total Knee Arthroplasty in Patients With Previous Ischemic Stroke

The present study evaluated the prevalence and therapy of deep vein thrombosis (DVT) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) in 57 patients with previous ischemic stroke. Postoperative anticoagulants were used for DVT prophylaxis, and batroxobin and prolonged anticoagulants were used for thrombolysis in DVT subjects. The incidence of DVT after THA and TKA in patients with previous ischemic stroke was 16.2% and 20%, respectively. No bleeding complications were observed and no new ischemic stroke occurred during the following 3 months. The prevalence DVT after THA and TKA in patients with previous ischemic stroke was not specific, and the treatment of DVT with batroxobin and anticoagulants was effective and safe.

Dosing and monitoring of enoxaparin therapy in children

Pediatric deep vein thrombosis (DVT) is an emerging problem in tertiary care hospitals, recent reviews shows a rate of 40.2/10,000 admissions. Experts affirm that enoxaparin has become in the drug of choice for DVT therapy. Despite this, there is a little information regarding the optimal dose schedule for enoxaparin therapy in children and the therapeutic guidelines for enoxaparin use in children are extrapolated from adult guidelines. Monitoring by antifactor Xa (anti-Xa) measurement and target concentrations between 0.5-1 U/ml at 4-6 h postdose are recommended. This study was designed to analyse our experience in paediatric-specific dosage requirements for enoxaparin therapy. A retrospective study was performed with patients less than 16 years old, who were treated with enoxaparin for DVT and monitored by anti-Xa concentration, between January 2005 and March 2012. Demographic and clinical characteristics and outcomes were obtained. Fourteen patients were analyzed: boy/girl ratio, 8/4; median age, 3.5 months. Cerebral venous sinus thrombosis was the most common indication for therapy. All patients presented thrombosis risks factors. Dose increases were necessary only in patients less than 6 years old. Target anti-Xa concentrations were achieved in 12 (85%) patients. Children younger than 1 year required a higher dose of enoxaparin/kg (1.5-2.7 mg/kg per 12 h). Complete resolutions of DVT were registered in all cases. The mean number of dose increases was three and a median of 11 days to achieve target anti-Xa concentration. This study indicates that an initial higher enoxaparin dose may be necessary in neonates and infants, but other factors must be considered to improve management.

HIPERSENSIBILIDADE RETARDADA A HEPARINA DE BAIXO PESO MOLECULAR – QUE ALTERNATIVA À ANTICOAGULAÇÃO?

Um doente de 75 anos de idade, obeso, realizou terapêutica anticoagulante por trombose venosa profunda (TVP) do membro inferior: heparina clássica endovenosa durante 3 dias e dalteparina subcutânea durante 10 dias. Três dias depois do término do tratamento o doente é observado por placas eczematiformes nos locais de administração da heparina de baixo peso molecular (HBPM). Os testes epicutâneos, prick, intradérmicos e subcutâneos realizados se- quencialmente com várias HBPM e fondaparinux foram negativos nas leituras imediatas e às 48h. Às 72 horas sugiram lesões eczematiformes nos testes intradérmicos e subcutâneos à enoxaparina, fraxiparina e dalteparina, confirmando o diagnóstico de hipersensibilidade retardada a HBPM. Os testes com o fondaparinux foram negativos, considerando-o uma alternativa anticoagulante segura. Os testes epicutâneos revelaram discreta reacção em D7 apenas à dalteparina e fraxiparina. Os testes de alergia, sobretudo os intradérmicos, com várias heparinas e heparinóides são essenciais para confirmar o diagnóstico e identificar alternativas seguras em caso de necessidade de anticoagulação futura, como neste doente com factores de risco para TVP.PALAVRAS-CHAVE – Anticoagulantes; Hipersensibilidade Retardada; Heparinas de baixo peso molecular; Erupções Cutâneas; Testes Cutâneos.

Deep Vein Thrombosis Risk Stratification

Pulmonary thromboembolism (PTE) is a life-threatening disease which always presents in patients with deep vein thrombosis (DVT). There are few statements in guidelines regarding indications for anticoagulation based on the location of DVT. We investigated whether the relative risk of PTE depends on thrombus location and bleeding complications with anticoagulation therapy. Between January 1 and July 10, 2007, 461 patients underwent lower extremity venous ultrasound studies, and 129 patients were diagnosed as DVT (60 males, 66.9 ± 13.3 years). We retrospectively studied the incidence of PTE and bleeding complications associated with anticoagulation therapy. Average follow-up period was 536 ± 324 days. Above and below knee thrombosis was present in 60 and 69 patients, respectively. Warfarin was administered in 60 patients. Nine patients developed PTE. Multivariate analysis showed the absence of anticoagulation therapy and location of DVT (above knee) to be significantly correlated with onset of PTE (anticoagulation; P < 0.01, location; P = 0.02). However, the incidence of bleeding was not significantly different between above knee and below knee vein thrombosis (P = 0.72). In conclusion, below knee vein thrombosis carries a relatively low risk of PTE, but the incidence of bleeding complications does not depend on thrombosis location. This suggests that the indication of anticoagulation therapy should be based on DVT location.

Safety and efficacy of catheter directed thrombolysis in children with deep venous thrombosis

Safety and efficacy of catheter directed thrombolysis in children with deep venous thrombosis

Axillary vein thrombosis as the first clinical manifestation of inflammatory breast cancer: report of a case

Inflammatory breast cancer is a rare and aggressive form of breast cancer. Venous thromboembolism is often related to cancer conditions but this report presents a case in which the thromboembolic event predicted the diagnosis of cancer. A 48-year-old female was admitted with the evidence of acute right axillary vein thrombosis. There was also erythema and edema of the skin of the right breast. Further evidence revealed a case of inflammatory breast cancer. The patient underwent anticoagulant therapy, and neoadjuvant systemic chemotherapy was initiated. The patient underwent extensive unilateral mastectomy following neoadjuvant chemotherapy. Follow-up (after 2 months of anticoagulation therapy for deep vein thrombosis) revealed recanalization of the right axillary vein, without evidence of residual thrombus. A case of acute vein thrombosis as the first manifestation of breast cancer may delay the diagnosis and subsequent appropriate treatment.

Medical Therapy in Venous Thromboembolism

Immediate intense anticoagulation with parenteral anticoagulants (heparin or fondaparinux) followed by vitamin K antagonists is the current standard therapy for deep vein thrombosis (DVT) or nonmassive pulmonary embolism. In the future, new oral anticoagulants may replace not only vitamin K antagonists but also initial parenteral anticoagulation. Duration of anticoagulation should be at least 3 months because shorter courses double the recurrence rates. More prolonged anticoagulation therapy may be warranted in the presence of specific clinical risk factors. Global markers of coagulation, particularly D-dimer, may discriminate low- and high-risk patients. Models that combine clinical characteristics and laboratory markers further improve prediction of the recurrence risk in individual patients, but these models await validation before they can be applied in routine care.

Aktuelle Studiensituation der neuen Antikoagulantien - Thromboembolische Erkrankungen

Safe and effective anticoagulation is a therapeutic cornerstone of thromboembolic diseases. Until recently oral vitamin K antagonists were the standard drugs for this indication. The new oral antagonists of the coagulation factors Xa (apixaban, rivaroxaban) or thrombin (dabigatran) demonstrated a safe and effective profile in large clinical trial in the fields of prevention of deep vein thrombosis, therapy of deep vein thrombosis (rivaroxaban) and prevention of stroke or systemic embolism in patients with atrial fibrillation. Their entry into clinical practice will initiate a new age of anticoagulation.

Deep Vein Thrombosis: Thrombolysis in the Pediatric Population

Improved medical treatment options have advanced pediatric care but often necessitate both invasive vascular procedures and venous access predisposing these patients to venous thrombotic events. Although pediatric deep vein thrombosis (DVT) is an increasingly recognized phenomenon, high-quality evidence for its antithrombotic treatment in general remains limited, and even more so with respect to thrombolytic therapy. Correspondingly, current American College of Chest Physicians guidelines discourage the routine use of thrombolytic therapy for pediatric DVT; by contrast, American Heart Association guidelines suggest consideration for such therapy in young patients in whom the balance of benefit to risk may be most favorable. The developing hemostatic system and relative rarity of thrombotic events have historically posed impediments to the design and conduction of prospective clinical trials of thrombolysis in children. This narrative review summarizes available information regarding thrombolytic therapy for pediatric DVT.

Incidence of Venous Thromboembolism Using 64 Channel Multidetector Row Computed Tomography-Indirect Venography and Anti-Coagulation Therapy after Total Knee Arthroplasty in Korea

PurposeThis study evaluated the incidence of a venous thromboembolism (VTE) after total knee arthroplasty (TKA) using multidetector row computed tomography-indirect venography (MDCT-indirect venography) and assessed the efficacy of anti-coagulation therapy.Materials and MethodsWe enrolled 118 patients with 126 cases of TKA. The average age of the patients was 68.4 years. We used 64 channel MDCT-indirect venography for the detection of VTE. We treated selectively proximal deep vein thrombosis (DVT) or pulmonary thromboembolism (PTE) cases according to the results of MDCT-indirect venography. We re-evaluated the change in VTE using follow-up MDCT-indirect venography after 3 months.ResultsWe identified VTE in 35.7%. DVT only was identified in 22.2% including 8 cases of proximal DVT and 20 cases of distal DVT. PTE without DVT was identified in 4.8%, and combined DVT and PTE in 8.7%. All patients with PTE were asymptomatic, but 4 DVT patients had signs of leg swelling. After anti-coagulation therapy, 20 patients showed complete resolution in 16 cases, improvement in 3 cases and one case showed a new distal DVT.ConclusionsThe incidence of VTE after primary TKA was 35.7% in Korea. Furthermore, anti-coagulation therapy for proximal DVT and PTE patients may be a useful method for preventing the occurrence of a fatal PTE.

Results of the PHLEFI study (PHLEbothrombosis-FIbrinolytic therapy): A prospective, multicenter study of the fate of 1498 patients receiving fibrinolytic therapy for deep vein thrombosis

Results of the PHLEFI study (PHLEbothrombosis-FIbrinolytic therapy): A prospective, multicenter study of the fate of 1498 patients receiving fibrinolytic therapy for deep vein thrombosis

Results of the PHLEFI Study (PHLEbothrombosis-FIbrinolytic therapy): A prospective, multicenter study of the fate of 1498 patients receiving fibrinolytic therapy for deep vein thrombosis

Fibrinolytic therapy for DVT has not gained universal acceptance. A notable percentage of DVTs in Germany are treated by clot-dissolving methods. This is in contrast to clinical practice in the United States where fibrinolytic treatment for DVT is virtually unknown. It is unique in modern medicine that such a frequent disease is treated so differently on a national basis. The PHLEFI Study is a multicenter, prospective trial on the fate of 1498 patients receiving different forms of fibrinolytic therapy for DVT (ultrahigh streptokinase and urokinase short-term therapy, streptokinase, urokinase, and rt-PA long-term infusions, locoregional and sequential therapies). Interest focused primarily on side-effects such as cerebral bleeding and fatal pulmonary embolism as well as on the clinical outcome in terms of revascularization. The major factor for the rate of cerebral bleeding under fibrinolytic therapy was the age of the patient (0.355% bleeding in patients under and 2.03% in patients over 50 years). The major factor for pulmonary embolism was the site of the thrombosis (2.16% with iliac, 0.701% with femoral, none with popliteal, calf and subclavian vein thromboses). Use of a temporary caval filter during lysis therapy eliminated fatal pulmonary embolism. Results of lytic therapy were stated as complete, partial, and no clearance. The outcome was dependent on the thrombus age and the medication used. The highest clearance rate achieved was 50% in patients treated with short-term ultrahigh streptokinase therapy and a history of up to three days. Fibrinolytic therapy for DVT is a reliable means of achieving revascularization. The above data may enable the physician to balance the usefulness of this therapeutic method against the risk of its side effects.

Outpatient management of acute deep vein thrombosis: Results from the OTIS-DVT registry

Objectives We aimed to investigate clinical practice patterns for the outpatient management of acute deep vein thrombosis (DVT). Methods In the prospective Outpatient Treatment of Deep Vein Thrombosis in Switzerland (OTIS-DVT) registry, 534 consecutive outpatients with acute DVT (49% proximal, 24% recurrent, and 12% cancer-associated) were enrolled: 41% patients were managed in private angiology practice, 34% in an outpatient hospital department, and 25% in private general or internal medicine practice. Results For diagnosis, ultrasound was used in 95% and D-dimer testing in 53%. Low-molecular-weight heparin (LMWH) was prescribed for a median (IQR) duration of 7 (5-12) days in 83% of patients, and vitamin K-antagonists for 163 (92-183) days in 81%. Mechanical measures to prevent post-thrombotic syndrome were prescribed in 83%; compression stockings or bandages for a median (IQR) duration of 364 (101-730) days from hospital physicians, and 92 (45-183) days from private practice physicians (p < 0.001). Among patients with symptomatic proximal DVT, mechanical measures were prescribed for at least 2 years in 24% patients; 55% in hospital, and 6% in private practice (p < 0.001). Among patients with cancer-associated DVT, the median (IQR) duration of LMWH therapy was 16 (8-45) days, and 35% received LMWH for less than 90 days. Conclusions The OTIS-DVT registry provides representative information on clinical practice patterns for outpatients with acute DVT managed by hospital or private practice physicians. The use of mechanical measures in patients with symptomatic proximal DVT and the administration of LMWH for a long-term therapy of cancer-associated DVT require improvement to comply with current guidelines.

Massive muscle haematoma three months after starting vitamin K antagonist therapy for deep-vein thrombosis in an antithrombin deficient patient: Another case of factor IX propeptide mutation

Massive muscle haematoma three months after starting vitamin K antagonist therapy for deep-vein thrombosis in an antithrombin deficient patient: Another case of factor IX propeptide mutation -

Anticoagulant therapy for deep vein thrombosis (DVT) in pregnancy

Thromboembolic complications are much higher in pregnancy due to procoagulant changes. Heparin does not cross the placenta and the use of unfractionated heparin (UFH) is the current established practice in prophylaxis and treatment for thromboembolism in pregnancy. To compare the effectiveness of anticoagulant therapies for the treatment of deep vein thrombosis in pregnancy. The anticoagulant drugs included are UFH, low molecular weight heparin (LMWH) and warfarin. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2010) and reference lists of retrieved studies. Randomised controlled trials comparing any combination of warfarin, UFH, LMWH and placebo in pregnant women. We used methods described in the Cochrane Handbooks for Systemic Reviews of Interventions for assessing the eligibility of studies identified by the search strategy. A minimum of two review authors independently assessed each study. We did not identify any eligible studies for inclusion in the review.We identified three potential studies; after assessing eligibility, we excluded all three as they did not meet the prespecified inclusion criteria. One study compared LMWH and UFH in pregnant women with previous thromboembolic events and, for most of these women, anticoagulants were used as thromboprophylaxis. There were only three women who had a thromboembolic event during the current pregnancy and it was unclear whether the anticoagulant was used as therapy or prophylaxis. We excluded one study because it included only women undergoing caesarean birth. The third study was not a randomised trial. There is no evidence from randomised controlled trials on the effectiveness of anticoagulation for deep vein thrombosis in pregnancy. Further studies are required.

The Efficacy of Endovascular Treatment for Deep Vein Thrombosis

Background: Deep vein thrombosis (DVT) is a serious disease that causes life-threatening pulmonary embolism and chronic venous insufficiency. Anticoagulation is the standard therapy for DVT. However, the results of standard anticoagulation for treating DVT have been disappointing, so endovascular treatment is commonly performed nowadays. The aim of this study was to evaluate the efficacy of an endovascular procedure for treating patients with DVT. Material and Method: We retrospectively evaluated the clinical data of 29 DVT patients who underwent an endovascular procedure between December 2006 and July 2008. We compared the results of the 29 patients with the results of another 45 patients who were treated with only aspirin and heparin. Result: The patient’s mean age was 55.4 years in the intervention group and 53.7 years in the control group. DVT occurred more frequently in the females. Catheter-directed thrombolysis was performed in 22 patients (75.8%). Aspiration thrombectomy was performed in 18 patients (62%) and a endovascular stent was placed in 25 patients (86.2%). Fifteen patients (51.7%) underwent percutaneous insertion of a retrievable IVC filter for the prevention of pulmonary embolism. In the control group, thirty nine patients (86.7%) were treated with low-molecular heparin, and seven patients (15.6%) who were contraindicated for warfarin were treated with aspirin. No bleeding complications occurred during thrombolysis or anticoagulation. We analyzed the statistical data according to recurrence of DVT and the incidence of post-thrombotic syndrome (PTS) during the follow-up period. The intervention group had a significantly lower incidence of PTS (p-value=0.008), but they had the same result as the control group for the recurrence of DVT. In addition, death from the DVT did not occur in the intervention group. Thus, we obtained better clinical outcomes in the intervention group as compared to those in the anticoagulation only group. Conclusion: Endovascular procedures are effective alternative modalities, as compared to systemic anticoagulation, for the treatment of DVT. But more studies are needed to determine the specific indications and to validate the long-term efficacy of endovascular procedures for the treatment of DVT.

Low-dose Systemic Thrombolytic Therapy for Deep Vein Thrombosis in Pediatric Patients

Reduction of thrombus size and recanalization of vessels after deep vein thrombosis (DVT) are important goals to prevent recurrent thrombosis and development of postthrombotic syndrome. Thrombolysis is effective but concern for bleeding complications has limited its use in children. We retrospectively analyzed data for children with DVT treated with a low-dose systemic tissue plasminogen activator (tPA) regimen. Twenty-three pediatric patients (12 males and 11 females, median age 12 y) received low-dose systemic tPA, initiated at 0.03 to 0.06 mg/kg/h for a median of 24 hours (range 12 to 48 h). Of the 20 patients imaged within 24 hours of therapy, 6 (30%) showed partial to complete thrombus resolution. Eight patients subsequently received increased tPA at 0.12 mg/kg/h for an additional 24 hours (range 12 to 36 h). Six of these 8 (75%) patients responded to the increased dose. The overall response at the end of thrombolytic therapy was 59% (13/22). Two bleeding complications occurred without serious sequelae. Low-dose tPA administration leads to a substantial response rate although the risk of bleeding remains unclear. A prospective multicenter trial of low-dose thrombolytic therapy in children with acute DVT is warranted.

Inferior Vena Cava (IVC) Filter Retrieval Rates after Catheter Directed Thrombolysis or Pharmacomechanical Thrombectomy in Deep Vein Thrombosis (DVT) and Its Characteristics

Purpose: Inferior vena cava (IVC) filter is commonly practiced to prevent pulmonary embolism during endovascular therapy of deep vein thrombosis (EndoDVT). When the thrombus is trapped inside the filter during intervention, its removal is quite challenging. The purpose of this study is to determine retrieval rates of IVC filter after EndoDVT and its characteristics. Methods: Patients who underwent EndoDVT in Inha Unversity Hospital from June 2004 to May 2009 were reviewed retrospectively. Retrievable IVC filter was inserted before EndoDVT. EndoDVT was done by catheter directed thrombolysis or pharmacomechanical thrombectomy using urokinase. IVC filter retrieval was decided according to computed tomography after 2 weeks. Results: 126 patients were treated with EndoDVT. Optease (n=101) and Tulip (n=25) IVC filters were inserted. IVC filters were retrieved in 42.9% (54/126). There was no IVC filter related complication during its insertion and removal. IVC filter was not retrieved in 72 patients. Reasons for its failure include residual thrombosis in IVC filter (n=28), high risk for recurrent DVT (n=34), massive pulmonary embolism (n=8), and death (n=2). Residual thrombus inside IVC filter disappeared in 5 patients during 6-month follow up. Conclusion: IVC filters retrieval rate after EndoDVT was 42.9%. This can be improved by thorough patient follow up and extended retrievability.

Treatment of venous thromboembolism: guidelines translated for the clinician

Venous thromboembolism is a major cause of morbidity and mortality affecting over 2 million people in the United States each year. The American College of Chest Physicians (ACCP) published their first consensus statement on antithrombotic therapy in 1986, and the most recent guidelines from the ACCP on this topic were released in 2008. We aim to summarize the most recent ACCP guidelines on therapy for venous thromboembolism with practical application and interpretation for the practicing physician. We will briefly review the rating system used in the guidelines for the level of evidence and the strength of the recommendation. We will then discuss the recommendations for initial anticoagulant therapies including low molecular weight heparin, unfractionated heparin, and fondaparinux for patients with both deep vein thrombosis (DVT) and pulmonary embolism (PE). A discussion of the guidelines on duration of anticoagulant therapy with a vitamin K antagonist is also included. In addition, we will address the use of thrombolytic therapy and inferior vena cava filter placement for DVT and PE. Prevention of postphlebitic syndrome is discussed as well. We will conclude with a brief discussion of future directions including several novel therapeutic anticoagulants.

Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal

Suresh Vedantham, MD, Akhilesh K. Sista, MD, Seth J. Klein, MD, Lina Nayak, MD, Mahmood K. Razavi, MD, Sanjeeva P. Kalva, MD, Wael E. Saad, MD, Sean R. Dariushnia, MD, Drew M. Caplin, MD, Christine P. Chao, MD, Suvranu Ganguli, MD, T. Gregory Walker, MD, and Boris Nikolic, MD, MBA, for the Society of Interventional Radiology and Cardiovascular and Interventional Radiological Society of Europe Standards of Practice Committees