Intravascular Tumor Extension and Pulmonary Tumor Embolism in Children With Solid Malignancies: Is There a Role for Inferior Vena Cava Filters?

Intravascular tumor extension is an uncommon complication of solid malignancies that, when present in the inferior vena cava (IVC), can result in fatal pulmonary tumor embolism. Currently, neoadjuvant chemotherapy and surgery are the mainstays of treatment; however, there are no consensus guidelines for management. We describe three cases of pediatric solid malignancies with associated IVC extension and pulmonary tumor embolism. We hypothesize that there is scope for IVC filter placement in such cases to mitigate the risk of fatal pulmonary tumor embolism.

Risk Factors for Postdischarge Major Thromboembolism and Mortality in Hospitalized Patients with COVID-19 with Cardiovascular Comorbidities: Insights from the CORE-19 Registry

BACKGROUND

 Coronavirus disease 2019 (COVID-19) is associated with venous and arterial thromboembolism (VTE and ATE) and all-cause mortality (ACM) in hospitalized patients. High-quality data are needed on postdischarge outcomes in patients with cardiovascular disease.

OBJECTIVES

 To analyze outcomes and identify risk factors for ATE, VTE, and ACM in a high-risk subgroup of hospitalized COVID-19 patients with baseline cardiovascular disease.

METHODS

 We investigated postdischarge rates and associated risk factors of ATE, VTE, and ACM in 608 hospitalized COVID-19 patients with coronary artery disease, carotid artery stenosis (CAS), peripheral arterial disease (PAD), or ischemic stroke.

RESULTS

 Through 90 days postdischarge, outcome rates were: ATE 27.3% (10.2% myocardial infarction, 10.1% ischemic stroke, 13.2% systemic embolism, 12.7% major adverse limb event); VTE 6.9% (4.1% deep vein thrombosis, 3.6% pulmonary embolism); composite of ATE, VTE, or ACM 35.2% (214/608). Multivariate analysis showed significant association between this composite endpoint and age >75 years (odds ratio [OR]: 1.90, 95% confidence interval [CI]: 1.22-2.94, p = 0.004), PAD (OR: 3.23, 95% CI: 1.80-5.81, p ≤ 0.0001), CAS (OR: 1.74, 95% CI: 1.11-2.75, p = 0.017), congestive heart failure (CHF) (OR: 1.84, 95% CI: 1.02-3.35, p = 0.044), previous VTE (OR: 3.08, 95% CI: 1.75-5.42, p < 0.0001), and intensive care unit (ICU) admission (OR: 2.93, 95% CI: 1.81-4.75, p < 0.0001).

CONCLUSION

 COVID-19 inpatients with cardiovascular disease experience high rates of ATE, VTE, or ACM through 90 days postdischarge. Age >75 years, PAD, CAS, CHF, previous VTE, and ICU admission are independent risk factors.

Racial Disparities in Administration of Venous Thromboembolism Prophylaxis After Severe Traumatic Injuries

BACKGROUND

Race is associated with differences in quality of care process measures and incidence of venous thromboembolism (VTE) in trauma patients. We aimed to investigate if racial disparities exist in the administration of VTE prophylaxis in trauma patients.

METHODS

We queried the Trauma Quality Improvement Project database from 2017 to 2019. Patients ages ≥16 years old with ISS ≥15 were included. Patients with no signs of life on arrival, any AIS ≥6, hospital length of stay <1 day, anticoagulant use before admission, or without recorded race were excluded. Patients were grouped by race: white, black, Asian, American Indian, and Native Hawaiian or Pacific Islander. The association between VTE prophylaxis administration and race was determined using a Poisson regression model with robust standard errors to adjust for confounders.

RESULTS

A total of 285,341 patients were included. Black patients had the highest rates of VTE prophylaxis exposure (73.8%), shortest time to administration (1.6 days), and highest use of low molecular weight heparin (56%). Black patients also had the highest incidence of deep vein thrombosis (2.8%) and pulmonary embolism (1.4%). Black patients were 4% more likely to receive VTE prophylaxis than white patients [adj. IRR (95% CI): 1.04 (1.03-1.05), P < .001]. American Indians were 8% less likely to receive VTE prophylaxis [adj. IRR (95% CI): .92 (.88-.97), P < .001] than white patients. No differences between white and Asian or Native Hawaiian or Pacific Islander patients existed.

DISCUSSION

While black patients had the highest incidence of DVT and PE, they had higher administration rates and earlier initiation of VTE prophylaxis. Further work can elucidate modifiable causes of these differences.

Early venous thromboembolism prophylaxis in patients with trauma intracranial hemorrhage: Analysis of the prospective multicenter Consortium of Leaders in Traumatic Thromboembolism study

BACKGROUND

The optimal time to initiate venous thromboembolism prophylaxis (VTEp) for patients with intracranial hemorrhage (ICH) is controversial and must balance the risks of VTE with potential progression of ICH. We sought to evaluate the efficacy and safety of early VTEp initiation after traumatic ICH.

METHODS

This is a secondary analysis of the prospective multicenter Consortium of Leaders in the Study of Thromboembolism study. Patients with head Abbreviated Injury Scale score of > 2 and with immediate VTEp held because of ICH were included. Patients were divided into VTEp ≤ or >48 hours and compared. Outcome variables included overall VTE, deep vein thrombosis (DVT), pulmonary embolism, progression of intracranial hemorrhage (pICH), or other bleeding events. Univariate and multivariate logistic regressions were performed.

RESULTS

There were 881 patients in total; 378 (43%) started VTEp ≤48 hours (early). Patients starting VTEp >48 hours (late) had higher VTE (12.4% vs. 7.2%, p = 0.01) and DVT (11.0% vs. 6.1%, p = 0.01) rates than the early group. The incidence of pulmonary embolism (2.1% vs. 2.2%, p = 0.94), pICH (1.9% vs. 1.8%, p = 0.95), or any other bleeding event (1.9% vs. 3.0%, p = 0.28) was equivalent between early and late VTEp groups. On multivariate logistic regression analysis, VTEp >48 hours (odds ratio [OR], 1.86), ventilator days >3 (OR, 2.00), and risk assessment profile score of ≥5 (OR, 6.70) were independent risk factors for VTE (all p < 0.05), while VTEp with enoxaparin was associated with decreased VTE (OR, 0.54, p < 0.05). Importantly, VTEp ≤48 hours was not associated with pICH (OR, 0.75) or risk of other bleeding events (OR, 1.28) (both p = NS).

CONCLUSION

Early initiation of VTEp (≤48 hours) for patients with ICH was associated with decreased VTE/DVT rates without increased risk of pICH or other significant bleeding events. Enoxaparin is superior to unfractionated heparin as VTE prophylaxis in patients with severe TBI.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Pulmonary Embolism and Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a frequent and devastating chronic respiratory disease. COPD is ranked among the top five causes of death worldwide. Patients with COPD suffer from persistent dyspnea, with periods of acute worsening, called exacerbations. Such exacerbations may be severe. In fact, one-third of COPD patients will be hospitalized because of an exacerbation. Hospitalization due to respiratory failure has been identified as a powerful predisposing risk factor for venous thromboembolism (VTE) for many years. Therefore, COPD is recognized as a moderate risk factor for VTE, with an odds ratio between 2 and 9, similar to other risk factors such as estrogen-containing contraceptives or (any) cancer. However, unlike other risk factors such as contraception, the presence of COPD can modify the initial presentation of VTE and worsen the short-term prognosis of patients who have acute pulmonary embolism (PE), particularly during a COPD exacerbation. It is not only that both stable COPD and acute exacerbations of COPD might increase the risk of VTE, but PE itself may mimic the symptoms of a COPD exacerbation. Hence, some authors have evaluated the prevalence of PE among COPD patients with acute worsening. This clinical review (1) gives an update on epidemiological data, clinical presentation, and prognosis of PE associated with COPD; (2) presents the results of the Prevalence de l'Embolie Pulmonaire chez les patients admis pour exacerbation de BPCO study, which aimed at determining the frequency of PE in COPD patients hospitalized for an acute exacerbation; (3) discusses the results of the Significance of Pulmonary Embolism in COPD Exacerbations study, the first randomized trial having compared the efficacy of a systematic search for PE versus routine care on admission for a COPD exacerbation; and (4) provides a selection of remaining unmet needs on the association between COPD and PE.

Massive bilateral pulmonary embolism in a child

We describe a rare case of acute pulmonary artery thromboembolism in a 17-year-old male patient who presented to our emergency department following a syncopal episode. A chest radiograph showed a convex pulmonic cone and an increased cardiothoracic index, and two-dimensional echocardiogram suggested near-occlusion of both pulmonary arterial branches. Multi-slice pulmonary angio-tomography revealed massive thrombosis of the pulmonary artery. He was treated with systemic anticoagulation and subsequently required surgical thrombectomy, with favourable early outcome. Although the cause of the thromboembolism remains unproven, we discuss possible etiologies.

Accelerated fixation is associated with fewer pulmonary embolism in patients with isolated and unilateral femoral shaft fractures: A TQIP analysis

INTRODUCTION

The optimal time to intramedullary internal fixation for patients with isolated and unilateral femoral shaft fractures was investigated by the American College of Surgeons-Trauma Quality Improvement Program (ACS-TQIP).

MATERIAL AND METHODS

Adult patients from the TQIP between 2017 and 2019 were eligible for inclusion. The associations between time to fixation and target outcomes (pulmonary embolism [PE], deep vein thrombosis [DVT], acute respiratory distress syndrome [ARDS], and mortality) were assessed. Maximization of the sum of sensitivity and specificity was used to determine the optimal cut point. The patients were divided into three groups according to different time to fixation intervals. A multinomial propensity scores weighting using generalized boosted models was performed for all unbiased pre-treatment factors between the groups. Multivariate logistic regression was used to clarify the outcomes predictors.

RESULTS

The univariate and multivariate analysis before weighting showed that only PE was significantly associated with time to fixation (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.09; p = 0.012). The optimal cut point of time to fixation was 13.88 h. The patients were divided into accelerated (≤ 13.88 h), standard (> 13.88 and ≤ 24 h), and delayed (> 24 and < 36 h) groups. After weighting for all unbiased pre-treatment factors between the groups, multivariate logistic regression showed that standard group significantly increased the risk of PE compared with accelerated group (OR, 4.436; 95% CI, 1.844-10.672; p = 0.001).

CONCLUSION

Accelerated intramedullary internal fixation within 13.88 h was associated with a significantly decreased risk of PE compared with standard fixation in patients with isolated and unilateral femoral shaft fractures without additional mortality risks.

Validation of the Pulmonary Embolism Severity Index Risk Classification and the 2019 European Society of Cardiology Risk Stratification in the Southeast Asian Population with Acute Pulmonary Embolism

AIM

To date, no studies representing the Southeast Asian population have validated the Pulmonary Embolism Severity Index (PESI) and 2019 European Society of Cardiology (ESC) risk stratification. Therefore, this study aimed to validate the PESI score, simplified PESI (sPESI), PESI risk classification, and 2019 ESC risk stratification in Southeast Asian patients with acute pulmonary embolism (APE).

METHODS

The present study is a 10-year cross-sectional study. Here, risk regressions were conducted to identify the PESI risk classification, sPESI, and 2019 ESC risk stratification as predictors for 30-day all-cause and PE-related mortalities. Receiver operating characteristic (ROC) curves were constructed to determine the diagnostic ability of the PESI score, sPESI score, PESI risk classification, and 2019 ESC risk stratification to predict 30-day mortality.

RESULTS

A total of 696 patients (male, 286; female, 410; mean age, 57.7±15.7 years) were included in this study from 2011 to 2020. The risk of 30-day all-cause mortality progressively increased with the 2019 ESC risk stratification, being approximately 6-fold higher in the high-risk than in the low-risk class [risk ratio: 6.24 (95% confidence interval (CI), 3.12, 12.47), P＜0.001]. The risk of 30-day all-cause mortality with the PESI risk classification also increased with the risk classes, being approximately 6-fold higher in class V than in class I [adjusted risk ratio: 5.91 (95% CI, 2.25, 15.51), P＜0.001]. The highest area under the receiver operating characteristic curve (AuROC) of the predictive model was the PESI score [AuROC=0.733 (95% CI, 0.685, 0.782)].

CONCLUSION

Our study represents a good validation of the PESI and 2019 ESC risk stratification to predict 30-day mortality after APE diagnosis in the Southeast Asian population.

COVID-19-Associated Pulmonary Embolism: Review of the Pathophysiology, Epidemiology, Prevention, Diagnosis, and Treatment

COVID-19 is associated with endothelial activation in the setting of a potent inflammatory reaction and a hypercoagulable state. The end result of this thromboinflammatory state is an excess in thrombotic events, in particular venous thromboembolism. Pulmonary embolism (PE) has been of special interest in patients with COVID-19 given its association with respiratory deterioration, increased risk of intensive care unit admission, and prolonged hospital stay. The pathophysiology and clinical characteristics of COVID-19-associated PE may differ from the conventional non-COVID-19-associated PE. In addition to embolic events from deep vein thrombi, in situ pulmonary thrombosis, particularly in smaller vascular beds, may be relevant in patients with COVID-19. Appropriate prevention of thrombotic events in COVID-19 has therefore become of critical interest. Several changes in viral biology, vaccination, and treatment management during the pandemic may have resulted in changes in incidence trends. This review provides an overview of the pathophysiology, epidemiology, clinical characteristics, and risk factors of COVID-19-associated PE. Furthermore, we briefly summarize the results from randomized controlled trials of preventive antithrombotic therapies in COVID-19, focusing on their findings related to PE. We discuss the acute treatment of COVID-19-associated PE, which is substantially similar to the management of conventional non-COVID-19 PE. Ultimately, we comment on the current knowledge gaps in the evidence and the future directions in the treatment and follow-up of COVID-19-associated PE, including long-term management, and its possible association with long-COVID.

Acute osteomyelitis, thrombophlebitis, and pulmonary embolism: a case report

BACKGROUND

Septic pulmonary embolism (SPE), deep vein thrombophlebitis (DVT), and acute osteomyelitis (AOM) form a triad that is rarely seen in children and is usually associated with a history of trauma on long bones. Unfortunately, a delay in diagnosis is frequently observed in this syndrome, which places the patient at risk of life-threatening complications. This delay can largely be attributed to the failure to consider osteomyelitis as a potential underlying cause of DVT.

CASE PRESENTATION

In this case report, we present the case of a 16-year-old Arabian male who presented with limb trauma and fever. The patient had a delayed diagnosis of osteomyelitis, which resulted in the formation of an abscess and subsequent joint destruction. Surgical drainage and joint replacement surgery were deemed necessary for treatment.

CONCLUSIONS

persistent fever along with a history of trauma on a long bone with signs of DVT of the limb in a child should raise concern for osteomyelitis and an MRI evaluation of the limb should be obtained.

Ultrasound surveillance for deep venous thrombosis and subsequent venous thromboembolism in adults with trauma: A systematic review and meta-analysis

BACKGROUND

Studies have shown routine ultrasound surveillance (RUSS) will facilitate deep vein thrombosis (DVT) detection in patients with trauma and reduce the subsequent incidence of pulmonary embolism (PE); however, the findings were inconsistent. In adults with trauma at a high risk of venous thromboembolism, this systematic review and meta-analysis compared RUSS outcomes with those of "no RUSS."

METHODS

Three databases were screened for relevant articles from inception to October 18, 2021. Randomized controlled trials (RCTs) and observational studies comparing RUSS with no RUSS were included. We used relative risks (RRs), odds ratios (ORs), and mean differences to pool effect estimates for dichotomous and continuous outcomes. The cochrane risk of bias or the risk of bias in non-randomized studies of interventions were used to assess bias risk. The grading of recommendations, assessment, development, and evaluation framework assessed the certainty of the evidence.

FINDINGS

Out of 1685 articles, 5 met the inclusion criteria (RCT: 1; observational studies: 4). Observational studies suggested RUSS is associated with higher odds of DVT detection (OR, 4.87; 95% confidence interval [CI], 3.13-7.57; very low certainty). Whereas higher risks of DVT were associated with RUSS in the RCT (distal DVT: RR, 15.48; 95% CI, 7.62-31.48; low certainty, and proximal DVT: RR, 2.37; 95% CI, 1.04-5.39; very low certainty). Reduced odds of PE risk were observed with the RUSS (OR, 0.47; 95% CI, 0.24-0.91; very low certainty). Observational studies indicated that RUSS had an uncertain effect on mortality (OR, 0.46; 95% CI, 0.06-3.49). In the RCT, times to proximal and distal DVT diagnoses were shorter with RUSS (proximal DVT, mean difference 2.25 days shorter [95% CI, 5.74-1.24]; distal DVT, mean differences 1.56 days shorter [95% CI, 4.22-1.12]; very low certainty for both). Increasing bleeding risk was not linked to the RUSS group (RR, 1.24; 95% CI, 0.31-4.92).

INTERPRETATION

The RUSS efficacy in adults with trauma at high risk for venous thromboembolism showed that it increases DVT detection, decreases PE incidence, and shortens the time to DVT diagnosis, with an uncertain impact on mortality. The evidence is low or very low in certainty because of bias, inconsistency, imprecision, and indirectness.

Is there an indication for simultaneous bilateral knee arthroplasty in morbidly obese patients? Should the patients' request for simultaneous operation be considered?

PURPOSE

This study aimed to analyse the safety of simultaneous bilateral total knee arthroplasty (SBTKA) surgery by comparing morbidly obese (MO) patients with obese patients.

METHODS

SBTKA was performed to 494 patients by a single surgeon in a single center between 2014-2020. The patients followed for a mean of 26 months. They were divided into two groups according to body mass index (BMI) as MO (BMI> 40 kg/m2, n = 65) and obese(O) (BMI = 30-39.9 kg/m2, n = 429 patients). The groups were compared in terms of wound healing problems (WHP), mobilization time (MT), operation time (OT), prosthesis infection, aseptic loosening (AL), early complications, revision, and length of hospitalization using univariate and multivariate logistic regression analyses.

RESULTS

Logistic regression analysis revealed significant differences in the clinical outcomes and complications between MO and O patients. Parameters such as length of stay, OT, MT, WHP, debridement, medial retinaculum detachment (MRD) and AL, and short-term complications such as acute kidney injury (AKI), and pulmonary embolism (PE) incidence were significantly higher in the MO group. Among the MO patients, the clinical outcomes were worse than those among the O patients, and the complication incidence was higher.

CONCLUSION

We do not find SBTKA surgery feasible in morbidly obese patients due to the high complication rate and unsatisfactory clinical outcomes. We suggest that the patient's request to undergo SBTKA should not be taken into account, and that staged surgery be preferred.

Non-bacterial thrombotic endocarditis in a patient with COVID

Non-bacterial thrombotic endocarditis is mainly associated with malignancies and rheumatological diseases. We report the case of mildly symptomatic COVID-19 infection with non-bacterial aortic valve vegetation complicated by transient ischemic attack (TIA) and pulmonary embolism during his hospitalisation. This case emphasised rare life-threatening complications from a hypercoagulable state related to COVID-19 infection. To the best of our knowledge, this is the third case report of non-bacterial endocarditis in a patient with COVID-19 patients as a potential rare complication of COVID-19.

A Pediatric Case of Septic Pulmonary Embolism Caused by Tsukamurella paurometabola

We herein report a three-year-old boy with septic pulmonary embolism caused by Tsukamurella paurometabola bacteremia during chemotherapy for rhabdomyosarcoma. During the interval of chemotherapy, the patient was temporarily discharged with a peripherally inserted central venous catheter but was re-admitted to the hospital with a fever on the same day. A blood culture taken at the time of re-admission showed T. paurometabola. The patient had a persistent fever, and computed tomography performed on the ninth day showed septic pulmonary embolism. We stress the importance of being aware of the possibility of septic pulmonary embolism in patients with Tsukamurella bacteremia.

Risk of venous thromboembolism in patients undergoing gastric cancer surgery: a systematic review and meta-analysis

BACKGROUND

Venous thromboembolism (VTE) is a common postoperative complication in patients undergoing surgery for gastric cancer (GC). Although VTE incidence may vary among cancers, guidelines rarely stratify preventive methods for postoperative VTE by cancer type. The risk of VTE in patients undergoing surgery for GC remains unclear.

METHODS

A systematic review and meta-analysis was undertaken to determine the risk of VTE after GC surgery and discuss the clinical value of pharmacological thromboprophylaxis in these cases. Medline, Embase, Web of Science, and Cochrane Library databases were searched for articles published from their inception to September 2022.

RESULTS

Overall, 13 studies (111,936 patients) were included. The overall 1-month incidence of VTE, deep vein thrombosis (DVT), and pulmonary embolism (PE) after GC surgery was 1.8% (95% CI, 0.8-3.1%; I²=98.5%), 1.2% (95% CI, 0.5-2.1%; I²=96.1%), and 0.4% (95% CI, 0.1-1.1%; I²=96.3%), respectively. The prevalence of postoperative VTE was comparable between Asian and Western populations (1.8% vs. 1.8%; P > 0.05). Compared with mechanical prophylaxis alone, mechanical plus pharmacological prophylaxis was associated with a significantly lower 1-month rate of postoperative VTE and DVT (0.6% vs. 2.9% and 0.6% vs. 2.8%, respectively; all P < 0.05), but not PE (P > 0.05). The 1-month postoperative incidence of VTE was not significantly different between laparoscopic and open surgery (1.8% vs. 4.3%, P > 0.05).

CONCLUSION

Patients undergoing GC surgery do not have a high risk of VTE. The incidence of VTE after GC surgery is not significantly different between Eastern and Western patients. Mechanical plus pharmacological prophylaxis is more effective than mechanical prophylaxis alone in postoperative VTE prevention. The VTE risk is comparable between open and laparoscopic surgery for GC.

Perioperative Dexamethasone Associated With Decreased Length of Stay After Total Hip and Knee Arthroplasty

INTRODUCTION

Dexamethasone is increasingly used after total joint arthroplasty (TJA) to reduce postoperative nausea and vomiting (PONV) and pain. The primary aim of this study was to examine the relationship between perioperative intravenous (IV) dexamethasone and length of stay (LOS) in patients undergoing primary, elective TJA.

METHODS

All patients who underwent TJA from 2015 to 2020 and received perioperative IV dexamethasone were queried from the Premier Healthcare Database. The cohort of patients who received dexamethasone was randomly truncated by a power of 10 and matched in a 1:2 ratio based on age and sex to patients who did not receive dexamethasone. Patient characteristics, hospital factors, comorbidities, 90-day postoperative complications, LOS, and postoperative morphine milligram equivalents were recorded for each cohort. Univariate and multivariate analyses were conducted to assess differences.

RESULTS

Overall, 190,974 matched patients were included, 63,658 (33.3%) of whom received dexamethasone and 127,316 (66.7%) did not. The dexamethasone cohort was composed of fewer patients with uncomplicated diabetes (11.6% vs. 17.5%, P < 0.001). Patients who received dexamethasone had significantly decreased mean LOS compared with patients who did not receive dexamethasone (1.66 vs. 2.03 days, P < 0.001). After controlling for confounding variables, dexamethasone was associated with significantly lower risk of pulmonary embolism (adjusted odds ratio [aOR]: 0.74, 95% CI: 0.61 to 0.90, P = 0.003), deep vein thrombosis (aOR: 0.78, 95% CI: 0.68 to 0.89, P < 0.001), PONV (aOR: 0.75, 95% CI: 0.70 to 0.80, P < 0.001), acute kidney injury (aOR: 0.82, 95% CI: 0.75 to 0.89, P < 0.001), and urinary tract infection (aOR: 0.77, 95% CI: 0.70 to 0.80, P < 0.001). In aggregate, dexamethasone was associated with similar postoperative opioid utilization between cohorts ( P = 0.061).

CONCLUSION

Perioperative dexamethasone was associated with reduced LOS and decreased postoperative complications including PONV, pulmonary embolism, deep vein thrombosis, acute kidney injury, and urinary tract infection after TJA. Although perioperative dexamethasone was not associated with notable reductions in postoperative opioid utilization, this study supports the use of dexamethasone to decrease LOS through multifactorial mechanisms beyond decreased pain.

Multiple sclerosis and the incidence of venous thromboembolism: a systematic review and meta-analysis

A number of studies have suggested that multiple sclerosis (MS) can be associated with serious vascular complications, for which pulmonary thromboembolism (PTE) is a potentially lethal complication. The purpose of this study is to establish a current literature-based estimate of the incidence of venous thromboembolism (VTE), deep vein thrombosis (DVT), and PTE in patients with MS (pwMS) due to the lack of systematic reviews and meta-analyses on this topic. In this systematic review and meta-analysis, studies were assessed regarding the association between MS and the incidence of VTE. The studies were identified through a systematic search of major electronic databases spanning the period from 1950 to February 2022. A random-effects analysis was conducted to calculate the pooled effect size (ES) and 95% confidence intervals (CI) using STATA software. Nine out of 4605 studies were included in the meta-analysis, with an overall sample size of 158,546 individuals. Meta-analysis revealed that the pooled incidence of VTE was 1.8% (95% CI 1.4-2.3) among pwMS. Also, there was an incidence of 0.9% (95% CI 0.4-1.4) and 1.5% (95% CI 1-2.2) for PTE and DVT, respectively in pwMS. Analysis showed MS would be significantly associated with a twofold increased risk of VTE [risk ratios (RR) = 2.12 (95% CI 1.53-2.93)]. Although MS is not typically considered a major risk factor for VTE, the meta-analysis of cohort studies shows that MS has a relative association with an increased incidence of VTE. Future research should focus on the investigation of the effects of MS and its treatments on VTE risk, and also a full range of confounding adjustments will be needed.

Combination of enoxaparin and low-dose aspirin for thromboprophylaxis in selective patients after primary total joint arthroplasty in a Taiwanese population

BACKGROUND

The incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) after total joint arthroplasty (TJA) procedures are lower in Asian populations than in Caucasian populations. Therefore, the need for thromboprophylaxis in Asian patients undergoing TJA remains inconclusive. The aim of this study was to validate the clinical outcomes of thromboprophylaxis in selective TJA patients in a Taiwanese population.

METHODS

We retrospectively reviewed records of patients who underwent TJA procedures performed by a single-surgeon between January 2010 through December 2019. Patients received thromboprophylaxis with a combination of enoxaparin and low-dose aspirin if they fulfilled any of the following criteria: 1) body mass index >30 (kg/m 2 ), 2) presence of varicose veins, 3) history of DVT or PE, or 4) simultaneous bilateral TJA procedure. We assessed the incidence of DVT and PE, 90-day postoperative complications, length of stay, in-hospital mortality, 30-day and 90-day readmission, and 1-year reoperation.

RESULTS

Of the 7511 patients included in this study, 2295 (30.6%) patients received thromboprophylaxis. For patients who received thromboprophylaxis(N = 2295), the incidence of DVT and PE were 0.44% and 0%, respectively. For patients who did not receive thromboprophylaxis (N = 5216), the incidence of DVT and PE was 0.46% and 0.04%, respectively. The overall rates of 90-day postoperative complications (2.3%), 30-day (1.8%) and 90-day readmission (2.3%), and 1-year reoperation (1.1%) were low.

CONCLUSION

Providing thromboprophylaxis for selective TJA patients within the Taiwanese population was effective, as indicated by the low incidence of DVT and PE. Complications, such as surgical site infection, should be carefully weighed and managed.

Pulmonary Embolism in a Liver Donor: A Case Report and Review of the Literature

Liver transplant is an important treatment option for end-stage liver disease, and living related donation is an option to shorten or eliminate the waiting period for the patients, especially when shortage of organs is of concern. It is crucial to provide optimal safety for the donors and to thoroughly examine them preoperatively in order to decrease perioperative and postoperative complications. Here, we report the case of a living donor who had undergone a left liver lobectomy and on postoperative day 2 presented with a radiologically severe pulmonary embolism, despite the absence of any risk factor for venous thromboembolism or pulmonary embolism. The patient was treated with tissue plasminogen activator and heparin infusions and was discharged 1 week later.

The use of pre-operative Inferior Vena Cava filters for thromboprophylaxis in ultra-high-risk patients undergoing total hip and knee arthroplasty: a systematic review and narrative analysis

PURPOSE

Patients undergoing total hip (THA) or knee (TKA) arthroplasty are at high risk of venous thromboembolism (VTE). As the number performed annually increases, the population at risk of fatal pulmonary embolism (PE) also grows. Ultra-high-risk arthroplasty patients (UHRAPs) include those with additional comorbidities, or a history of VTE, for many of whom routine prophylaxis will previously have failed. Pre-operative insertion of Inferior Vena Cava filters (IVCFs) has been recommended for thromboprophylaxis in UHRAPs, and this review was performed to establish their results.

METHODS

A systematic search of MEDLINE and Embase databases was performed for studies reporting the use of Inferior Vena Cava filters in hip and knee arthroplasty patients.

RESULTS

Ten studies met the inclusion criteria, containing 718 IVCFs in Orthopaedic patients, 343 of which were permanent (47.8%), 369 potentially retrievable (51.4%), 5 absorbable (0.6%) and one of unknown design (0.1%). Patient age averaged 64.7yrs (17-95) and 56% were female. Pre-operatively, 415 prophylactic IVCFs were inserted in 409 UHRAPs, undergoing a total of 438 total joint arthroplasties (TJA). There were 11 cases of PE in the entire series (1.5%) only one of which was fatal (0.01%), with four non-fatal PE in the UHRAP group (0.96%). Removal was attempted for 283 of the retrievable filters (76.7%) and was successful in 280 (98.9%).

CONCLUSION

The use of IVCFs eliminated fatal PE in UHRAPs, but larger, high-quality studies, with standardised reporting, are still required to determine their absolute indications for use, complication profile, efficacy and optimum design.

Outcomes in High-Risk Pulmonary Embolism Patients Undergoing FlowTriever Mechanical Thrombectomy or Other Contemporary Therapies: Results From the FLAME Study

BACKGROUND

Hemodynamically unstable high-risk, or massive, pulmonary embolism (PE) has a reported in-hospital mortality of over 25%. Systemic thrombolysis is the guideline-recommended treatment despite limited evidence. The FLAME study (FlowTriever for Acute Massive PE) was designed to generate evidence for interventional treatments in high-risk PE.

METHODS

The FLAME study was a prospective, multicenter, nonrandomized, parallel group, observational study of high-risk PE. Eligible patients were treated with FlowTriever mechanical thrombectomy (FlowTriever Arm) or with other contemporary therapies (Context Arm). The primary end point was an in-hospital composite of all-cause mortality, bailout to an alternate thrombus removal strategy, clinical deterioration, and major bleeding. This was compared in the FlowTriever Arm to a prespecified performance goal derived from a contemporary systematic review and meta-analysis.

RESULTS

A total of 53 patients were enrolled in the FlowTriever Arm and 61 in the Context Arm. Context Arm patients were primarily treated with systemic thrombolysis (68.9%) or anticoagulation alone (23.0%). The primary end point was reached in 9/53 (17.0%) FlowTriever Arm patients, significantly lower than the 32.0% performance goal (P<0.01). The primary end point was reached in 39/61 (63.9%) Context Arm patients. In-hospital mortality occurred in 1/53 (1.9%) patients in the FlowTriever Arm and in 18/61 (29.5%) patients in the Context Arm.

CONCLUSIONS

Among patients selected for mechanical thrombectomy with the FlowTriever System, a significantly lower associated rate of in-hospital adverse clinical outcomes was observed compared with a prespecified performance goal, primarily driven by low all-cause mortality of 1.9%.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04795167.

Sex-Related Differences in Patient Characteristics, Risk Factors, and Symptomatology in Older Adults with Pulmonary Embolism: Findings from the SERIOUS-PE Study

Sex-specific factors are implicated in pulmonary embolism (PE) presentation in young patients, as indicated by increased risk in pregnancy. Whether sex differences exist in PE presentation, comorbidities, and symptomatology in older adults, the age group in which most PEs occur, remains unknown. We identified older adults (aged ≥65 years) with PE in a large international PE registry replete with information about relevant clinical characteristics (RIETE registry, 2001-2021). To provide national data from the United States, we assessed sex differences in clinical characteristics and risk factors of Medicare beneficiaries with PE (2001-2019). The majority of older adults with PE in RIETE (19,294/33,462, 57.7%) and in the Medicare database (551,492/948,823, 58.7%) were women. Compared with men, women with PE less frequently had atherosclerotic diseases, lung disease, cancer, or unprovoked PE, but more frequently had varicose veins, depression, prolonged immobility, or history of hormonal therapy (p < 0.001 for all). Women less often presented with chest pain (37.3 vs. 40.6%) or hemoptysis (2.4 vs. 5.6%) but more often with dyspnea (84.6 vs. 80.9%) (p < 0.001 for all). Measures of clot burden, PE risk stratification, and use of imaging modalities were comparable between women and men. PE is more common in elderly women than in men. Cancer and cardiovascular disease are more common in men, whereas transient provoking factors including trauma, immobility, or hormone therapy are more common in elderly women with PE. Whether such differences correlate with disparities in treatment or differences in short- or long-term clinical outcomes warrants further investigation.