Clinical implications of different risk factor profiles in patients with mesenteric venous thrombosis and systemic venous thromboembolism: a population-based study

Hypercoagulability status, operative mortality, and long-term survival in patients operated on for mesenteric venous thrombosis

OBJECTIVE

Mesenteric venous thrombosis (MVT) is a rare cause of acute surgical abdomen, with high mortality. The aim of this study was to analyze long-term outcomes and possible factors influencing its prognosis.

METHODS

All patients who underwent urgent surgery for MVT from 1990 to 2020 in our center were reviewed. Epidemiological, clinical, and surgical data; postoperative outcomes; origin of thrombosis; and long-term survival were analyzed. Patients were divided into two groups: primary MVT (hypercoagulability disorders or idiopathic MVT) and secondary MVT (underlying disease).

RESULTS

Fifty-five patients, 36 (65.5%) men and 19 (34.5%) women, mean age 66.7 years (standard deviation: ±18.0 years), underwent surgery for MVT. Arterial hypertension (63.6%) was the most prevalent comorbidity. Regarding the possible origin of MVT, 41 (74.5%) patients had primary MVT and 14 (25.5%) patients had secondary MVT. From these, 11 (20%) patients had hypercoagulable states, 7 (12.7%) had neoplasia, 4 (7.3%) had abdominal infection, 3 (5.5%) had liver cirrhosis, 1 (1.8%) patient had recurrent pulmonary thromboembolism, and 1 (1.8%) had deep venous thrombosis. Computed tomography was diagnostic of MVT in 87.9% of the cases. Intestinal resection was performed in 45 patients due to ischemia. Only 6 patients (10.9%) had no complication, 17 patients (30.9%) presented minor complications, and 32 patients (58.2%) presented severe complications according to the Clavien-Dindo classification. Operative mortality was 23.6%. In univariate analysis, comorbidity measured by the Charlson index (P = .019) and massive ischemia (P = .002) were related to operative mortality. The probability of being alive at 1, 3, and 5 years was 66.4%, 57.9%, and 51.0%, respectively. In univariate analysis of survival, age (P < .001), comorbidity (P < .001), and type of MVT (P = .003) were associated with a good prognosis. Age (P = .002; hazard ratio: 1.05, 95% confidence interval: 1.02-1.09) and comorbidity (P = .019; hazard ratio: 1.28, 95% confidence interval: 1.04-1.57) behaved as independent prognostic factors for survival.

CONCLUSIONS

Surgical MVT continues to show high lethality. Age and comorbidity according to the Charlson index correlate well with mortality risk. Primary MVT tends to have a better prognosis than secondary MVT.

Venous thromboembolism in non-COVID-19 population during the pandemic: a nationwide multicenter retrospective survey

Impact of pandemic on the incidence of venous thromboembolism (VTE) in non-COVID-19 patients is undetermined. Thus, a nationwide multicenter retrospective survey was conducted to evaluate the disease burden in non-COVID-19 population. This multi-center survey involved 94 hospitals from 24 provinces in the mainland of China, and collected data on non-COVID-19 patients admitted to the radiology departments due to VTE between January 24 and April 16, 2020. Baseline characteristics, VTE risk factors, clinical manifestations and the treatments were compared with those in the same period of 2019. 3,358 patients with VTE from 74 hospitals were included in this study (1,458 in 2020, 1,900 in 2019). Most aged ≥ 50 years (80.6% in the pandemic, 81.2% in 2019). The number of patients aged 30-39 years increased from 3.9% in 2019 period to 5.8% in the pandemic (p = 0.009). Among the VTE risk factors, the rate of decreased activity increased significantly in the pandemic, and was much higher than that in 2019 (30.7% vs 22.6%, p < 0.0001). Under the risk of decreased activity, patients with comorbidities chronic diseases, especially diabetes, showed significantly a higher incidence of VTE (30.4% vs 22.0%, p < 0.0001). In the pandemic period, fewer patients were treated with anticoagulation alone (33.5% vs 36.7%, p = 0.05), and more underwent inferior vena cava filter (IVCF) implantation, compared with those in 2019 (66.5% vs 63.2%, p = 0.046). The pandemic increased the VTE risk of decreased activity among the non-COVID-19 population. Patients with comorbidities, especially diabetes, have a significant higher risk of VTE during the pandemic.

ABO Blood Groups and Thrombophilia Markers in Patients With Unstimulated Thrombosis in Kurdistan Region of Iraq

Thromboembolism (TE) is a complex disease caused by various acquired and inherited factors. The common mutations; factor V Leiden G1691A (FVL G1691A), prothrombin G20210A (PTG20210A), and methylene tetrahydrofolate reductase C677T (MTHFR C677T) are important inherited causes in both venous and arterial thrombosis. The association between ABO blood groups and thrombophilia has been noted by researchers. We aimed to determine the frequency and association of ABO blood groups as a risk factor along with 3 thrombophilia mutations and another 3 thrombophilia markers in a group of patients with unstimulated thrombosis. In a prospective case-control study, we focused on 100 samples, 50 patients with documented thrombosis as well as 50 healthy age-matched controls. Multiplex polymerase chain reaction and reverse hybridization to oligonucleotide particular probes were employed to detect FVL G1691A, PT G20210A, and MTHFR C677T mutations. Analysis of other thrombophilia markers including protein C (PC), protein S (PS), and antithrombin (AT) assays was also performed. ABO blood group typing was done according to standard methods. Non-O blood group was significantly more frequent among cases than controls (76% vs 54%) with high odds of TE (odds ratio [OR] = 2.69). Positivity for at least 1 thrombophilia marker was more in cases (60%) than controls (34%; OR = 2.9). The combined effect of non-O blood group and thrombophilia markers raised the risk of TE (OR = 4.16, P = .001), particularly FVL (OR = 6.76). This study illustrates that harboring the non-O blood group poses an additive effect with other thrombophilia markers in the causation of TE.

Management of Acute Mesenteric Venous Thrombosis: A Systematic Review of Contemporary Studies

Background and Aims:

Acute mesenteric venous thrombosis accounts for up to 20% of all patients with acute mesenteric ischemia in high-income countries. Acute mesenteric venous thrombosis is nowadays relatively more often diagnosed with intravenous contrast-enhanced computed tomography in the portal phase than at explorative laparotomy No high-quality comparative studies between anticoagulation alone, endovascular therapy, or surgery exists. The aim of the present systematic review was to offer a contemporary overview on management.

Materials and Methods:

Eleven relevant published original studies with series of at least ten patients were retrieved from a Pub Med search between 2015 and 2020 using the Medical Subject Heading term “mesenteric venous thrombosis.”

Results:

When MVT is diagnosed early, immediate anticoagulation with either unfractionated heparin or subcutaneous low-molecular-weight heparin should commence. Surgeons need to be aware of the importance to scrutinize the computed tomography images themselves for assessment of secondary intestinal abnormalities to mesenteric venous thrombosis and the risk of bowel resection and worse prognosis. Progression toward peritonitis is an indication for explorative laparotomy and assessment of bowel viability. Frank transmural small bowel necrosis should be resected and bowel anastomosis may be delayed for several days until second look. Meanwhile, intravenous full-dose unfractionated heparin should be given at the end of the first operation. Postoperative major intra-abdominal or gastrointestinal bleeding occurs rarely, but the heparin effect can instantaneously be reversed by protamine sulfate. Patients who do not improve during conservative therapy with anticoagulation alone but without developing peritonitis may be subjected to endovascular therapy in expert centers. When the patient’s intestinal function has recovered, with or without bowel resection, switch from parenteral unfractionated heparin or low-molecular-weight heparin therapy to oral anticoagulation can be performed. There is a trend that direct oral anticoagulants are increasingly used instead of vitamin K antagonists. Up to now, direct oral anticoagulants have been shown to be equally effective with the same rate of bleeding complications. Patients with no strong permanent trigger factor for mesenteric venous thrombosis such as intra-abdominal cancer should undergo blood screening for inherited and acquired thrombophilia.

Conclusion:

Early diagnosis with emergency computed tomography with intravenous contrast-enhancement and imaging in the portal phase and anticoagulation therapy is necessary to be able to have a succesful non-operative succesful course.

Primary mesenteric vein thrombosis: a case series

Mesenteric vein thrombosis (MVT) is a rare condition, often misdiagnosed due to its vague and misleading clinical presentation. It can cause intestinal infarction, peritonitis, and consequently necessitate bowel resection. CT scanning with intravenous contrast enhancement is the gold standard for its diagnosis. Radiologists have an important role in defining the extent of thrombosis and identifying any signs of intestinal infarction influencing the decision whether or not to operate. In patients with no clinical signs of peritonitis or radiological evidence of intestinal infarction, the treatment can be exclusively medical, based on full anticoagulation (initially with low molecular weight heparin, followed by vitamin K antagonists or direct acting oral-anticoagulants). The duration of medical treatment depends on radiological evidence of resolution of thrombosis and the identification of pro-coagulant risk factors.