Postthrombotic Syndrome: Long-Term Sequela of Deep Venous Thrombosis

Assessing the Readability of English and Spanish Online Patient Educational Materials for Deep Venous Thrombosis

INTRODUCTION

Online patient educational materials (OPEMs) help patients engage in their health care. The American Medical Association (AMA) recommends OPEM be written at or below the 6th grade reading level. This study assessed the readability of deep venous thrombosis OPEM in English and Spanish.

METHODS

Google searches were conducted in English and Spanish using "deep venous thrombosis" and "trombosis venosa profunda," respectively. The top 25 patient-facing results were recorded for each, and categorized into source type (hospital, professional society, other). Readability of English OPEM was measured using several scales including the Flesch Reading Ease Readability Formula and Flesch-Kincaid Grade Level. Readability of Spanish OPEM was measured using the Fernández-Huerta Index and INFLESZ Scale. Readability was compared to the AMA recommendation, between languages, and across source types.

RESULTS

Only one (4%) Spanish OPEM was written at an easy level, compared to 7 (28%) English OPEM (P = 0.04). More English (28%) OPEM were easy to read compared to Spanish (4%), with a significant difference in reading difficulty breakdown between languages (P = 0.04). The average readability scores for English and Spanish OPEM across all scales were significantly greater than the recommended level (P < 0.01). Only four total articles (8%) met the AMA recommendation, with no significant difference between English and Spanish OPEM (P = 0.61).

CONCLUSIONS

Nearly all English and Spanish deep venous thrombosis OPEM analyzed were above the recommended reading level. English resources had overall easier readability compared to Spanish, which may represent a barrier to care. To limit health disparities, information should be presented at accessible reading levels.

Metabolomic profiling of deep vein thrombosis

Deep vein thrombosis (DVT) of the lower extremities is one of the most common peripheral vascular diseases, with significant complications and sequelae. Metabolomics aims to identify small molecules in biological samples. It can serve as a promising method for screening compounds that can be used for early disease detection, diagnosis, treatment response prediction, and prognosis. In addition, high-throughput metabolomics screening can yield significant insights into the pathophysiological pathways of DVT. Currently, the metabolomic profiles of DVT have yielded inconsistent expression patterns. This article examines the recent advancements in metabolomic studies of DVT and analyzes the factors that may influence the results.

A computational model-based study on the feasibility of predicting post-splenectomy thrombosis using hemodynamic metrics

For portal hypertensive patients with splenomegaly and hypersplenism, splenectomy is an effective surgery to relieve the complications. However, patients who have undergone splenectomy often suffer from portal venous system thrombosis, a sequela that requires prophylaxis and timely treatment to avoid deterioration and death. The aim of this study is to investigate the feasibility of predicting post-splenectomy thrombosis using hemodynamic metrics based on computational models. First, 15 portal hypertensive patients who had undergone splenectomy were enrolled, and their preoperative clinical data and postoperative follow-up results were collected. Next, computational models of the portal venous system were constructed based on the preoperative computed tomography angiography images and ultrasound-measured flow velocities. On this basis, splenectomy was mimicked and the postoperative area of low wall shear stress (ALWSS) was simulated for each patient-specific model. Finally, model-simulated ALWSS was statistically compared with the patient follow-up results to investigate the feasibility of predicting post-splenectomy thrombosis using hemodynamic metrics. Results showed that ALWSS could predict the occurrence of post-splenectomy thrombosis with the area under the receiver operating characteristic curve (AUC) equal to 0.75. Moreover, statistical analysis implied that the diameter of the splenic vein is positively correlated with ALWSS (r = 0.883, p < 0.0001), and the anatomical structures of the portal venous system also influence the ALWSS. These findings demonstrated that the computational model-based hemodynamic metric ALWSS, which is associated with the anatomorphological features of the portal venous system, is capable of predicting the occurrence of post-splenectomy thrombosis, promoting better prophylaxis and postoperative management for portal hypertensive patients receiving splenectomy.

Neutrophil extracellular traps mediate deep vein thrombosis: from mechanism to therapy

Deep venous thrombosis (DVT) is a part of venous thromboembolism (VTE) that clinically manifests as swelling and pain in the lower limbs. The most serious clinical complication of DVT is pulmonary embolism (PE), which has a high mortality rate. To date, its underlying mechanisms are not fully understood, and patients usually present with clinical symptoms only after the formation of the thrombus. Thus, it is essential to understand the underlying mechanisms of deep vein thrombosis for an early diagnosis and treatment of DVT. In recent years, many studies have concluded that Neutrophil Extracellular Traps (NETs) are closely associated with DVT. These are released by neutrophils and, in addition to trapping pathogens, can mediate the formation of deep vein thrombi, thereby blocking blood vessels and leading to the development of disease. Therefore, this paper describes the occurrence and development of NETs and discusses the mechanism of action of NETs on deep vein thrombosis. It aims to provide a direction for improved diagnosis and treatment of deep vein thrombosis in the near future.

The burden and predictors of venous thromboembolic diseases in patients with multiple primary malignancies

BACKGROUND

Venous thromboembolism (VTE) represents a considerable burden on cancer patients' survival and quality of life, but this burden varies based on the patient's baseline characteristics and cancer-related factors. Although solid evidence on the predictors and effect of VTE in cancer patients exists.

AIM

To evaluate VTE rate, morbidity, and mortality to develop parameters that could predict VTEs and their associated mortality in patients with multiple primary malignancies (MPMs).

METHOD AND RESULTS

This was a retrospective cohort study that took place at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia. Two hundred and forty-two patients with at least two biopsy-proven malignancies and had at least 3 months of follow-up after MPMs diagnosis were included. VTE was diagnosed in 14.5% of the cases, two-thirds of which were deep vein thrombosis. VTE was significantly associated with a higher mortality and worse survival. Predictors of VTE after MPMs diagnosis were a high ECOG performance status at MPMs diagnosis, a metastatic first primary malignancy, and ICU admission after MPMs diagnosis. Having a GI or hematological malignancy as the second primary malignancy, a high D-dimer at ICU admission, and palliative care referral were significantly associated with a higher mortality in patients who had VTE.

CONCLUSION

VTE was diagnosed in 14.5% of patients with MPMs and it significantly compromises their survival. We believe that these results might be of particular benefit since the phenomenon of MPMs is becoming more frequently encountered.

Predicting the risk of postsplenectomy thrombosis in patients with portal hypertension using computational hemodynamics models: A proof-of-concept study

BACKGROUND

The high incidence of thrombosis in the portal venous system following splenectomy (a frequently adopted surgery for treating portal hypertension in patients with splenomegaly and hypersplenism) is a critical clinical issue. The aim of this study was to address whether quantification of postsplenectomy hemodynamics has potential value for assessing the risk of postsplenectomy thrombosis.

METHODS

Computational models were constructed for three portal hypertensive patients treated with splenectomy based on their preoperative clinical data to quantify hemodynamics in the portal venous system before and after splenectomy, respectively. Each patient was followed up for three or five months after surgery and examined with CT to screen potential thrombosis.

FINDINGS

The area ratio of wall regions exposed to low wall shear stress was small before splenectomy in all patients, which increased markedly after splenectomy and exhibited enlarged inter-patient differences. The largest area ratio of low wall shear stress and most severe flow stagnation after splenectomy were predicted for the patient suffering from postsplenectomy thrombosis, with the wall regions exposed to low wall shear stress corresponding well with the CT-detected distribution of thrombus. Further analyses revealed that postoperative hemodynamic characteristics were considerably influenced by the anatomorphological features of the portal venous system.

INTERPRETATION

Postoperative hemodynamic conditions in the portal venous system are highly patient-specific and have a potential link to postsplenectomy thrombosis, which indicates that patient-specific hemodynamic studies may serve as a complement to routine clinical assessments for refining risk stratification and postoperative patient management.

Analysis of Related Influencing Factors of Deep Vein Thrombosis after Lumbar Internal Fixation and Treatment Strategy

Lumbar internal fixation is a traditional surgical method for the treatment of degenerative diseases of the lumbar spine. However, due to its large surgical trauma, it easily causes complications such as deep venous thrombosis (DVT) after the operation. DVT refers to the abnormal coagulation of blood in deep veins, blocking the lumen, causing venous blood return disorder, causing venous blood return disorder to cause swelling and pain, which affects the recovery of the patient's lumbar spine function. In severe cases, even complicated pulmonary embolism endangers the life and health of the patient. Therefore, it is extremely important to explore the related influencing factors and effective treatment of DVT. The purpose of this study was to investigate the influencing factors and effective treatment of DVT after lumbar internal fixation. Univariate analysis and multivariate a logistic regression model were used to analyze the related factors affecting DVT after lumbar internal fixation. Conventional treatments such as anticoagulation, promotion of venous blood return, and improvement of limb circulation were given to patients with DVT, and functional exercise was guided to compare the hypercoagulability and hyperviscosity of blood in patients with DVT before and after treatment. The results showed that the incidence of DVT after lumbar internal fixation was related to age, BMI, and bed time. Getting out of bed for functional exercise in time after surgery can effectively prevent the formation of DVT. Preoperative grading examination, intraoperative intervention, postoperative physical exercise, and other preventive guidance can be carried out according to different individuals during the perioperative period to prevent the formation of postoperative DVT.

Micronized purified flavonoid fraction for the treatment of chronic venous insufficiency, with a focus on postthrombotic syndrome: A narrative review

INTRODUCTION

Postthrombotic syndrome (PTS) is a form of secondary chronic venous insufficiency (CVI) that occurs after deep vein thrombosis (DVT). Effective treatments for PTS are lacking. Micronized purified flavonoid fraction (MPFF) is a venoactive drug used in the treatment of CVI.

OBJECTIVE

To determine whether MPFF is a good candidate to explore as a therapeutic agent for PTS.

METHODS

We performed a narrative review in which we identified 14 systematic reviews, 33 randomized controlled trials, and 19 observational studies that discussed the use of MPFF in CVI, as well as studies that reported on the mechanistic action of MPFF in relation to the pathophysiology of PTS.

RESULTS

MPFF targets a number of pathophysiologic components of PTS. Based on animal models and human studies investigating objective vascular and lymphatic measures, MPFF promotes venous recanalization after DVT, decreases venous remodeling and reflux, inhibits inflammatory processes, improves venous tone and stasis, improves lymphatic circulation, improves capillary hyperpermeability, and decreases tissue hypoxia. Furthermore, MPFF shows promise in improving clinical manifestations, quality of life, and objective venous parameters of CVI. Studies suggest good patient acceptability and tolerability with the use of MPFF in CVI.

CONCLUSION

MPFF is a good candidate to explore as a potential therapy for PTS. Confirmatory high-quality studies are still needed to reinforce the evidence supporting the use of MPFF in CVI. Double-blind randomized controlled trials with clinical endpoints are needed to assess the clinical efficacy of MPFF in the treatment of PTS.

Clinical guidelines versus current clinical practice for the management of deep vein thrombosis

BACKGROUND

Deep vein thrombosis (DVT) is one of the major health problems worldwide with potentially serious outcomes related to mortality and morbidity. We provide a current view on how patients with DVT are managed in routine practice compared with the recommendations of published clinical guidelines.

METHODS

A literature review was conducted on studies reporting diagnostic and treatment patterns for acute DVT. Four dimensions were evaluated to compare the differences between clinical practice and clinical guidelines recommendations: diagnostic pathway, prescription of pharmacologic treatment and related duration, and prescription of compression therapy. For each aspect, the agreement with the corresponding guideline has been estimated as a percentage ranging from 0% (no agreement) to 100% (full agreement).

RESULTS

Sixteen studies reported clinical practices in 10 countries. Among them, Japan showed the highest agreement with guidelines, followed by the UK and Switzerland. Hong Kong showed the highest agreement with diagnosis guidelines, Spain for drug treatment, UK for treatment duration, and France for compression therapy. Conversely, Germany reported a complete disagreement with guidelines for diagnosis, followed by low agreement level by UK and Italy, and Switzerland reported a lower agreement level with prescription of compression therapy.

CONCLUSIONS

The implementation of clinical guidelines for the management of patients with DVT varies among countries from strict adherence to a complete lack of adherence. In this context, registries may be a useful tool to analyze clinical practice and produce findings that may be generalizable across populations.

Neurologic complications of venous thromboembolism

Patients with neurologic disease are at high risk of venous thromboembolism (VTE). The converse risk of neurological complications in concert or following peripheral VTE is rarely considered. The major neurologic complication following pulmonary embolism or peripheral VTE is intracranial hemorrhage that occurs following anticoagulation therapy for VTE. Ischemic stroke may occur concomitantly with VTE. VT occurrence may also be a marker for a future increased risk of stroke. Peripheral neuropathy may occur or neuropathic pain may occur as a result of thrombophlebitis following deep venous thrombosis. Other sequelae of VTE are somewhat theoretical including the discovery of central nervous system malignancies after incident VTE.

Impact of oral anticoagulation choice on healthcare utilization for the primary treatment of venous thromboembolism

Little is known about the impact of oral anticoagulation (OAC) choice on healthcare encounters during venous thromboembolism (VTE) primary treatment. Among anticoagulant-naïve patients with VTE, we tested the hypotheses that healthcare utilization would be lower among users of direct OACs (DOACs; rivaroxaban or apixaban) than among users of warfarin. MarketScan databases for years 2016 and 2017 were used; healthcare utilization was identified in the first 6 months after initial VTE diagnoses. The 23,864 patients with VTE had on average 0.2 ± 0.5 hospitalizations, spent 1.3 ± 5.2 days in the hospital, had 5.7 ± 5.1 outpatient encounters, and visited an emergency department 0.4 ± 1.1 times. As compared to warfarin, rivaroxaban and apixaban were associated with fewer hospitalizations, days hospitalized, outpatient office visits, and emergency department visits after accounting for age, sex, comorbidities, and medications. Hospitalization rates were 24% lower (incidence rate ratio (IRR): 0.76; 95% CI: 0.69, 0.83) with rivaroxaban and 22% lower (IRR: 0.78; 95% CI: 0.71, 0.87) with apixaban, as compared to warfarin (IRR: 1.00 (reference)). Healthcare utilization was similar between apixaban and rivaroxaban users. Patients with VTE prescribed rivaroxaban and apixaban had lower healthcare utilization than those prescribed warfarin, while there was no difference when comparing apixaban to rivaroxaban. These findings complement existing literature supporting the use of DOACs over warfarin.

Long-Term Association of Venous Thromboembolism With Frailty, Physical Functioning, and Quality of Life: The Atherosclerosis Risk in Communities Study

Background

Relatively little is known about the long‐term consequences of venous thromboembolism (VTE) on physical functioning. We compared long‐term frailty status, physical function, and quality of life among survivors of VTE with survivors of coronary heart disease (CHD) and stroke, and with those without these diseases.

Methods and Results

Cases of VTE, CHD, and stroke were continuously identified since ARIC (Atherosclerosis Risk in Communities Study) recruitment during 1987 to 1989. Functional measures were objectively captured at ARIC clinic visits 5 (2011–2013) and 6 (2016–2017); quality of life was self‐reported. The 6161 participants at visit 5 were, on average, 75.7 (range, 66–90) years of age. By visit 5, 3.2% had had a VTE, 6.9% CHD, and 3.4% stroke. Compared with those without any of these conditions, VTE survivors were more likely to be frail (odds ratio [OR], 3.11; 95% CI, 1.80–5.36) and have low (<10) versus good scores on the Short Physical Performance Battery (OR, 3.59; 95% CI, 2.36–5.47). They also had slower gait speed, less endurance, and lower physical quality of life. VTE survivors were similar to coronary heart disease and stroke survivors on categorical frailty and outcomes on Short Physical Performance Battery assessment. When score on the Short Physical Performance Battery instrument was modeled continuously, VTE survivors performed better than stroke survivors but worse than CHD survivors.

Conclusions

VTE survivors had triple the odds of frailty and poorer physical function than those without the vascular diseases considered. Their function was somewhat worse than that of CHD survivors, but better than stroke survivors. These findings suggest that VTE patients may benefit from additional efforts to improve postevent physical functioning.

Gastrointestinal Malignancies and Venous Thromboembolic Disease: Clinical Significance and Endovascular Interventions

Gastrointestinal malignancy encompasses a wide range of disease processes. Its incidence and mortality rate rank among the highest of all cancers. Venous thromboembolic disease is a common complication of gastrointestinal malignancy. Anticoagulation remains the first-line therapy. However, for patients who cannot tolerate or have failed anticoagulation, inferior vena cava (IVC) filter placement may be an option. Furthermore, to improve symptom resolution and reduce the severity of postthrombotic syndrome, catheter-directed thrombolysis (CDT) may be an option. Recent randomized trials including the ATTRACT (Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis) trial have shed new light on the efficacy and safety of CDT and related methods. Overall, the decision to proceed with IVC filter placement or CDT must be individualized.

Venoplasty and stenting in post-thrombotic syndrome and non-thrombotic iliac vein lesion

Introduction: Venous outflow obstruction is a common condition among patients with chronic venous insufficiency. Endovascular treatment is favourable over open surgery. This study aimed to assess stent patency and clinical outcome in venous outflow obstruction of lower limbs, and also to compare it between post-thrombotic syndrome and non-thrombotic iliac vein lesions.Material and methods: The study was a historical cohort study. Patients with chronic deep venous insufficiency referred to our tertiary referral centre who underwent venoplasty were recruited. Patients were divided into two groups: non-thrombotic-iliac-vein-lesions and post-thrombotic syndrome. Stent patency rate, clinical improvement and risk factors were evaluated during a six-months course after venoplasty.Results: One-hundred-sixty-four patients were included. Six-months primary, assisted primary and secondary patency rates were 98.86%, 100% and100% in the non-thrombotic-iliac-vein-lesions group and 88%, 93% and 96% in the post thrombotic syndrome groups (p-value = .005, p-value = .02, and p-value = .09, respectively). Pain, claudication and edema were the most common symptoms in both groups and significantly improved after six months. Early thrombosis in the PTS group was more common (9 vs. 1, P value = .007).Conclusion: Percutaneous stenting in patients with venous outflow obstruction is safe and effective with a high patency rate and significant decrease in clinical score in both post-thrombotic syndrome and non-thrombotic-iliac-vein lesions groups.