Advanced Management of Acute Iliofemoral Deep Venous Thrombosis: Emergency Department and Beyond

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.

Incidence of deep vein thrombosis from screening by venous ultrasonography in Japanese patients

The aim of the present study was to investigate the incidence of deep vein thrombosis (DVT) patients in a Japanese population by screening them with venous ultrasonography. This retrospective, single-center analysis examined 963 patients who underwent venous ultrasonography in 2015. The primary outcome was the incidence of DVT, and secondary outcomes were predictive factors of DVT in patient characteristics, treatment strategy for DVT patients, and proportion of post thrombotic syndrome (PTS). The overall incidence rate of DVT was 10.3% (100/963). The location of thrombus was the iliac vein in 3.6% (n = 35), the femoral vein in 4.4% (n = 43), and the calf vein in 8.2% (n = 79) of the patients. The main complaint or purpose of examination was perioperative screening in 37% of the patients, leg edema and/or limb swelling in 27% of the patients, and skin disease in 8% of the patients. In a multivariate analysis, the incidence of DVT was significantly higher in the hospitalization group and the "having symptoms" group. Fifty percent of DVTs received treatment, and almost all therapies were medical treatment with oral anticoagulants (OAC). Within a three-year follow-up period, the proportion of PTS was 27% with no significant difference between anticoagulation or non-anticoagulation patients; the risk of PTS was in concomitant varicose veins. In conclusion, of the patients, 10.3% were diagnosed with DVT, and only half received treatment with only anticoagulation.

A Guitaring Technique with 035 Wire and Perforated Coronary Balloon for Thrombolysis in the Treatment of Acute Deep Vein Thrombosis

A patient who underwent thrombolysis and inferior vena cava filter implantation for acute deep vein thrombosis treatment nine years before, presented with deep vein thrombosis on the other limb. The venous angiogram showed deep vein thrombosis in the ilio-femoral vessels. Through left femoral vein puncture, a 6F right Judkins diagnostic catheter was advanced up to the proximal iliac veins, and further advancement was not possible. Hence, a 035 hydrophilic wire was advanced, and through a guitaring technique, the clots were disrupted at the mid-thigh level. Through a 014 coronary wire, a punctured coronary balloon was placed at the distal mid-thigh level, and intravascular thrombolysis was performed for 12 hours, followed by removal of the balloon and the right coronary Judkins catheters. The leg swelling reduced in the first day, and subsequently, the patient was followed up for 7 months with anticoagulation and good resolution of the symptoms.

Secondary Varicose Small Pelvic Veins and Their Treatment with Micronized Purified Flavonoid Fraction

The aim of this study was to examine secondary varicose small pelvic veins (VSPV) and their treatment with micronized purified flavonoid fraction (MPFF). We examined 70 patients with a history of acute iliac thrombosis of > 1 year. Patients with urination difficulties associated with other symptoms (n = 24) received MPFF 1,000 mg once daily for 1 month. Clinical manifestations were assessed by collecting complaints and analyzing results of physician examinations. VSPV was identified in 48 (68.6%) patients, the majority (58%) had grade 2 (7.0-9.0 mm) venous dilation. VSPV severity correlated with time since the thrombotic event. In most women, varicosities were found in the parametrial venous plexus (mean vein diameter 7.91 mm); retrograde flow during the Valsalva maneuver was found in 14 (78%). In men, all varicosities occurred in the paraprostatic plexus (mean vein diameter 7.20 mm); retrograde flow was found in 21 (70%). MPFF significantly reduced VSPV dilation in 18 (75%) patients (p = 0.0863) and returned ultrasonic indices to normal values in the remainder. Patients with bilateral varices decreased from 10 to 2. Only four patients had retrograde flow in the SPV plexus after treatment. MPFF decreased mean paraprostatic vein diameter in men and parametrial vein diameter in women to near-normal values. Clinical improvement was reported in 13 (54%) patients. Patients with pelvic pain decreased from 8 to 1 and patients with urination disorders from 24 to 9. VSPV is common in patients with a history of iliac vein thrombosis. MPFF decreases the diameter of affected veins, improves retrograde flow and pelvic hemodynamics, and significantly reduces the severity of the clinical manifestations.

The use of oral anticoagulants for the treatment of venous thromboembolic events in an ED

Venous thromboembolism (VTE) is a disease spectrum that ranges from deep vein thrombosis (DVT) to pulmonary embolism (PE). Rapid diagnosis and treatment of VTE by emergency care providers are critical for decreasing patient mortality, morbidity, and the incidence of recurrent events. Recent American College of Chest Physicians guidelines recommend initial treatment with unfractionated heparin, low-molecular weight heparin, or fondaparinux overlapped with warfarin for a minimum of 5 days for the treatment of VTE in most cases. Warfarin monotherapy is thereafter continued for 3, 6, or 12 months. These guidelines were published before the approval of target-specific oral anticoagulants (TSOACs), and they have yet to be updated to reflect these new treatment options. For some patients, TSOACs, which act by directly inhibiting factor IIa or factor Xa, may provide safer, more convenient alternatives to warfarin. Their advantages include ease of use, reduced monitoring requirements, and lower bleeding risk than traditional therapy. Additionally, clinical trials have established noninferiority of TSOACs to warfarin for the prevention of recurrent VTE. These trials have demonstrated that TSOACs exhibit similar or lower bleeding rates, particularly intracranial bleeding rates compared with warfarin. Anticoagulation therapy with TSOACs may allow early discharge or outpatient management options for low-risk patients with DVT and PE. This review addresses the importance of early diagnosis and treatment of VTE, outcomes of VTE risk assessment, key efficacy and safety data from phase 3 clinical trials for the various TSOACs for the treatment of DVT and PE, and the corresponding considerations for clinical practice.

Catheter-directed thrombolysis with argatroban and tPA for massive iliac and femoropopliteal vein thrombosis

PURPOSE

Catheter-directed thrombolysis (CDT) is a highly effective approach in the treatment of deep venous thrombosis (DVT). There are no data on the primary use of CDT with argatroban and tissue plasminogen activator (tPA) in patients without heparin-induced thrombocytopenia (HIT). The aim of this study was to evaluate the efficacy and safety of the combined administration of argatroban and tPA during CDT for massive DVT in patients without HIT.

METHODS

Thirty-three patients with massive symptomatic iliac and femoropopliteal DVT underwent CDT with tPA and argatroban within 28 ± 6 h of presentation. The dose of tPA was 0.75-1 mg/h through the infusion port and that of argatroban at 0.3-1 μg/kg/min through the side port of the sheath. The patients were evaluated for the efficacy and safety of CDT and recurrent symptomatic venous thromboembolism (VTE) at a mean follow-up of 22 months.

RESULTS

There was no bleeding or iatrogenic pulmonary embolism with the CDT regimen we used. Grade III lysis (complete resolution of thrombus on venography) was achieved in 30 patients (91 %). In 3 patients with additional inferior vena cava filter thrombosis, further thrombectomy of the filter was required. No patient developed recurrent VTE.

CONCLUSION

Concomitant administration of argatroban and tPA is a highly safe and effective regimen for CDT for massive DVT.

Management of proximal deep vein thrombosis

Iliofemoral DVT constitutes approximately 20-25% of lower limb DVT and represents a specific subgroup of patients at highest risk for post-thrombotic syndrome (PTS). Anticoagulation alone has no significant thrombolytic activity and has not impact on PTS prevention. Early thrombus removal has reduced PTS in uncontrolled reports and reviews but major trials are awaited. The optimal timing for treatment appear to be thrombus <2 weeks old and, methods for thrombus removal include direct open or suction thrombectomy, catheter directed thrombolysis (CDT), with or without percutaneous mechanical thrombectomy (PMT) devices. Three principle types of PMT device are in use (rotational, rheolytic and ultrasound enhanced devices) and are combined with CDT in pharmocomechanical thrombolysis (PhMT) to enhance early thrombus removal. These devices have individual device specific attributes and side effects that are additional to the bleeding complications of thrombolysis. A number of additional interventions may be utilised to the improve results of CDT and PhMT. IVC filter deployment to reduce periprocedural PE, is supported by little evidence unless an indication for its use already exists. However, balloon venoplasty and vein stents undoubtedly vein patency after treatment. Early thrombus removal comes with additional upfront costs derived from devices, imaging and critical care bed usage. However, significant potential savings from reduction in PTS and rethrombosis rates may reduce overall societal costs. This review focuses on iliofemoral thrombosis, however, the less commonly encountered but clinically important subclavian vein thrombosis is also discussed.

[The role of thrombolysis in the clinical management of deep vein thrombosis]

Acute Deep Venous Thrombosis (DVT) therapies have been judged primarily on their ability to prevent symptomatic pulmonary embolism, early thrombus progression, and recurrent VTE. The cornerstones of current management of DVT, supported by the 2008 American College of Chest Physicians (ACCP) guidelines, are the routine use of anticoagulant therapy, graduated elastic compression stockings, and early ambulation. For selected appropriate patients with extensive acute proximal DVT, while the French recommendations (Afssaps 2009) still consider thrombolysis not indicated, ACCP guidelines now suggest in-situ thrombolysis in addition to anticoagulation to reduce the risk of subsequent postthrombotic syndrome (PTS) and recurrent DVT (Grade 2 B recommendation). Contemporary invasive endovascular treatments, called pharmacomechanical treatment, mitigate the drawbacks (major bleeding) historically associated with systemic thrombolytic approaches, by means of intra-thrombus delivery of drugs, followed by mechanical dispersion to accelerate lysis and then aspiration of remaining drug and clot debris. The proof of concept for the "open vein" hypothesis - that a strategy of early thrombus removal can reduce the incidence of PTS long term - comes incrementally and randomized trials (ATTRACT trial with a 2016 target completion date) are currently under way and might lead to a shift of the paradigms of the management of acute DVT focused on active thrombus removal.