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Timing and choice of systemic anticoagulation in the setting of extremity arterial injury repair. Eur J Trauma Emerg Surg 2023; 49:473-485. [PMID: 36203031 DOI: 10.1007/s00068-022-02092-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/16/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The role of perioperative anticoagulation in the setting of peripheral arterial injury remains unclear. We hypothesized that early initiation of anticoagulation is associated with a reduced amputation rate without increasing bleeding complications. METHODS Using the 2016-2019 ACS-TQIP database, adult patients with upper and lower extremity vascular injuries who underwent open arterial repair and received anticoagulation were included. Patients were divided into two groups: (1) early venous thromboembolism prophylaxis (≤ 24 h) and (2) late prophylaxis (> 24 h) following arterial repair. The primary outcomes were the rates of limb amputation and bleeding complications. Multivariable logistic regression was used to estimate the impact of timing and type of anticoagulation on the rates of limb amputation and bleeding complications. RESULTS 4379 patients were included, and 83.9% were males. 68.1% of patients received early anticoagulation, whereas 31.9% received late thromboprophylaxis. Low-molecular-weight heparin (LMWH) was used in 62.0% of patients, and unfractionated heparin (UFH) was administered in 34.3% of patients. Multivariable analysis showed that late initiation of thromboprophylaxis (OR = 1.69 [1.16-2.45], p = 0.006) and use of UFH (OR = 2.61 [1.80-3.79], p < 0.001) were associated with increased rate of amputation. Early initiation of anticoagulation (OR = 2.16 [1.63-2.85], p < 0.001) was associated with increased risk of bleeding complications requiring blood transfusions. Similarly, the use of UFH was associated with a higher rate of bleeding events compared to LWMH (OR = 2.61, [1.80-3.79], p < 0.001). CONCLUSION Patients with the operative repair of arterial injuries receiving early perioperative anticoagulation demonstrated an improved limb salvage outcome than those who received late thromboprophylaxis. Our data also suggest that early initiation of prophylaxis may be associated with increased bleeding risk, which may be attenuated using LMWH compared to UFH.
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Abstract
Lower extremity deep venous thrombosis is a leading cause of morbidity and mortality. The mainstay of therapy is medical. However, anticoagulation does not remove the thrombus and restore venous patency. In select patients, early thrombus removal and anticoagulation can restore venous patency, preserve venous valve function, and may reduce the incidence of postthrombotic syndrome. Catheter-directed therapies are minimally invasive with low complication rates. However, in patients with a contraindication to thrombolytic agents who can receive anticoagulation, open thrombectomy should be considered if indications for thrombus removal are met and patients are good operative risks.
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Dueppers P, Grabitz K, Li Y, Schelzig H, Wagenhäuser MU, Duran M. Surgical management of iliofemoral vein thrombosis during pregnancy and the puerperium. J Vasc Surg Venous Lymphat Disord 2016; 4:392-9. [PMID: 27638991 DOI: 10.1016/j.jvsv.2016.06.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 06/30/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The risk of deep venous thrombosis is elevated during pregnancy and the puerperium. Therapy is usually limited to conservative measures as invasive thrombus removal is feared because of possible complications. However, leg- or life-threatening situations require fast thrombus removal, and the long-term rate of post-thrombotic syndrome (PTS) may be reduced by venous recanalization. Our center's experience may give support to surgical venous thrombectomy (VT). METHODS Between 1996 and 2016, all women who received VT for pregnancy-related deep venous thrombosis in our department were included. Retrospective data were combined with a current follow-up. RESULTS The study included 82 women with a mean age of 29 years (17-38 years). An additional arteriovenous fistula was performed in 79 and planned simultaneous cesarean section in 13 patients. Neither pulmonary emboli nor fetal complications occurred during surgery, and perioperative and postoperative mortality was 0%. Operative revision was required in 38% mainly for rethrombosis (24%) and bleeding (12%). One fetus died 2 months after VT of unrelated causes. After a mean of 83 months, complete venous recanalization was seen in 88%, venous valve sufficiency in 90%, and PTS in 31% without any ulcers. At 10 years, PTS incidence rose to reach 50% with limited statistical significance because of the number of patients reaching long-term follow-up. CONCLUSIONS Iliofemoral venous recanalization during pregnancy can be performed safely in a specialized center, with lower PTS rates than in historical controls.
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Affiliation(s)
- Philip Dueppers
- Department of Vascular and Endovascular Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Klaus Grabitz
- Department of Vascular and Endovascular Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - You Li
- Department of Vascular and Endovascular Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Hubert Schelzig
- Department of Vascular and Endovascular Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Markus Udo Wagenhäuser
- Department of Vascular and Endovascular Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Mansur Duran
- Department of Vascular and Endovascular Surgery, University Hospital Duesseldorf, Duesseldorf, Germany.
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Skuterud Wik H, Flem Jacobsen A, Morten Sandset P. Long-term outcome after pregnancy-related venous thrombosis. Thromb Res 2015; 135 Suppl 1:S1-4. [DOI: 10.1016/s0049-3848(15)50430-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Casey ET, Murad MH, Zumaeta-Garcia M, Elamin MB, Shi Q, Erwin PJ, Montori VM, Gloviczki P, Meissner M. Treatment of acute iliofemoral deep vein thrombosis. J Vasc Surg 2012; 55:1463-73. [DOI: 10.1016/j.jvs.2011.12.082] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 12/08/2011] [Accepted: 12/27/2011] [Indexed: 11/25/2022]
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Meissner MH, Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Lohr JM, McLafferty RB, Murad MH, Padberg F, Pappas P, Raffetto JD, Wakefield TW. Early thrombus removal strategies for acute deep venous thrombosis: Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2012; 55:1449-62. [DOI: 10.1016/j.jvs.2011.12.081] [Citation(s) in RCA: 285] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 12/08/2011] [Accepted: 12/27/2011] [Indexed: 11/26/2022]
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Wik HS, Jacobsen AF, Sandvik L, Sandset PM. Prevalence and predictors for post-thrombotic syndrome 3 to 16 years after pregnancy-related venous thrombosis: a population-based, cross-sectional, case-control study. J Thromb Haemost 2012; 10:840-7. [PMID: 22452811 DOI: 10.1111/j.1538-7836.2012.04690.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The long-term outcome of pregnancy-related venous thrombosis (VT) is not known. OBJECTIVES To assess predictors and long-term frequency of post-thrombotic syndrome (PTS) after pregnancy-related VT. PATIENTS/METHODS In 2006, 313 women with pregnancy-related VT during 1990-2003 and 353 controls answered a comprehensive questionnaire that included self-reported Villalta score as a measure of PTS. Cases were identified from 18 Norwegian hospitals using the Norwegian Patient Registry and the Medical Birth Registry of Norway. The latter was used to select as possible controls women who gave birth at the same time as a case. Thirty-nine patients and four controls were excluded because of VT outside the lower limbs/lungs or missing Villalta scores. Two hundred and four patients had DVT in the lower limb and 70 had pulmonary embolism (PE). The control group comprised 349 women naive for VT at the time of the index pregnancy. RESULTS Forty-two per cent of cases with DVT in the lower limb, compared with 24% of cases with PE and 10% of controls, reported a Villalta score of ≥ 5. Severe PTS (Villalta score of ≥ 15) was reported among 7%, 4% and 1%. Proximal postnatal, but not antenatal, thrombosis was a strong predictor of PTS with an adjusted odds ratio of 6.3 (95% confidence interval, 2.0-19.8; P = 0.002). Daily smoking before the index pregnancy and age above 33 years at event were independent predictors for post-thrombotic syndrome. CONCLUSIONS PTS is a common long-term complication after pregnancy-related DVT. Proximal postnatal thrombosis, smoking and higher age were independent predictors of the development of PTS.
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Affiliation(s)
- H S Wik
- Department of Haematology, Clinical Research, Oslo University Hospital, and Institute of Clinical Medicine, Oslo, Norway
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Rosfors S, Norén A, Hjertberg R, Persson L, Lillthors K, Törngren S. A 16-year haemodynamic follow-up of women with pregnancy-related medically treated iliofemoral deep venous thrombosis. Eur J Vasc Endovasc Surg 2001; 22:448-55. [PMID: 11735184 DOI: 10.1053/ejvs.2001.1499] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to evaluate clinical and functional long-term outcomes following pregnancy-related medically treated iliofemoral deep venous thrombosis (DVT). DESIGN retrospective follow-up of patients identified through a registry search. MATERIAL AND METHODS twenty-five women underwent clinical examination, colour duplex ultrasound and computerised strain-gauge plethysmography on two occasions a mean of nine and 16 years after DVT. RESULTS 40% of the patients were completely asymptomatic and 52% had no clinical signs of venous disease after a mean follow-up of 16 years. The clinical signs were in general mild, and none of the 25 patients had skin changes or ulcers. Deep venous reflux was found in 36% of the patients; the same percentage at nine- and 16-years follow-up, and 24% had normal ultrasonographic appearance of all deep veins. None of the patients had plethysmographic evidence of outflow obstruction. There was a significant relationship between measures of venous reflux and the presence of leg swelling, but there was no clear relation between functional abnormalities and the extent of the initial DVT. CONCLUSION even after 16 years there are relatively mild symptoms and signs of venous disease in women with medically treated pregnancy-related iliofemoral DVT. Our results do not support earlier stated opinions that these patients represent a particular risk group for developing post-thrombotic syndrome.
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Affiliation(s)
- S Rosfors
- Department of Clinical Physiology, Stockholm Söder Hospital, Karolinska Institutet, S-118 83 Stockholm, Sweden
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Van Rooijen M, Bremme K. A family history can display a synergistic effect of atherogenic and prothrombotic risk in pregnancy. Acta Obstet Gynecol Scand 2001. [DOI: 10.1034/j.1600-0412.2001.080009873.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Porter JM. Vascular surgery. J Am Coll Surg 1998; 186:247-62. [PMID: 9482637 DOI: 10.1016/s1072-7515(98)00035-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- J M Porter
- Division of Vascular Surgery, Oregon Health Sciences University, Portland 97201 USA
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Eriksen L, Pachler J, Christoffersen JK, Bækgaard N, Mantoni M, Lund JO, Lenstrup C, Jacobsen B. Venous Thrombectomy in Pregnancy: A Follow-up Study. Phlebology 1997. [DOI: 10.1177/026835559701200406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To evaluate women who have been treated by venous thrombectomy in pregnancy because of iliofemoral venous thrombosis, reporting the outcome of their pregnancy and frequency of objectively measured venous insufficiency. Design: A retrospective study. The patients were assessed by questionnaire, clinical examination, tests of venous function and ultrasonography. Setting: Department of Vascular Surgery, Gentofte Hospital, University of Copenhagen. Patients: Nineteen women treated previously by venous thrombectomy during pregnancy, with a subsequent pregnancy. Results: None of the women had complications during subsequent pregnancies or deliveries, 47% had an occluded iliac segment and 53% had dilated or varicose veins. None had ulcers or skin changes. None of the women showed signs of of re-thrombosis. Conclusion: Women who have been treated for deep venous thrombosis in pregnancy by thrombectomy and arteriovenous fistula followed by anticoagulant therapy may undergo further pregnancies with a very low risk of obstetric complications and a low risk of developing re-thrombosis or chronic venous insufficiency.
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Affiliation(s)
- L. Eriksen
- Department of Obstetrics and Gynaecology, University of Copenhagen, Denmark
| | - J. Pachler
- Department of Vascular Surgery, University of Copenhagen, Denmark
| | | | - N. Bækgaard
- Department of Vascular Surgery, University of Copenhagen, Denmark
| | - M. Mantoni
- Department of Radiology and Ultrasonography, University of Copenhagen, Denmark
| | - J. O. Lund
- Department of Clinical Physiology and Nuclear Medicine, University of Copenhagen, Denmark
| | - C. Lenstrup
- Department of Obstetrics and Gynaecology, University of Copenhagen, Denmark
| | - B. Jacobsen
- Department of Coagulation Laboratory, Gentofte Hospital, University of Copenhagen, Denmark
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Sharafuddin MJ, Hicks ME. Current status of percutaneous mechanical thrombectomy. Part I. General principles. J Vasc Interv Radiol 1997; 8:911-21. [PMID: 9399459 DOI: 10.1016/s1051-0443(97)70687-0] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- M J Sharafuddin
- Section of Vascular and Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University Medical Center, St. Louis, MO 63110, USA
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Plate G, Eklöf B, Norgren L, Ohlin P, Dahlström JA. Venous thrombectomy for iliofemoral vein thrombosis--10-year results of a prospective randomised study. Eur J Vasc Endovasc Surg 1997; 14:367-74. [PMID: 9413377 DOI: 10.1016/s1078-5884(97)80286-9] [Citation(s) in RCA: 187] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To study if venous thrombectomy prevents late post-thrombotic sequelae, venous obstruction reflux, and improves venous physiology following an acute iliofemoral venous thrombosis. DESIGN Prospective randomised controlled study. MATERIAL Thirty patients returned for follow-up 10 years after an acute iliofemoral venous thrombosis initially treated with conventional anticoagulation treatment (medical group, n = 17) or with thrombectomy combined with a temporary arteriovenous fistula and anticoagulation (surgical group, n = 13). Clinical assessment, radionuclide angiography, duplex ultrasound and venous physiology tests were performed. RESULTS Leg swelling was recorded in 12 (71%) and leg ulcers in three (18%) of the medical patients and in, respectively, six (46%) and one (8%) of the surgical patients. The surgical patients had less severe sequelae (class 0-2). Radionuclide angiography demonstrated that the iliac vein was more commonly occluded following medical (59%) than following surgical (17%) treatment (p < 0.05). Duplex examination demonstrated slightly (n.s.) more reflux in the femoral and popliteal veins in the medical group. Venous physiology (occlusion plethysmography, foot volumetry, and foot vein pressures) did not show any significant differences, although the medical group tended to have a more severe pathology. CONCLUSION Venous thrombectomy improves venous patency and possibly reduces venous reflux and post-thrombotic sequelae as compared to anticoagulation treatment.
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Affiliation(s)
- G Plate
- Department of Surgery, Helsingborg Hospital, Sweden
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