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Potere N, Yamashita Y, Ageno W. Anticoagulation in Patients with Isolated Distal Deep Vein Thrombosis: Bringing the Puzzle Together. Thromb Haemost 2024; 124:811-814. [PMID: 38242170 DOI: 10.1055/a-2250-3298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Affiliation(s)
- Nicola Potere
- Department of Medicine and Ageing Sciences, "G. d'Annunzio" University, Chieti, Italy
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Qiu YH, Yang Z, Yang FJ, Su X, Chen BC, Ni HZ. Prophylactic Dose of Rivaroxaban Versus Warfarin for the Treatment of Isolated Calf Muscle Vein Thrombosis: A Retrospective Propensity Score-Matched Analysis. Ann Vasc Surg 2024; 108:508-518. [PMID: 39025209 DOI: 10.1016/j.avsg.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 05/14/2024] [Accepted: 06/10/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Prophylactic dose of rivaroxaban is often used in treatment of isolated calf muscle vein thrombosis (ICMVT); nevertheless, its effect is less reported. This study aims to evaluate short-term outcomes in patients with ICMVT who received prophylactic dose of rivaroxaban or warfarin therapy. METHODS A retrospective analysis of 472 ICMVT patients who received 2 different treatment regimens was undertaken. Propensity score matching method was used to balance the confounding effect of baseline clinical data. Chi-squared test and logistic regression analysis were used to compare outcomes (venous thromboembolism events, bleeding events, complete clot resolution) according to the type of treatment regimens before and after propensity score matching. Univariate and multivariable analysis were used to investigate risk factors for incomplete clot resolution of ICMVT after propensity score matching. RESULTS 242 ICMVT patients received prophylactic dose of rivaroxaban (rivaroxaban group, RG), and 230 received warfarin (warfarin group, WG). After propensity score matching, 156 patients were included in each group; Venous thromboembolism (VTE) events occurred in 14 (9.0%) patients in the RG and 10 (6.4%) in the WG (P = 0.395); no major bleeding events occurred in each group, and clinically relevant nonmajor bleeding events occurred in 5 (3.2%) patients in the RG and 10 (6.4%) in the WG (P = 0.186); complete clot resolution at 3 months occurred in 80 (51.3%) patients in the RG and 100 (64.1%) in the WG (P = 0.022). Logistic regression analysis showed that there were no significant differences between RG and WG in VTE events (odds ratio 1.439, 95% confidence interval 0.619-3.347, P = 0.397) and clinically relevant nonmajor bleeding events (odds ratio 0.483, 95% confidence interval 0.161-1.449, P = 0.194); it revealed that complete clot resolution rate at 3 months was different in the 2 groups (odds ratio 0.589, 95% confidence interval 0.375-0.928, P = 0.022). Treatment regimens (prophylactic dose of rivaroxaban), thrombosis (maximum diameter >7 mm), and risk factors for VTE (nonsurgery risk factors, mainly referring to active malignancy) were risk factors for incomplete clot resolution of ICMVT (P < 0.05). CONCLUSIONS In this retrospective study with a short-term follow-up, ICMVT patients who received prophylactic dose of rivaroxaban had no significant differences in VTE and bleeding events compared to those who received warfarin therapy (the overall INR >2.0 for >50% of the time); but it was not conducive to complete clot resolution.
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Affiliation(s)
- Yi-Hui Qiu
- Department of Vascular Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhe Yang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Fa-Jing Yang
- Department of Vascular Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xiang Su
- Department of Vascular Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Bi-Cheng Chen
- Key Laboratory of Diagnosis and Treatment of Severe Hepato-Pancreatic Diseases of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.
| | - Hai-Zhen Ni
- Department of Vascular Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.
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Yang WT, Jin ZY, Li CM, Wen JH, Ren HL. Recurrence in isolated distal DVT after anticoagulation: a systematic review and meta-analysis of axial and muscular venous thrombosis. Thromb J 2024; 22:57. [PMID: 38951855 PMCID: PMC11218106 DOI: 10.1186/s12959-024-00623-6] [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: 02/07/2024] [Accepted: 06/12/2024] [Indexed: 07/03/2024] Open
Abstract
OBJECTIVE To identify recurrent venous thromboembolism (VTE) after discontinuation of anticoagulation in patients with isolated distal deep vein thrombosis based on its anatomic localization (axial or muscular veins). METHODS Data were sourced from PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov databases in the time period up to October 2023. The study followed PRISMA guidelines using a registered protocol (CRD42023443029). Studies reporting recurrent VTE in patients with axial or muscular DVT were included in the analysis. RESULTS Five studies with a total of 1,403 participants were evaluated. The results showed a pooled odds ratio of 1.12 (95% confidence interval 0.77-1.63) between axial and muscular DVT. Heterogeneity was low (I2 = 0%, p = 0.91) and there was no significant difference in the rate of recurrent VTE between axial and muscular DVT in each subgroup. CONCLUSIONS Muscular and axial DVT showed comparable recurrent VTE rates after anticoagulation. However, uncertainties regarding the possibility of recurrence affecting the popliteal vein or resulting in pulmonary embolism following muscular DVT anticoagulation persisted. Randomized trials in patients with isolated distal DVT are still needed to clarify its prognosis for different anatomical thrombus locations.
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Affiliation(s)
- Wen-Tao Yang
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Beijing, 100020, China
| | - Zhen-Yi Jin
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Beijing, 100020, China
| | - Chun-Min Li
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Beijing, 100020, China
| | - Jia-Hao Wen
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Beijing, 100020, China
| | - Hua-Liang Ren
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Beijing, 100020, China.
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Takahashi Y, Fujiwara H, Yamamoto K, Takano M, Miyamoto M, Hasegawa K, Miwa M, Satoh T, Itagaki H, Hirakawa T, Mori-Uchino M, Nagai T, Hamada Y, Yamashita S, Yano H, Kato T, Fujiwara K, Suzuki M. Prevention of symptomatic pulmonary embolism for gynecologic malignancies with preoperative asymptomatic venous thromboembolism: GOTIC-VTE trial. J Gynecol Oncol 2024; 35:e37. [PMID: 38178702 PMCID: PMC11262890 DOI: 10.3802/jgo.2024.35.e37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 10/07/2023] [Accepted: 12/11/2023] [Indexed: 01/06/2024] Open
Abstract
OBJECTIVE In Japan, perioperative prophylaxis of pulmonary embolism (PE) in gynecologic cancer patients with preoperative asymptomatic venous thromboembolism (VTE) has not been well established yet. The GOTIC-VTE trial was a prospective, multi-center, single-arm clinical trial to investigate the prevention of postoperative symptomatic PE onset by seamless anticoagulant therapy from the preoperative period to 4 weeks after surgery instead of using intermittent pneumatic compression. METHODS Anticoagulant therapy was started immediately after asymptomatic VTE diagnosis and stopped preoperatively according to the rules of each institution. Unfractionated heparin administration was resumed within 12 hours postoperatively, and this was followed by the switch to low-molecular-weight heparin and subsequently, edoxaban; this cycle was continued for 28 days. Primary outcome was the occurrence of symptomatic PE in 28 days postoperatively. Secondary outcomes were the incidence of VTE-related events in 28 days and 6 months postoperatively and protocol-related adverse events. RESULTS Between February 2018 and September 2020, 99 patients were enrolled; of these, 82 patients were assessed as the full analysis set, including 58 for ovarian cancer, fallopian tube, or peritoneal cancer; 21 for endometrial cancer; and 3 for cervical cancer. No symptomatic PE was observed within 28 days postoperatively; two patients had bleeding events (major bleeding and clinically relevant nonmajor bleeding) and three had grade 3 adverse events (increased alanine transaminase, aspartate aminotransferase, or gamma-glutamyl transferase). CONCLUSION The multifaceted perioperative management for gynecologic malignancies with asymptomatic VTE effectively prevented postoperative symptomatic PE. TRIAL REGISTRATION JRCT Identifier: jRCTs031180124.
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Affiliation(s)
- Yoshifumi Takahashi
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, Japan.
| | - Hiroyuki Fujiwara
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, Japan
| | - Kouji Yamamoto
- Department of Biostatistics, School of Medicine, Yokohama City University, Kanagawa, Japan
| | - Masashi Takano
- Department of Obstetrics and Gynecology, National Defense Medical College, Saitama, Japan
| | - Morikazu Miyamoto
- Department of Obstetrics and Gynecology, National Defense Medical College, Saitama, Japan
| | - Kosei Hasegawa
- Department of Gynecologic Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Maiko Miwa
- Department of Gynecologic Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Toyomi Satoh
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hiroya Itagaki
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Takashi Hirakawa
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Mayuyo Mori-Uchino
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomonori Nagai
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Yoshinobu Hamada
- Department of Obstetrics and Gynecology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Soichi Yamashita
- Department of Gynecology, Gunma Prefectural Cancer Center, Gunma, Japan
| | - Hiroko Yano
- Department of Gynecologic Oncology, Hyogo Cancer Center, Hyogo, Japan
| | - Tomoyasu Kato
- Department of Gynecology, National Cancer Center Hospital, Tokyo, Japan
| | - Keiichi Fujiwara
- Department of Gynecologic Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Mitsuaki Suzuki
- Department of Obstetrics and Gynecology, Shin-Yurigaoka General Hospital, Kanagawa, Japan
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Ogihara Y, Yamada N, Izumi D, Sato Y, Sato T, Nakaya H, Mori T, Ota S, Makino M, Ogura T, Tamaru S, Nishimura Y, Tanigawa T, Kasai A, Nishikawa M, Dohi K. Exploratory rivaroxaban trial for isolated calf deep vein thrombosis with a risk factor of thrombosis extension: an open-label, multicenter, randomized controlled trial. Res Pract Thromb Haemost 2024; 8:102515. [PMID: 39188889 PMCID: PMC11347048 DOI: 10.1016/j.rpth.2024.102515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/22/2024] [Accepted: 06/26/2024] [Indexed: 08/28/2024] Open
Abstract
Background Limited evidence exists regarding the incidence of recurrent venous thromboembolism (VTE) in patients diagnosed with isolated distal deep vein thrombosis (DVT) who are at risk of thrombosis extension whether they receive anticoagulation therapy or not. Objectives The study aimed to investigate the incidence of recurrent VTE and the impact of rivaroxaban in this patient population. Methods This open-label, exploratory, and randomized controlled trial was conducted at 7 centers in Japan between April 2019 and April 2022. Adult patients with isolated distal DVT at risk of thrombosis extension received either rivaroxaban combined with physical therapy or physical therapy alone for 90 days. Whole-leg ultrasound was performed at 14 and 90 days. We assessed a composite outcome of symptomatic or asymptomatic proximal DVT or symptomatic pulmonary embolism as the primary outcome until the end of the treatment period using an intention-to-treat analysis. Major bleeding was evaluated as a key secondary outcome. Results Out of 90 enrolled patients, 3 were excluded due to withdrawal of consent; therefore, we analyzed 87 participants. The rivaroxaban group (n = 42) reported no primary outcomes (0%; 95% CI, 0.0%-8.4%), whereas the physical therapy group (n = 45) had 2 cases of symptomatic proximal DVT (4.4%; 95% CI, 0.5%-15.1%). Major bleeding events occurred in 4 patients in the rivaroxaban group (9.5%; 95% CI, 2.7%-22.6%), whereas no events occurred in the physical therapy group (0%; 95% CI, 0%-7.9%). Conclusion Preliminary data suggest that rivaroxaban may reduce the risk of VTE recurrence among this patient subset, albeit with an increased incidence of bleeding events.
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Affiliation(s)
- Yoshito Ogihara
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Norikazu Yamada
- Department of Cardiology, Kuwana City Medical Center, Kuwana, Japan
| | - Daisuke Izumi
- Department of Cardiology, Matsusaka Municipal Hospital, Matsusaka, Japan
| | - Yuichi Sato
- Department of Cardiology, Matsusaka Chuo General Hospital, Matsusaka, Japan
| | - Toru Sato
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hitoshi Nakaya
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Tatsuya Mori
- Department of Cardiology, Ise Red Cross Hospital, Ise, Japan
| | - Satoshi Ota
- Department of Cardiology, Suzuka General Hospital, Suzuka, Japan
| | - Midori Makino
- Department of Cardiology, Suzuka General Hospital, Suzuka, Japan
| | - Toru Ogura
- Clinical Research Support Center, Mie University Hospital, Tsu, Japan
| | - Satoshi Tamaru
- Clinical Research Support Center, Mie University Hospital, Tsu, Japan
| | - Yuki Nishimura
- Clinical Research Support Center, Mie University Hospital, Tsu, Japan
| | - Takashi Tanigawa
- Department of Cardiology, Matsusaka Chuo General Hospital, Matsusaka, Japan
| | - Atsunobu Kasai
- Department of Cardiology, Ise Red Cross Hospital, Ise, Japan
| | | | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - ISE CALF DVT Study Investigators
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
- Department of Cardiology, Kuwana City Medical Center, Kuwana, Japan
- Department of Cardiology, Matsusaka Municipal Hospital, Matsusaka, Japan
- Department of Cardiology, Matsusaka Chuo General Hospital, Matsusaka, Japan
- Department of Cardiology, Ise Red Cross Hospital, Ise, Japan
- Department of Cardiology, Suzuka General Hospital, Suzuka, Japan
- Clinical Research Support Center, Mie University Hospital, Tsu, Japan
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Baumgartner C, Tritschler T, Aujesky D. Subsegmental Pulmonary Embolism. Hamostaseologie 2024; 44:197-205. [PMID: 37871632 DOI: 10.1055/a-2163-3111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023] Open
Abstract
Subsegmental pulmonary embolism (SSPE) is increasingly diagnosed with the growing use and technological advancements of multidetector computed tomography pulmonary angiography. Its diagnosis is challenging, and some presumed SSPE may actually represent imaging artifacts. Indirect evidence and results from small observational studies suggest that SSPE may be more benign than more proximal pulmonary embolism, and may thus not always require treatment. Therefore, guidelines suggest to consider a management strategy without anticoagulation in selected patients with SSPE at low risk of recurrent venous thromboembolism (VTE), in whom proximal deep vein thrombosis is excluded. Recently, a large prospective study among low-risk patients with SSPE who were left untreated showed a higher VTE recurrence risk than initially deemed acceptable by the investigators, and thus was prematurely interrupted after recruitment of 97% of the target population. However, the risk-benefit ratio of anticoagulation for low-risk patients with SSPE remains unclear, and results from randomized trials are needed to answer the question about their optimal management.
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Affiliation(s)
- Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Houghton DE, Carman T. Caution: Inferior vena cava filters in distal deep vein thrombosis. Vasc Med 2024:1358863X241255968. [PMID: 38818712 DOI: 10.1177/1358863x241255968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Affiliation(s)
- Damon E Houghton
- Department of Cardiovascular Diseases, Division of Vascular Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Teresa Carman
- Harrington Heart & Vascular Institute, University Hospitals, Cleveland, OH, USA
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Le Pennec R, Le Roux PY, Robin P, Couturaud F, Righini M, Le Gal G, Salaun PY. Comparison of three diagnostic strategies for suspicion of pulmonary embolism: planar ventilation-perfusion scan (V/Q), CT pulmonary angiography (CTPA) and single photon emission CT ventilation-perfusion scan (SPECT V/Q): a protocol of a randomised controlled trial. BMJ Open 2024; 14:e075712. [PMID: 38754880 PMCID: PMC11097801 DOI: 10.1136/bmjopen-2023-075712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 04/09/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Pulmonary embolism (PE) is a challenge to diagnose and when missed, exposes patients to potentially fatal recurrent events. Beyond CT pulmonary angiography (CTPA) and planar ventilation/perfusion (V/Q) scan, single photon emission CT (SPECT) V/Q emerged a new diagnostic modality of scintigraphic acquisition that has been reported to improve diagnostic performances. To date, no management outcome study or randomised trial evaluated an algorithm based on SPECT V/Q for PE diagnosis. We present the design of a randomised multicentre, international management study comparing SPECT V/Q with validated strategies. MATERIAL AND METHODS We will include a total of 3672 patients with suspected PE requiring chest imaging, randomised into three different groups, each using a different diagnostic strategy based on SPECT V/Q, CTPA and planar V/Q scan. Randomisation will be unbalanced (2:1:1), with twice as many patients in SPECT V/Q arm (n=1836) as in CTPA and planar V/Q arms (n=918 in each). Our primary objective will be to determine whether a diagnostic strategy based on SPECT V/Q is non-inferior to previously validated strategies in terms of diagnostic exclusion safety as assessed by the 3-month risk of thromboembolism in patients with a negative diagnostic workup. Secondary outcomes will be the proportion of patients diagnosed with PE in each arm, patients requiring additional tests, the incidence of major and clinically relevant non-major bleeding and the incidence and cause of death in each arm. ETHICS AND DISSEMINATION This trial is funded by a grant from Brest University Hospital and by INVENT. The study protocol was approved by Biomedical Research Ethics Committee. The investigator or delegate will obtain signed informed consent from all patients prior to inclusion in the trial. Our results will inform future clinical practice guidelines and solve the current discrepancy between nuclear medicine guidelines and clinical scientific society guidelines. TRIAL REGISTRATION NUMBER NCT02983760.
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Affiliation(s)
| | | | | | | | - Marc Righini
- University of Geneva, Switzerland, Geneva, Switzerland
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Sartori M, Iotti M, Camporese G, Siragusa S, Imberti D, Bucherini E, Corradini S, Ageno W, Prandoni P, Ghirarduzzi A. Six-week low-molecular-weight heparin versus 12-week warfarin for calf deep vein thrombosis: A randomized, prospective, open-label study. Am J Hematol 2024; 99:854-861. [PMID: 38375893 DOI: 10.1002/ajh.27255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/24/2024] [Accepted: 02/05/2024] [Indexed: 02/21/2024]
Abstract
Current guidelines suggest a 3-month anticoagulant treatment course for isolated distal deep vein thrombosis (IDDVT), but shorter durations of treatment are frequently prescribed in clinical practice. We investigated whether a 6-week treatment with low-molecular-weight heparin (LMWH) at intermediate dosage can be an effective and safe alternative to vitamin K antagonists (VKA) in patients with IDDVT (non-inferiority trial). In a multicenter, open-label, randomized trial, 260 outpatients with symptomatic IDDVT were randomly assigned to receive either LMWH followed by VKA for 12 weeks or LMWH 1 mg/kg subcutaneously twice a day for 2 weeks followed by 1 mg/kg subcutaneously once a day for 4 weeks. The follow-up was 6 months and the primary endpoint was the composite measure of recurrent venous thromboembolism (VTE) defined as: recurrence or extension of IDDVT, proximal DVT, and pulmonary embolism (PE). The study was stopped prematurely due to slow recruiting rates. The primary efficacy outcome occurred in 14 patients receiving LMWH (10.8%) and in five patients receiving VKA (3.8%); risk difference was 0.069 (95% CI: 0.006-0.132), hazard ratio 2.8 (95% CI: 1.04-7.55). There was one PE in the VKA group and one proximal DVT in the LMWH group. IDDVT recurrence was 10.0% in the LMWH group versus 3.1% in the VKA group (p = .024). Two patients had clinically relevant bleedings (1.6%) in the LMWH group versus one (0.8%) in VKA group (p = .56). In conclusion, VKA for 12 weeks seems superior to LMWH for 6 weeks in reducing the risk of VTE recurrences in our cohort of outpatients with IDDVT.
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Affiliation(s)
- Michelangelo Sartori
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Iotti
- Cardiovascular Medicine Unit - AUSL-IRCCS, Reggio Emilia, Italy
| | - Giuseppe Camporese
- General Medicine Unit, Thrombotic and Haemorrhagic Disorders Unit, Department of Internal Medicine, University Hospital of Padua, Padua, Italy
| | - Sergio Siragusa
- Haematology Unit, Thrombosis and Haemostasis Reference Regional Center, University of Palermo, Palermo, Italy
| | - Davide Imberti
- Haemostasis and Thrombosis Center, Department of Internal Medicine, Hospital of Piacenza, Piacenza, Italy
| | | | - Sara Corradini
- Cardiovascular Medicine Unit - AUSL-IRCCS, Reggio Emilia, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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10
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Righini M, Robert-Ebadi H. Management of isolated distal deep vein thrombosis. VASA 2024; 53:185-192. [PMID: 38546285 DOI: 10.1024/0301-1526/a001119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Isolated distal deep vein thrombosis (DVT) represents up to 50% of all lower limb DVT in ultrasound series and is a frequent medical condition, which management is not well established. Data arising from registries and non-randomized studies suggest that most distal DVTs do not extend to the proximal veins and have an uneventful follow-up when left untreated. This data had some impact on international recommendations like the American College of Chest Physicians (ACCP), whose last version stated that ultrasound surveillance might be an option for selected low-risk patients. However, robust data arising from randomized studies are scarce. Indeed, only seven randomized trials assessing the need for anticoagulation for calf DVT have been published. Many of these trials had an open-label design and were affected by methodological limitations. When considering randomized placebo-controlled trials, one included low-risk patients and was hampered by a limited statistical power (CACTUS study). Nevertheless, data from this trial tend to confirm that the use of therapeutic anticoagulation in low-risk patients with symptomatic calf DVT is not superior to placebo in reducing VTE but is associated with a higher risk of bleeding. A second randomized placebo-controlled trial did not assess the necessity of anticoagulant treatment but rather the long-term risk of recurrence and compared 6 weeks versus 12 weeks of treatment with rivaroxaban (RIDTS study). Finally, the last available randomized trial compared a 3-month versus a 12-month edoxaban treatment in patients with cancer and mainly asymptomatic distal DVT, detected by systematic compression ultrasonography. Overall, available data suggest that the use of therapeutic anticoagulation in low-risk patients with symptomatic calf DVT is not superior to placebo in reducing VTE. High risk patients (previous VTE, active cancer, inpatients) might benefit from a course of anticoagulant treatment. However, the optimal anticoagulant intensity and duration are uncertain and further studies are needed.
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Affiliation(s)
- Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
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11
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Huang Y, Luo H, Liu X, Li Y, Gong J. Independent association between IVC filter placement and VTE risk in patients with upper gastrointestinal bleeding and isolated distal DVT: A retrospective cohort study. Vasc Med 2024:1358863X241240442. [PMID: 38607947 DOI: 10.1177/1358863x241240442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
BACKGROUND The placement of inferior vena cava (IVC) filters often emerges as an alternative preventative measure against pulmonary embolism in patients with upper gastrointestinal (GI) bleeding and isolated distal deep vein thrombosis (DVT). We aimed to investigate the association of IVC filter placement and the incidence of venous thromboembolism (VTE) recurrence in this patient population. METHODS We performed a retrospective cohort study including 450 patients with upper GI bleeding and isolated distal DVT. Propensity score matching using logistic regression was conducted to mitigate potential selection bias. Logistic regression models and additional sensitivity analyses were conducted to estimate the association between IVC filter implantation and VTE recurrence. Interaction and stratified analyses were also performed according to the background covariates. RESULTS Patients who underwent IVC filter placement were significantly younger than patients in the surveillance group (55.8 ± 9.0 vs 58.4 ± 11.2 years, p = 0.034). Patients in the IVC filter group demonstrated a higher distal thrombus burden. The VTE recurrence composite was significantly higher in patients who underwent IVC filter placement (44.1% [45/102] vs 25% [87/348], p < 0.001). Unmatched crude logistic regression analysis identified a significant association between IVC filter placement and VTE recurrence composite (OR = 2.37; 95% CI, 1.50-3.75). Sensitivity analyses yielded congruent outcomes. CONCLUSION This study revealed an increased risk of VTE recurrence among patients receiving IVC filter placement, suggesting that IVC filter placement may not be suitable as a primary treatment for patients with upper GI bleeding and isolated distal DVT.
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Affiliation(s)
- Ying Huang
- Department of Vascular Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hailong Luo
- Department of Vascular Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xin Liu
- Department of Emergency Medicine, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yanlin Li
- Department of Emergency Medicine, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Gong
- Department of Emergency Medicine, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Tan M, Lurie F, Kim DI, Wakefield T, Parsi K, Davies AH. Management of isolated distal deep venous thrombosis. Phlebology 2024; 39:143-146. [PMID: 37908099 PMCID: PMC10877996 DOI: 10.1177/02683555231211095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Affiliation(s)
- Matthew Tan
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Dong-Ik Kim
- Division of Vascular Surgery, Samsung Medical Center, Seoul, South Korea
| | - Thomas Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Kurosh Parsi
- Department of Dermatology, St. Vincent’s Hospital, Sydney, NSW, Australia
| | - Alun H Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
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13
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Wang B, Wang Q, Ji Y, Zhang Y, Qiao T. The clinical outcomes of different doses of rivaroxaban in patients with isolated distal deep vein thrombosis. J Vasc Surg Venous Lymphat Disord 2024; 12:101653. [PMID: 37490950 DOI: 10.1016/j.jvsv.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/10/2023] [Accepted: 07/15/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE Isolated distal deep vein thrombosis (IDDVT) is defined as thrombosis involving the infrapopliteal veins. The optimal anticoagulant therapy of IDDVT remains controversial. This study aimed to assess whether reduced dose of rivaroxaban was suitable in patients with IDDVT. METHODS Consecutive patients with acute IDDVT were identified by reviewing the venous thromboembolism (VTE) registry databases. Outcomes including VTE recurrence, major bleeding, clinically relevant non-major (CRNM) bleeding, and death. Patients were followed until the first occurrence of any outcomes or the study end date (December 31, 2018). Hazard ratios (HRs) and 95% confidence intervals (CIs) were computed. RESULTS A total of 1246 patients were divided into low-dose (10 or 15 mg/day; n = 716) and standard-dose (20 mg/day; n = 530) groups. The incidences of VTE recurrence, major bleeding, CRNM bleeding, and death between the two groups were 9.64% vs 5.66%, 1.68% vs 3.02%, 4.61% vs 8.68%, and 13.83% vs 10.75%, respectively. After the inverse probability of treatment weighting, HRs for standard-dose vs low-dose of VTE recurrence, major bleeding, CRNM bleeding, and death were 0.54 (95% CI, 0.35-0.84), 1.71 (95% CI, 0.80-3.67), 2.28 (95% CI, 1.40-3.74), and 1.30 (95% CI, 0.91-1.86), respectively. For the subgroup analysis, the interaction with anticoagulation duration and treatment was evident for VTE recurrence (P for interaction = .002), but not for major bleeding. Patients with residual vein thrombosis were associated with an increased risk of VTE recurrence (HR, 1.95; 95% CI, 1.29-2.95). The interaction between risk factors and residual vein thrombosis was evident for VTE recurrence (P for interaction = .085). CONCLUSIONS Standard-dose rivaroxaban reduced the risk of VTE recurrence without increasing the risk of major bleeding in patients with IDDVT. Anticoagulant therapy for >1.5 months should be preferred over shorter durations. Residual vein thrombosis should be assessed as a predictor of recurrence in patients with IDDVT, especially for patients with non-transient factors.
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Affiliation(s)
- Baoyan Wang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Qing Wang
- Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| | - Ye Ji
- Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| | - Yepeng Zhang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Tong Qiao
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China; Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, China.
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14
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Galanaud JP, Trujillo-Santos J, Bikdeli B, Bertoletti L, Di Micco P, Poénou G, Falgá C, Zdraveska M, Lima J, Rivera-Civico F, Muixi JF, Monreal M. Clinical Presentation and Outcomes of Patients With Cancer-Associated Isolated Distal Deep Vein Thrombosis. J Clin Oncol 2024; 42:529-537. [PMID: 37471683 DOI: 10.1200/jco.23.00429] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/26/2023] [Accepted: 05/23/2023] [Indexed: 07/22/2023] Open
Abstract
PURPOSE Patients with isolated distal deep vein thrombosis (DVT) have lower rates of adverse outcomes (death, venous thromboembolism [VTE] recurrence or major bleeding) than those with proximal DVT. It is uncertain if such findings are also observed in patients with cancer. METHODS Using data from the international Registro Informatizado de la Enfermedad TromboEmbolica venosa registry, we compared the risks of adverse outcomes at 90 days (adjusted odds ratio [aOR]; 95% CI) and 1 year (adjusted hazard ratio [aHR; 95% CI]) in 886 patients with cancer-associated distal DVT versus 5,196 patients with cancer-associated proximal DVT and 5,974 patients with non-cancer-associated distal DVT. RESULTS More than 90% of patients in each group were treated with anticoagulants for at least 90 days. At 90 days, the adjusted risks of death, VTE recurrence, or major bleeding were lower in patients with non-cancer-associated distal DVT than in patients with cancer-associated distal DVT (reference): aOR = 0.16 (0.11-0.22), aOR = 0.34 (0.22-0.54), and aOR = 0.47 (0.27-0.80), respectively. The results were similar at 1-year follow-up: aHR = 0.12 (0.09-0.15), aHR = 0.39 (0.28-0.55), and aHR = 0.51 (0.32-0.82), respectively. Risks of death, VTE recurrence, and major bleeding were not statistically different between patients with cancer-associated proximal versus distal DVT, both at 90 days: aOR = 1.11 (0.91-1.36), aOR = 1.10 (0.76-1.62), and aOR = 1.18 (0.76-1.83), respectively, and 1 year: aHR = 1.01 (0.89-1.15), aHR = 1.02 (0.76-1.35), and aHR = 1.10 (0.76-1.61), respectively. However, more patients with cancer-associated proximal DVT, compared with cancer-associated distal DVT, developed fatal pulmonary embolism (PE) during follow-up: The risk difference was 0.40% (95% CI, 0.23 to 0.58). CONCLUSION Cancer-associated distal DVT has serious and relatively comparable outcomes compared with cancer-associated proximal DVT. The lower risk of fatal PE from cancer-associated distal DVT needs further investigation.
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Affiliation(s)
- Jean-Philippe Galanaud
- Department of Medicine, Sunnybrook Heath Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Javier Trujillo-Santos
- Department of Internal Medicine, Hospital General Universitario Santa Lucía, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT
- Cardiovascular Research Foundation (CRF), New York, NY
| | - Laurent Bertoletti
- Department of Vascular Medicine and Therapeutics, Hôpital Nord-CHU St-Etienne, Saint-Etienne, France
| | - Pierpaolo Di Micco
- Department of Internal Medicine and Emergency Room, Ospedale Buon Consiglio Fate bene fratelli, Naples, Italy
| | - Géraldine Poénou
- Department of Vascular Medicine and Therapeutics, Hôpital Nord-CHU St-Etienne, Saint-Etienne, France
| | - Conxita Falgá
- Department of Internal Medicine, Hospital de Mataró, Barcelona, Spain
| | - Marija Zdraveska
- University Clinic of Pneumology and Allergy Skopje, Skopje, Republic of Macedonia
| | - Jorge Lima
- Department of Pneumonology, Hospital Universitario Virgen de Valme, Sevilla, Spain
| | | | | | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM-Universidad Católica San Antonio de Murcia, Murcia, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
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15
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Mlačo A, Mlačo N, Begić E, Mekić M, Džubur A. D-Dimer and Fibrinogen Values according to the Localization of Deep Venous Thrombosis. Int J Angiol 2023; 32:243-247. [PMID: 37927846 PMCID: PMC10624538 DOI: 10.1055/s-0042-1759819] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
D-dimer and fibrinogen are nonspecific diagnostic biomarkers for venous thromboembolism (VTE). The aim of this article was to present the values of D-dimer and fibrinogen in relation to the anatomical localization of deep vein thrombosis (DVT). This was an observational study, which included 1,142 patients hospitalized from 2010 to 2019 at the Department of Angiology, Clinical Center University of Sarajevo. Data on gender, age, and thrombosis location were collected of all patients. Fibrinogen and D-dimer values were available for 983 and 500 patients, respectively. Thrombosis location was classified as iliofemoral (521-45.6% patients), femoral-popliteal (486-42.6% patients), isolated calf DVT (63-5.5% patients), and upper extremity DVT (UEDVT in 72-6.3% patients). A majority, 448 (89.6%), of patients had high D-dimer (the cutoff is 0.55 mg/L) and 662 (67.3%) patients had high fibrinogen (reference range: 1.8-3.8 g/L). The highest D-dimer was detected in patients with iliofemoral DVT (mean: 10.48 mg/L), χ2 = 50.78, p = 0.00. The highest fibrinogen was detected in patients with iliofemoral DVT as well (mean 4.87 g/L), χ2 = 11.1, p = 0.01. D-dimer and fibrinogen values are significantly higher in patients iliofemoral DVT than femoral-popliteal and isolated calf DVT, and D-dimer values are significantly higher in lower extremity DVT than UEDVT, but these biomarkers cannot be used alone to discriminate between thrombosis locations. Further imaging is required.
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Affiliation(s)
- Akif Mlačo
- Department of Angiology, Clinic for Heart, Blood Vessel and Rheumatic Diseases, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | | | - Edin Begić
- Department of Cardiology, General Hospital “Prim. Dr. Abdulah Nakas,” Sarajevo, Bosnia and Herzegovina
| | - Mevludin Mekić
- Department of Rheumatology, Clinic for Heart, Blood Vessel and Rheumatic Diseases, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Alen Džubur
- Department of Cardiology, Clinic for Heart, Blood Vessel and Rheumatic Diseases, Clinical Center University of Sarajevo, Bosnia and Herzegovina
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16
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Kay AB, Morris DS, Woller SC, Collingridge DS, Majercik S. Below the knee, let it be: Management of calf DVT in hospitalized trauma patients. Am J Surg 2023; 226:891-895. [PMID: 37574336 DOI: 10.1016/j.amjsurg.2023.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Management of below-knee DVT (BKDVT) in trauma patients is uncertain. We hypothesized that BKDVT can be managed with observation only. METHODS Secondary analysis on trauma inpatients March 2017-September 2019 with risk assessment profile ≥5. Management of BKDVT included observation with ultrasound. BKDVT was compared to above-knee DVT (AKDVT), and BKDVT with progression to AKDVT/PE compared to no progression. RESULTS Of 1988 patients, 136 (6.8%) BKDVT and 23 (1.2%) AKDVT. 7 (6.9%) BKDVT progressed to AKDVT/PE. 6.9% had BKDVT progression, associated with higher ISS (36.7 vs 21.6, p = 0.005), longer prophylaxis delay (121 vs 45 h, p = 0.02) and longer hospital LOS (25.6 vs 7.8, p = 0.01). None experienced post-thrombotic syndrome. CONCLUSION Majority of BKDVT in hospitalized trauma patients did not progress to AKDVT. Observation for progression, rather than treatment, was not associated with increased PE risk or thrombotic sequelae. Observation with serial ultrasound may serve as a practical alternative to anticoagulation in trauma patients with BKDVT.
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Affiliation(s)
- Annika Bickford Kay
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT, USA.
| | - David S Morris
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT, USA.
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Murray, UT, USA; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | | | - Sarah Majercik
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT, USA.
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17
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Yamashita Y, Morimoto T, Muraoka N, Oyakawa T, Umetsu M, Akamatsu D, Nishimoto Y, Sato Y, Takada T, Jujo K, Minami Y, Ogihara Y, Dohi K, Fujita M, Nishikawa T, Ikeda N, Hashimoto G, Otsui K, Mori K, Sueta D, Tsubata Y, Shoji M, Shikama A, Hosoi Y, Tanabe Y, Chatani R, Tsukahara K, Nakanishi N, Kim K, Ikeda S, Mo M, Yoshikawa Y, Kimura T. Edoxaban for 12 Months Versus 3 Months in Patients With Cancer With Isolated Distal Deep Vein Thrombosis (ONCO DVT Study): An Open-Label, Multicenter, Randomized Clinical Trial. Circulation 2023; 148:1665-1676. [PMID: 37638968 DOI: 10.1161/circulationaha.123.066360] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/15/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND The optimal duration of anticoagulation therapy for isolated distal deep vein thrombosis in patients with cancer is clinically relevant, but the evidence is lacking. The prolonged anticoagulation therapy could have a potential benefit for prevention of thrombotic events; however, it could also increase the risk of bleeding. METHODS In a multicenter, open-label, adjudicator-blinded, randomized clinical trial at 60 institutions in Japan, we randomly assigned patients with cancer with isolated distal deep vein thrombosis, in a 1-to-1 ratio, to receive either a 12-month or 3-month edoxaban treatment. The primary end point was a composite of a symptomatic recurrent venous thromboembolism (VTE) or VTE-related death at 12 months. The major secondary end point was major bleeding at 12 months, according to the criteria of the International Society on Thrombosis and Haemostasis. The primary hypothesis was that a 12-month edoxaban treatment was superior to a 3-month edoxaban treatment with respect to the primary end point. RESULTS From April 2019 through June 2022, 604 patients were randomized, and after excluding 3 patients who withdrew consent, 601 patients were included in the intention-to-treat population: 296 patients in the 12-month edoxaban group and 305 patients in the 3-month edoxaban group. The mean age was 70.8 years, 28% of the patients were men, and 20% of the patients had symptoms of deep vein thrombosis at baseline. The primary end point of a symptomatic recurrent VTE event or VTE-related death occurred in 3 of the 296 patients (1.0%) in the 12-month edoxaban group and in 22 of the 305 patients (7.2%) in the 3-month edoxaban group (odds ratio, 0.13; 95% CI, 0.03-0.44). The major secondary end point of major bleeding occurred in 28 of the 296 patients (9.5%) in the 12-month edoxaban group and in 22 of the 305 patients (7.2%) in the 3-month edoxaban group (odds ratio, 1.34; 95% CI, 0.75-2.41). The prespecified subgroups did not affect the estimates on the primary end point. CONCLUSIONS In patients with cancer with isolated distal deep vein thrombosis, 12 months was superior to 3 months for an edoxaban treatment with respect to the composite outcome of a symptomatic recurrent VTE or VTE-related death. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03895502.
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Affiliation(s)
- Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (Y. Yamashita, Y. Yoshikawa)
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Japan (T.M.)
| | - Nao Muraoka
- Division of Cardiology, Shizuoka Cancer Center, Japan (N.M., T.O.)
| | - Takuya Oyakawa
- Division of Cardiology, Shizuoka Cancer Center, Japan (N.M., T.O.)
| | - Michihisa Umetsu
- Division of Vascular Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Japan (M.U., D.A.)
| | - Daijirou Akamatsu
- Division of Vascular Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Japan (M.U., D.A.)
| | - Yuji Nishimoto
- Division of Cardiology, Osaka General Medical Center, Japan (Y.N.)
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Japan (Y.S.)
| | - Takuma Takada
- Department of Cardiology, Tokyo Women's Medical University, Japan (T.T., K.J., Y.M.)
| | - Kentaro Jujo
- Department of Cardiology, Tokyo Women's Medical University, Japan (T.T., K.J., Y.M.)
| | - Yuichiro Minami
- Department of Cardiology, Tokyo Women's Medical University, Japan (T.T., K.J., Y.M.)
| | - Yoshito Ogihara
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan (Y.O., K.D.)
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan (Y.O., K.D.)
| | - Masashi Fujita
- Department of Onco-Cardiology, Osaka International Cancer Institute, Japan (M.F., T.N.)
| | - Tatsuya Nishikawa
- Department of Onco-Cardiology, Osaka International Cancer Institute, Japan (M.F., T.N.)
| | - Nobutaka Ikeda
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan (N.I., G.H.)
| | - Go Hashimoto
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan (N.I., G.H.)
| | - Kazunori Otsui
- Department of General Internal Medicine, Kobe University Graduate School of Medicine, Japan (K.O., K.M.)
| | - Kenta Mori
- Department of General Internal Medicine, Kobe University Graduate School of Medicine, Japan (K.O., K.M.)
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (D.S.)
| | - Yukari Tsubata
- Department of Internal Medicine, Division of Medical Oncology and Respiratory Medicine, Shimane University Faculty of Medicine, Izumo, Japan (Y. Tsubata)
| | - Masaaki Shoji
- Department of Cardiovascular Medicine, National Cancer Center Hospital, Tokyo, Japan (M.S.)
| | - Ayumi Shikama
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Japan (A.S.)
| | - Yutaka Hosoi
- Department of Cardiovascular Surgery, Kyorin University Faculty of Medicine, Tokyo, Japan (Y.H.)
| | - Yasuhiro Tanabe
- Department of Cardiology, St Marianna University School of Medicine, Kawasaki, Japan (Y. Tanabe)
| | - Ryuki Chatani
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Japan (R.C.)
| | - Kengo Tsukahara
- Division of Cardiology, Fujisawa City Hospital, Japan (K.T.)
| | - Naohiko Nakanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Japan (N.N.)
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Japan (K.K.)
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan (S.I.)
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Japan (M.M.)
| | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (Y. Yamashita, Y. Yoshikawa)
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Japan (T.K.)
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Jørgensen CT, Tavoly M, Førsund E, Pettersen HH, Tjønnfjord E, Ghanima W, Brækkan SK. Incidence of bleeding and recurrence in isolated distal deep vein thrombosis: findings from the Venous Thrombosis Registry in Østfold Hospital. J Thromb Haemost 2023; 21:2824-2832. [PMID: 37394122 DOI: 10.1016/j.jtha.2023.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/05/2023] [Accepted: 06/22/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Isolated distal deep vein thrombosis (IDDVT) is a common presentation of deep vein thrombosis. There are limited data on the long-term risk of recurrence after IDDVT. OBJECTIVES We aimed to determine the short- and long-term incidence of venous thrombosis (VTE) recurrence after cessation of anticoagulation and the 3-month incidence of bleeding during anticoagulant treatment in patients with IDDVT. METHODS Between January 2005 and May 2020, 475 patients with IDDVT and without active cancer were identified from the Venous Thrombosis Registry in Østfold Hospital, which is an ongoing registry of consecutive patients with VTE at Østfold Hospital, Norway. Major and clinically relevant, nonmajor bleeding as well as recurrent VTE were registered, and the cumulative incidences of these events were assessed. RESULTS The median age of the patients was 59 years (IQR, 48-72 years), 243 (51%) patients were women, and 175 events (36.8%) were classified as unprovoked. The 1-, 5-, and 10-year cumulative incidences of recurrent VTE were 5.6% (95% CI, 3.7-8.4), 14.7% (95% CI, 11.1-19.4), and 27.2% (95% CI, 21.1-34.5), respectively. The recurrence rates were higher for unprovoked IDDVT than for provoked IDDVT. Among the recurrent events, 18 (29%) were pulmonary embolisms and 21 (33%) were proximal deep vein thromboses. The 3-month cumulative incidence of major bleeding was 1.5% (95% CI, 0.7-3.1) overall and 0.8% (95% CI, 0.2-3.1) when restricted to patients treated with direct oral anticoagulants. CONCLUSION Despite initial treatment, the long-term risk of VTE recurrence after first-time IDDVT is high. The bleeding rates during anticoagulation, particularly with direct oral anticoagulants, were acceptably low.
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Affiliation(s)
- Camilla Tøvik Jørgensen
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Mazdak Tavoly
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway; Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eli Førsund
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway
| | | | - Eirik Tjønnfjord
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway
| | - Waleed Ghanima
- Department of Research, Østfold Hospital, Sarpsborg, Norway; Clinic of Internal Medicine, Østfold Hospital Sarpsborg, Sarpsborg, Norway; Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Sigrid Kufaas Brækkan
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway; Thrombosis Research Center, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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19
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Migita S, Okumura Y, Fukuda I, Nakamura M, Yamada N, Takayama M, Maeda H, Yamashita T, Ikeda T, Mo M, Yamazaki T, Hirayama A. Rivaroxaban treatment for asymptomatic venous thromboembolism: insights from the J'xactly study. Thromb J 2023; 21:88. [PMID: 37599351 PMCID: PMC10440934 DOI: 10.1186/s12959-023-00528-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: 03/19/2023] [Accepted: 08/02/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND An established treatment strategy for asymptomatic pulmonary embolism (PE) or deep vein thrombosis (DVT) remains uncertain in Japan; therefore, in this study, we clarify the characteristics and outcomes of symptomatic compared to asymptomatic patients with PE or DVT. METHODS This prospective, multicenter sub-analysis of the J'xactly study in Japan included 1,016 patients (mean age, 68; 41% male) with venous thromboembolism (VTE) treated with rivaroxaban. RESULTS Asymptomatic PE patients (47% of PE patients) were more likely to have active cancer and asymptomatic proximal DVT at lower severity than symptomatic PE patients, despite no differences in age, sex, or the proportion receiving intensive 30 mg/day-rivaroxaban. Patients with asymptomatic DVT (34% of DVT patients) were older, had higher rates of female sex, active cancer, and distal DVT, and received shorter, less intense rivaroxaban treatment. Incidences did not differ between asymptomatic and symptomatic PE patients for recurrent symptomatic VTE (hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.22-1.62; P = 0.31) or major bleeding (HR, 0.68; 95% CI, 0.20-2.33; P = 0.58), nor between asymptomatic and symptomatic DVT patients for recurrent symptomatic VTE (HR, 0.56; 95% CI, 0.23-1.40; P = 0.21) and major bleeding (HR, 1.47; 95% CI, 0.54-3.97; P = 0.45). CONCLUSIONS The real-world composite adverse event rate for treatment with rivaroxaban, as physician-adjusted for dose and duration, was similar for asymptomatic and symptomatic patients regardless of the presence of PE or DVT, suggesting a favorable safety profile for potential rivaroxaban treatment for asymptomatic VTE.
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Affiliation(s)
- Shohei Migita
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Ikuo Fukuda
- Department of Cardiology, Keimeikai Yokawa Hospital, Miki, Japan
| | | | - Norikazu Yamada
- Department of Cardiology, Kuwana City Medical Center, Kuwana, Japan
| | | | - Hideaki Maeda
- Department of Heart and Vascular Center, Ukima Central Hospital, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, International University of Health and Welfare, Tokyo, Japan
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Brown C, Brandt W, Wang TF, Delluc A, Carrier M. Incidence of recurrent venous thromboembolism and bleeding complications in patients with cancer and isolated distal deep vein thrombosis. Thromb Res 2023; 228:81-84. [PMID: 37301116 DOI: 10.1016/j.thromres.2023.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/13/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Isolated distal deep vein thrombosis (IDDVT) is a common clinical presentation of DVT. The efficacy and safety of anticoagulant therapy for the management of IDDVT in patients with cancer are unclear. We sought to assess the incidence of recurrent venous thromboembolism (VTE) and major bleeding in this patient population. METHODS A systematic search of MEDLINE, EMBASE and PubMed, from inception to June 2, 2022 was performed. The primary efficacy outcome was recurrent VTE and the primary safety outcome was major bleeding. The secondary outcomes were clinically relevant non-major bleeding (CRNMB) and mortality. The incidence rates of thrombotic, bleeding, and mortality outcomes were pooled using random effects model and expressed as events per 100 patient-months with associated 95 % confidence intervals (CI). RESULTS Out of a total of 5234 articles, 10 observational studies including 8160 patients with cancer and IDDVT were included in the analysis. The incidence rate of recurrent VTE was 5.65 (95 % CI: 2.09-15.30) per 100 patient-years regardless of type and duration of anticoagulant therapy. The incidence rate of major bleeding was 4.08 (95 % CI: 2.52-6.61) per 100 patient-years. The incidence rates for CRNMB and mortality per 100 patient-years were 8.11 (95 % CI: 5.56-11.83) and 30.22 (95 % CI: 22.60-40.42.89), respectively. CONCLUSION Patients with cancer and IDDVT are at high risk of developing recurrent VTE and bleeding complications (both major bleeding and CRNMB). More studies are needed to define the optimal management for this high-risk population.
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Affiliation(s)
- Cameron Brown
- Faculty of Arts and Science, Queen's University, Kingston, ON, Canada
| | - Willem Brandt
- Faculty of Science, University of Ottawa, Ottawa, Canada
| | - Tzu-Fei Wang
- Department of Medicine, The Ottawa Hospital Research Institute at University of Ottawa, Ottawa, ON, Canada
| | - Aurélien Delluc
- Department of Medicine, The Ottawa Hospital Research Institute at University of Ottawa, Ottawa, ON, Canada
| | - Marc Carrier
- Department of Medicine, The Ottawa Hospital Research Institute at University of Ottawa, Ottawa, ON, Canada.
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Mo M, Fukuda I, Nakamura M, Yamada N, Takayama M, Maeda H, Yamashita T, Ikeda T, Yamazaki T, Okumura Y, Hirayama A. Effectiveness and safety of the direct oral anticoagulant in acute distal deep vein thrombosis: From the prospective multicenter observational study, J'xactly, in Japan. Phlebology 2023; 38:4-15. [PMID: 36433754 DOI: 10.1177/02683555221141310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We assessed the effectiveness and safety of rivaroxaban in patients with isolated distal deep vein thrombosis (IDDVT). METHODS Symptomatic venous thromboembolism (VTE) and major bleeding were assessed. RESULTS Of 1016 patients with acute symptomatic/asymptomatic DVT and/or pulmonary embolism treated with rivaroxaban, 288 had IDDVT and 294 had proximal DVT (pDVT). The IDDVT group had fewer patients on the higher rivaroxaban dose (30 mg/day) (42.7% vs. 66.0%) and a shorter treatment duration (135.5 vs 369.5 days) than the pDVT group. VTE recurrence occurred in 14 and 11 patients with IDDVT and pDVT, respectively (2.89% vs. 2.29% per patient-year; p = 0.534). Major bleeding was less frequent in the IDDVT group (1.55% vs. 4.53% per patient-year; p = 0.044). Comparable effectiveness and safety were observed with 15 and 30 mg/day rivaroxaban in the IDDVT group. CONCLUSIONS Short-term, low-dose rivaroxaban seems safe and effective for IDDVT treatment.
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Affiliation(s)
- Makoto Mo
- Department of Cardiovascular Surgery, 73663Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - Ikuo Fukuda
- Department of Cardiology, Keimeikai Yokawa Hospital, Miki, Japan
| | | | - Norikazu Yamada
- Department of Cardiology, 38153Kuwana City Medical Center, Kuwana, Japan
| | - Morimasa Takayama
- Department of Cardiology, 26383Sakakibara Heart Institute, Fuchu, Japan
| | - Hideaki Maeda
- Division of Cardiovascular Surgery, 38113Nihon University School of Medicine, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, 36591Toho University Faculty of Medicine, Tokyo, Japan
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, 34804International University of Health and Welfare, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, 38113Nihon University School of Medicine, Tokyo, Japan
| | - Atsushi Hirayama
- Department of Cardiology, 38420Osaka Police Hospital, Osaka, Japan
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22
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Turner BRH, Thapar A, Jasionowska S, Javed A, Machin M, Lawton R, Gwozdz AM, Davies AH. Systematic Review and Meta-Analysis of the Pooled Rate of Post-Thrombotic Syndrome After Isolated Distal Deep Venous Thrombosis. Eur J Vasc Endovasc Surg 2023; 65:291-297. [PMID: 36257568 DOI: 10.1016/j.ejvs.2022.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/08/2022] [Accepted: 10/09/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To identify the rate of post-thrombotic syndrome (PTS) after isolated distal deep venous thrombosis (IDDVT) by performing a meta-analysis of the rate of PTS across randomised and observational studies. DATA SOURCES MEDLINE, Embase, the Cochrane Controlled Trials Register, Clinicaltrials.gov, European Union Clinical Trials, International Standard Randomised Controlled Trial Number, and the Australian and New-Zealand Trials Registries. REVIEW METHODS This review followed PRISMA guidelines using a registered protocol (CRD42021282136). Databases were searched up to December 2021 and prospective studies reporting the development of post-thrombotic syndrome were included; these were pooled with the meta-analysis. RESULTS The results showed a post-thrombotic rate of 17% (95% CI 11 - 26%) (seven studies, 217 cases, 1 105 participants). Heterogeneity was high (I2 = 89%). On meta-regression, the rate of post-thrombotic syndrome was not correlated with the length of follow up (p = .71). Three studies (302 participants) reported the severity of post-thrombotic syndrome: 78% were mild (Villalta score 5 - 9); 11% were moderate (Villalta score 10 - 14), and 11% were severe (Villalta score ≥ 15). CONCLUSION The risk of post-thrombotic syndrome after IDDVT was one in five and the risk of severe clinical manifestations, including ulceration, was one in 50. There was significant clinical, methodological, and statistical heterogeneity between studies and a substantial risk of bias from pooled studies. Randomised trials to support interventions for prevention of post-thrombotic syndrome are urgently needed.
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Affiliation(s)
- Benedict R H Turner
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ankur Thapar
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK; Centre for Circulatory Health, Anglia Ruskin University, Cambridge, UK
| | - Sara Jasionowska
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Azfar Javed
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Matthew Machin
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Rebecca Lawton
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Adam M Gwozdz
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alun H Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.
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23
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Righini M. Calf deep vein thrombosis: Really a wolf in sheep's clothing? JOURNAL DE MEDECINE VASCULAIRE 2023; 48:1-2. [PMID: 37120263 DOI: 10.1016/j.jdmv.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Indexed: 05/01/2023]
Affiliation(s)
- Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
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24
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Ageno W, Bertù L, Bucherini E, Camporese G, Dentali F, Iotti M, Lessiani G, Parisi R, Prandoni P, Sartori M, Visonà A, Bigagli E, Palareti G. Rivaroxaban treatment for six weeks versus three months in patients with symptomatic isolated distal deep vein thrombosis: randomised controlled trial. BMJ 2022; 379:e072623. [PMID: 36520715 PMCID: PMC9682494 DOI: 10.1136/bmj-2022-072623] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare two different treatment durations of rivaroxaban in patients with symptomatic isolated distal deep vein thrombosis (DVT). DESIGN Randomised, double blind, placebo controlled clinical trial. SETTING 28 outpatient clinics specialising in venous thromboembolism. PARTICIPANTS 402 adults (≥18 years) with symptomatic isolated distal DVT. INTERVENTIONS After receiving standard dose rivaroxaban for six weeks, participants were randomly assigned to receive rivaroxaban 20 mg or placebo once daily for an additional six weeks. Follow-up was for 24 months from study inclusion. MAIN OUTCOMES MEASURES The primary efficacy outcome was recurrent venous thromboembolism during follow-up after randomisation, defined as the composite of progression of isolated distal DVT, recurrent isolated distal DVT, proximal DVT, symptomatic pulmonary embolism, or fatal pulmonary embolism. The primary safety outcome was major bleeding after randomisation until two days from the last dose of rivaroxaban or placebo. An independent committee adjudicated the outcomes. RESULTS 200 adults were randomised to receive additional rivaroxaban treatment and 202 to receive placebo. Isolated distal DVT was unprovoked in 81 (40%) and 86 (43%) patients, respectively. The primary efficacy outcome occurred in 23 (11%) patients in the rivaroxaban arm and 39 (19%) in the placebo arm (relative risk 0.59, 95% confidence interval 0.36 to 0.95; P=0.03, number needed to treat 13, 95% confidence interval 7 to 126). Recurrent isolated distal DVT occurred in 16 (8%) patients in the rivaroxaban arm and 31 (15%) in the placebo arm (P=0.02). Proximal DVT or pulmonary embolism occurred in seven (3%) patients in the rivaroxaban arm and eight (4%) in the placebo arm (P=0.80). No major bleeding events occurred. CONCLUSIONS Rivaroxaban administered for six additional weeks in patients with isolated distal DVT who had an uneventful six week treatment course reduces the risk of recurrent venous thromboembolism, mainly recurrent isolated distal DVT, over a two year follow-up without increasing the risk of haemorrhage. TRIAL REGISTRATION EudraCT 2016-000958-36; ClinicalTrials.gov NCT02722447.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | - Lorenza Bertù
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | | | - Giuseppe Camporese
- Unit of Angiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | - Matteo Iotti
- Cardiovascular Medicine Unit - AUSL-IRCCS, Reggio Emilia, Italy
| | - Gianfranco Lessiani
- Angiology Unit, Department of Internal Medicine, Villa Serena Hospital, Città Sant'Angelo, Italy
| | - Roberto Parisi
- Department of Medicine, SS Giovanni e Paolo Hospital, Venice, Italy
| | | | - Michelangelo Sartori
- Division of Angiology and Blood Coagulation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Adriana Visonà
- Angiology Unit, Azienda ULSS 2 Marca Trevigiana, Castelfranco Veneto, Italy
| | - Elisabetta Bigagli
- Department of Neuroscience, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
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Muscular Calf Vein Thrombosis Is Associated With Increased 30-Day Mortality But Not 90-Day Mortality in Older Patients With Hip Fracture. Am J Cardiol 2022; 184:141-146. [PMID: 36123171 DOI: 10.1016/j.amjcard.2022.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/08/2022] [Accepted: 08/11/2022] [Indexed: 11/20/2022]
Abstract
Calf deep vein thrombosis (DVT) is common in patients with hip fractures. However, studies on whether calf DVT has an impact on the prognosis are limited. This retrospective cohort study explored the association between calf DVT and 30-day and 90-day all-cause mortality in older patients with hip fractures. A total of 564 consecutive patients who underwent ultrasound examination were identified from our hip fracture database and categorized into patients with calf DVT (axial DVT, muscular DVT) and no DVT. Of these, 86 patients (15.2%) had ultrasound-confirmed calf DVT, including 66 patients with muscular DVT, and 20 patients with axial DVT. The 30-day and 90-day all-cause mortality were 2.5% and 6.0%, respectively. Multivariate Cox analysis showed that calf DVT was significantly associated with an increased risk of 30-day mortality (hazard ratio [HR] 3.21, 95% confidence interval [CI] 1.05 to 9.84, p = 0.04), but this risk relationship did not persist at 90-day follow-up (HR 1.59, 95% CI 0.69 to 3.71, p = 0.28). When calf DVT was further categorized, muscular DVT remained an independent risk factor for 30-day mortality (HR 3.95, 95% CI 1.18 to 13.15, p = 0.03), whereas this relationship was not found in axial DVT (HR 1.79, 95% CI 0.21 to 15.02, p = 0.59). In conclusion, calf DVT, especially muscular calf DVT but not axial DVT, is independently associated with an increased risk of 30-day mortality in older patients with hip fracture, but this risk relationship did not persist at 90-day follow-up.
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Luo X, Zhang L, Hou C, Li P, Wu S, Wang Z, Yang E, Cui Y, Sun N, Yu Y, An Z, Jin J, Qin Z. Hospitalized patients with isolated distal deep vein thrombosis: anticoagulation therapy or not? Thromb J 2022; 20:52. [PMID: 36100922 PMCID: PMC9472408 DOI: 10.1186/s12959-022-00410-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background Isolated distal deep vein thrombosis (IDDVT), a disease frequently detected in hospitalized patients, can progress to proximal deep vein thrombosis (PDVT) and pulmonary embolism (PE). Here, we evaluated the effects of anticoagulation in hospitalized IDDVT patients. Methods We conducted a retrospective study in our hospital and enrolled hospitalized IDDVT patients diagnosed by compression ultrasonography (CUS) from January to December 2020. Participants were divided into anticoagulation (AC) and non-anticoagulation (non-AC) groups. After propensity score matching (PSM), multivariate Cox regression analyses were performed to assess whether anticoagulation was associated with PDVT/PE, and all-cause mortality. Results A total of 426 IDDVT inpatients with CUS follow-up were screened from 1502 distal DVT patients and finally enrolled. The median age was 67 years with 51.4% males and 15.5% cancer patients. The median follow-up was 11.6 months. There were 288 and 138 patients treated with or without anticoagulants, respectively. Patients in the non-AC group had less body mass index and more comorbidities. Patients in the AC group were treated with rivaroxaban or dabigatran (52.1%), low molecular weight heparin (42.7%), and warfarin (5.2%). The PSM generated 111 pairs of well-matched IDDVT patients with or without anticoagulation. The Kaplan–Meier analysis demonstrated that neither the incidence of PDVT/PE (5.4% vs. 2.7%, log-rank p = 0.313) nor all-cause mortality (27.9% vs. 18.9%, log-rank p = 0.098) was significant different between groups. Anticoagulation was not associated with PDVT/PE and all-cause mortality in the multivariable Cox regression analyses using the matched cohorts. The main risk factors for all-cause mortality were age, malignancy history, BMI, sepsis, heart failure, and white blood cell (WBC) count. Conclusions In hospitalized IDDVT patients, the thrombosis extension rate to PDVT/PE was low. Anticoagulation did not reduce the incidence of thrombosis extension of IDDVT and was not associated with all-cause mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00410-1.
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Affiliation(s)
- Xiaolin Luo
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China
| | - Liying Zhang
- Department of Cardiovascular Medicine, People's Hospital of Shapingba District, Chongqing, China
| | - Changchun Hou
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China
| | - Pengda Li
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China
| | - Shaofa Wu
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China
| | - Zebi Wang
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China
| | - Enpu Yang
- Department of Cardiology, People's Hospital of Dianjiang County, Chongqing, China
| | - Yun Cui
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China
| | - Ning Sun
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China
| | - Yang Yu
- Department of Cardiology, People's Hospital of Dianjiang County, Chongqing, China
| | - Zhixia An
- Department of Internal Medicine, Bashan Hospital, Chongqing, China
| | - Jun Jin
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China.
| | - Zhexue Qin
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China.
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Bikdeli B, Caraballo C, Trujillo-Santos J, Galanaud JP, di Micco P, Rosa V, Cusidó GV, Schellong S, Mellado M, del Valle Morales M, Gavín-Sebastián O, Mazzolai L, Krumholz HM, Monreal M. Clinical Presentation and Short- and Long-term Outcomes in Patients With Isolated Distal Deep Vein Thrombosis vs Proximal Deep Vein Thrombosis in the RIETE Registry. JAMA Cardiol 2022; 7:857-865. [PMID: 35830171 PMCID: PMC9280612 DOI: 10.1001/jamacardio.2022.1988] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Insufficient data exist about the clinical presentation, short-term, and long-term outcomes of patients with isolated distal deep vein thrombosis (IDDVT), that is, thrombosis in infrapopliteal veins without proximal extension or pulmonary embolism (PE). Objective To determine the clinical characteristics, short-term, and 1-year outcomes in patients with IDDVT and to compare the outcomes in unadjusted and multivariable adjusted analyses with patients who had proximal DVT. Design, Setting, and Participants This was a multicenter, international cohort study in participating sites of the Registro Informatizado Enfermedad Tromboembólica (RIETE) registry conducted from March 1, 2001, through February 28, 2021. Patients included in this study had IDDVT. Patients with proximal DVT were identified for comparison. Patients were excluded if they had a history of asymptomatic DVT, upper-extremity DVT, coexisting PE, or COVID-19 infection. Main Outcomes and Measures Primary outcomes were 90-day and 1-year mortality, 1-year major bleeding, and 1-year venous thromboembolism (VTE) deterioration, which was defined as subsequent development of proximal DVT or PE. Results A total of 33 897 patients were identified with isolated DVT (without concomitant PE); 5938 (17.5%) had IDDVT (mean [SD] age, 61 [17] years; 2975 male patients [50.1%]), and 27 959 (82.5%) had proximal DVT (mean [SD] age, 65 [18] years; 14 315 male patients [51.2%]). Compared with individuals with proximal DVT, those with IDDVT had a lower comorbidity burden but were more likely to have had recent surgery or to have received hormonal therapy. Patients with IDDVT had lower risk of 90-day mortality compared with those with proximal DVT (odds ratio [OR], 0.47; 95% CI, 0.40-0.55). Findings were similar in 1-year unadjusted analyses (hazard ratio [HR], 0.52; 95% CI, 0.46-0.59) and adjusted analyses (HR, 0.72; 95% CI, 0.64-0.82). Patients with IDDVT had a lower 1-year hazard of VTE deterioration (HR, 0.83; 95% CI, 0.69-0.99). In 1-year adjusted analyses of patients without an adverse event within the first 3 months, IDDVT was associated with lower risk of VTE deterioration (adjusted HR, 0.48; 95% CI, 0.24-0.97). By 1-year follow-up, symptoms or signs of postthrombotic syndrome were less common in patients with IDDVT (47.6% vs 60.5%). Conclusions and Relevance Results of this cohort study suggest that patients with IDDVT had a less ominous prognosis compared with patients with proximal DVT. Such differences were likely multifactorial, including the differences in demographics, risk factors, comorbidities, particularly for all-cause mortality, and a potential association of thrombus location with VTE deterioration and postthrombotic syndrome. Randomized clinical trials are needed to assess the optimal long-term management of IDDVT.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division and the Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Cardiovascular Research Foundation, New York, New York
| | - César Caraballo
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Javier Trujillo-Santos
- Department of Internal Medicine, Hospital General Universitario Santa Lucía, Cartagena, Murcia, Spain Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Jean Philippe Galanaud
- Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Pierpaolo di Micco
- Department of Internal Medicine and Emergency Room, Ospedale Buon Consiglio Fatebenefratelli, Naples, Italy
| | - Vladimir Rosa
- Department of Internal Medicine, Hospital Universitario Virgen de Arrixaca, Murcia, Spain
| | - Gemma Vidal Cusidó
- Department of Internal Medicine, Corporación Sanitaria Parc Taulí, Barcelona, Spain
| | - Sebastian Schellong
- Department of Medical Clinic, Municipal Hospital of Dresden Friedrichstadt, Dresden, Germany
| | - Meritxell Mellado
- Department of Angiology and Vascular Surgery, Hospital del Mar, Barcelona, Spain
| | | | - Olga Gavín-Sebastián
- Department of Haematology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Lucia Mazzolai
- Division of Angiology, Heart and Vessel Department, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Barcelona
- Universidad Autónoma de Barcelona, Barcelona, Spain
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, Universidad Católica San Antonio de Murcia, Spain
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Fukamachi D, Okumura Y, Fukuda I, Nakamura M, Yamada N, Takayama M, Maeda H, Yamashita T, Ikeda T, Mo M, Yamazaki T, Hirayama A. Characteristics and clinical outcomes of Japanese patients with venous thromboembolism receiving under-dose rivaroxaban: subanalysis of J'xactly. Curr Med Res Opin 2022; 38:1059-1068. [PMID: 35502571 DOI: 10.1080/03007995.2022.2070379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Rivaroxaban is commonly prescribed to prevent venous thromboembolism (VTE). Although lower than standard dosages (under-dosing) may be administered in the real-world setting, data on subsequent clinical outcomes in Japanese patients are lacking. METHODS The prospective, multicenter, observational J'xactly study enrolled patients with acute symptomatic/asymptomatic deep vein thromboses (DVT), pulmonary embolism (PE), or both, who were prescribed rivaroxaban. This subanalysis investigated patient characteristics and outcomes associated with rivaroxaban under-dosing. RESULTS Among 1016 evaluable patients, 667 (65.6%) received an initial standard dosage of rivaroxaban (30 mg/day) and 349 (34.4%) received an initial under-dosage (20 mg/day, n = 22; 15 mg/day, n = 282; and 10 mg/day, n = 45). Those receiving an under-dose had significantly lower body weight and slower pulse rate compared with the standard-dose group regardless of DVT or PE status. Under-dosing was common for distal DVTs, but less frequent for massive/submassive PEs. There were no differences between under-dose and standard-dose groups in the incidences of recurring symptomatic VTEs (DVT: 1.77% vs. 3.35% per patient-year, p = .138; PE: 0.84% vs. 2.84% per patient-year, p = .208) or major bleeding (DVT: 3.55% vs. 3.41% per patient-year, p = .960; PE: not observed vs. 2.83% per patient-year, p = .132). CONCLUSIONS In the real-world setting, rivaroxaban under-dosing for patients with VTE occurred in those with lower body weight, slower pulse rate, distal DVT, or non-massive PEs. There were no statistically significant differences in the clinical outcomes for patients received under-dose of rivaroxaban at the discretion of the physicians in the clinical practice compared with those received standard dose of rivaroxaban.
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Affiliation(s)
- Daisuke Fukamachi
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Ikuo Fukuda
- Department of Cardiovascular Surgery, Suita Tokushukai Hospital, Suita, Japan
| | - Mashio Nakamura
- Department of Internal Medicine, Pediatrics and Cardiology, Nakamura Medical Clinic, Kuwana, Japan
| | - Norikazu Yamada
- Department of Cardiology, Kuwana City Medical Center, Kuwana, Japan
| | | | - Hideaki Maeda
- Division of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, International University of Health and Welfare, Tokyo, Japan
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Day T, Tran H, Chunilal S, Bortz H, Esterman A. Isolated distal DVT in trauma: A study of the management of isolated distal deep vein thrombosis acquired as an inpatient in trauma patients. Injury 2022; 53:2562-2566. [PMID: 35197204 DOI: 10.1016/j.injury.2022.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 12/31/2021] [Accepted: 01/16/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Isolated distal deep vein thromboses (IDDVT) are common complications of trauma inpatient admission, however their management is controversial. We aimed to analyse outcomes in patients admitted to a level three tertiary referral centre who received therapeutic anticoagulation compared to those that did not. We hypothesised that therapeutic anticoagulation would be safe and effective in trauma inpatients who develop IDDVT. METHODS We performed a review of the electronic case notes of all patients with venous thromboembolism listed as a complication whilst admitted as an inpatient under the trauma unit at a tertiary institution over a 4-year period, from October 2014 to October 2018. Demographic data was collected, as well as data regarding management, major bleeding and progression of thrombosis to proximal DVT or PE. RESULTS 91 IDDVT in trauma inpatients were identified. 33 patients received therapeutic anticoagulation within seven days of their diagnosis. No major bleeding was observed in this group, while one episode of thrombus progression was observed. 58 patients were not given therapeutic anticoagulation within seven days of IDDVT diagnosis. There were seven episodes of thrombus progression in this group on median day 5 post diagnosis, while no major bleeding was observed. CONCLUSION Only approximately 1/3rd of patients with IDDVT after trauma received therapeutic anticoagulation, and in these selected cases it appears safe. Those who did not receive therapeutic anticoagulation had a significant rate of thrombosis extension into the proximal system and pulmonary embolus. Further studies on correctly identifying who can be safely anticoagulated are required and for those who cannot be, these data show more aggressive surveillance and prophylaxis needs to be considered.
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Affiliation(s)
- Thomas Day
- Alfred Health, 55 Commercial Rd, Melbourne VIC 3004, Australia.
| | - Huyen Tran
- Alfred Health, 55 Commercial Rd, Melbourne VIC 3004, Australia; Monash University, Wellington Rd, Clayton VIC 3800, Australia
| | - Sanjeev Chunilal
- Monash University, Wellington Rd, Clayton VIC 3800, Australia; Monash Health, 246 Clayton Road,Clayton VIC 3168, Australia
| | - Hadley Bortz
- Alfred Health, 55 Commercial Rd, Melbourne VIC 3004, Australia
| | - Adrian Esterman
- University of South Australia, 101 Currie St, Adelaide SA 5001, Australia
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Zhao WG, Yan JY, Li XL, Shi CY, Wang ZY, Guo W, Zhang K, Zhang WL, Jia XC, Cui SB, Jiang LQ, Zhao JL, Liu ZW, Yang ZH, Liu L, Zhang YZ. Characteristics and Treatment Strategy of Isolated Calf Deep Venous Thrombosis after Fractures: A Review of Recent Literature. Orthop Surg 2022; 14:1263-1270. [PMID: 35478486 PMCID: PMC9251287 DOI: 10.1111/os.13292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 03/10/2022] [Accepted: 03/26/2022] [Indexed: 12/03/2022] Open
Abstract
Isolated calf deep venous thrombosis (ICDVT) includes thrombosis located at the far end of the popliteal vein, such as the anterior tibial vein, posterior tibial vein, fibular vein, and intramuscular vein of the soleus and gastrocnemius. This type of thrombosis has the highest incidence, accounting for approximately half of all deep vein thrombosis (DVT) cases; however, there is no consistent recommendation for ICDVT treatment across countries, and there is also no optimal management strategy. In recent years, increasing evidence has shown that ICDVT can develop into proximal DVT, even causing pulmonary embolism (PE). Therefore, some experts suggest anticoagulant therapy for this type of DVT, while others hold an opposing attitude. Therefore, the treatment strategy for this type of DVT has become a hot and difficult research topic. The purpose of this review is to summarize the characteristics of ICDVT and the effects of different treatment strategies by analyzing recent and important classical works in the literature in an attempt to provide recommendations for the treatment of this most common type of DVT in orthopaedic clinics.
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Affiliation(s)
- Wei-Guang Zhao
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Ji-Ying Yan
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Xiao-Lei Li
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Cai-Ying Shi
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Zhi-Yun Wang
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Wei Guo
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Kai Zhang
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Wei-Li Zhang
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Xiao-Chuan Jia
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Shu-Bei Cui
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Li-Qiang Jiang
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Jian-Long Zhao
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Zhen-Wu Liu
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Zhao-Hui Yang
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Li Liu
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Ying-Ze Zhang
- Key Laboratory of Biomechanics of Hebei Province, Department of Trauma Emergency Center, the Third Hospital of Hebei Medical University, Orthopaedics Research Institution of Hebei Province, Shijiazhuang, Hebei, China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, (The Third Hospital of Hebei Medical University), Shijiazhuang, Hebei, China.,Chinese Academy of Engineering, Beijing, China
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Zhao W, Zhao J, Liu T, Liu Z, Liu L. Incidence and risk factors of preoperative isolated calf deep venous thrombosis following hip fractures. Medicine (Baltimore) 2022; 101:e29140. [PMID: 35357355 PMCID: PMC11319314 DOI: 10.1097/md.0000000000029140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 03/02/2022] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT There is still a lack of data on isolated calf deep vein thrombosis (ICDVT) following hip fractures surgery. The study aimed to determine the incidence of preoperative ICDVT and the associated risk factors in patients with hip fractures requiring surgery.The 289 patients who required hip surgery were included, duplex ultrasonography was routinely used to make a definite diagnosis of preoperative ICDVT located in unilateral or bilateral calf. Data on demographics and laboratory-associated blood biomarkers results were included. Univariate analyses were used to analyse the data of demographics, comorbidities, personal history operation related indexes and laboratory biomarkers, then the multivariate logistic regression analysis was employed to identify the independent risk factors associated with ICDVT.Sixty-eight (23.5%) patients were diagnosed with preoperative ICDVTs. The univariate analyses showed significant differences regarding ICDVT were age, current smoking, alcohol consumption, time from injury to operation, albumin, white blood cells, lymphocyte, red blood cells, hemoglobin, hematocrit, and activated partial thromboplastin time level among the 44 factors. The multivariable model confirmed 3 risk factors were significantly independent in association with preoperative ICDVTs, including current smoking, time delay from injury to operation and activated partial thromboplastin time ( < 28seconds).The incidence of preoperative ICDVT in hip fracture was 23.5%, and patients with associated risk factors are prone to form ICDVTs, identification of these factors may help to reduce the incidence of ICDVT with hip fractures by taking early prevention measures.
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Affiliation(s)
- Weiguang Zhao
- Department of Orthopaedic Surgery, Handan Central Hospital, Handan, Hebei, People's Republic of China,
| | - Jianlong Zhao
- Graduate School of Hebei North University, Zhangjiakou, Hebei, People's Republic of China,
| | - Tiantian Liu
- Chengde Medical University, Chengde, Hebei, People's Republic of China.
| | - Zhenwu Liu
- Department of Orthopaedic Surgery, Handan Central Hospital, Handan, Hebei, People's Republic of China,
| | - Li Liu
- Department of Orthopaedic Surgery, Handan Central Hospital, Handan, Hebei, People's Republic of China,
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33
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Thrombotic burden, d-dimer levels and complete compression ultrasound for diagnosis of acute symptomatic DEEP vein thrombosis of the lower limbs. Thromb Res 2022; 213:163-169. [DOI: 10.1016/j.thromres.2022.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 03/15/2022] [Accepted: 03/22/2022] [Indexed: 11/22/2022]
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Kim SM. Clinical presentation of isolated calf deep vein thrombosis in inpatients and prevalence of associated pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2022; 10:1037-1043. [PMID: 35218959 DOI: 10.1016/j.jvsv.2022.02.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 02/04/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE There is a controversy over the clinical significance and optimal treatment for isolated calf DVT. This study aimed to investigate the clinical presentation of isolated calf deep vein thrombosis (DVT) and the association of isolated calf DVT with pulmonary embolism (PE) in inpatients. METHODS A total of 1435 hospitalized patients underwent whole-leg duplex ultrasound between January 2018 and June 2020. Among them, 135 were diagnosed with isolated calf vein DVT. RESULTS The soleal vein was the most frequently involved (52.6%). Thrombus was detected only in axial veins in 57 patients (42.2%), muscular veins in 46 patients (34.4%), and in both axial and muscular veins in 32 patients (23.7%). Of the 135 patients, 44 patients (32.6%) had underwent recent orthopedic surgery, 31 patients (23.0%) had active cancer, and 22 patients (16.3%) had a history of recent stroke. The reasons for duplex ultrasound were leg edema and/or pain in 57 patients (42.2%), diagnosis of PE in 33 (24.4%), and elevated D-dimer level in 27 patients (20.0%). Sixteen patients (11.9%) were diagnosed as incidental findings on imaging studies for other purposes. Ninety-six patients (71.1%) received anticoagulation therapy. Concurrent PE was diagnosed in 45 patients (33.3%) and 14 patients had lesions in the main pulmonary artery. Among 45 patients with concurrent PE, 35 patients were diagnosed without leg edema and/or pain. Recurrent VTE was observed in four patients (3.0%) with a mean follow-up of 15.5±12.7 months. CONCLUSIONS Isolated calf DVT was associated with a high prevalence of PE in hospitalized patients. Patients with isolated calf DVT even without leg edema and/or pain may have concurrent PE. Anticoagulation therapy should be considered for isolated calf DVT in inpatients. The muscular veins were frequently involved, thus should be thoroughly evaluated and imaged.
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Affiliation(s)
- Suh Min Kim
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea.
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35
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Mahajan A, Brunson A, Eldredge J, White RH, Keegan T, Wun T. Incidence and Outcomes Associated with 6841 Isolated Distal Deep Vein Thromboses in Patients with 13 Common Cancers. Thromb Haemost 2022; 122:1407-1414. [PMID: 35038763 DOI: 10.1055/a-1742-0177] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION The epidemiology of isolated distal deep venous thrombosis (iDDVT) among cancer patients is not well described, particularly the incidence of recurrent venous thromboembolism (rVTE) and effect on mortality by cancer type. METHODS The cumulative incidence (CI) of iDDVT was determined for patients with 13 common cancers between 2005-2017 using the California Cancer Registry linked to the California Patient Discharge and Emergency Department Utilization datasets. The CI of rVTE was calculated and association of incident CAT location with rVTE was determined using Cox proportional hazards regression models. The association of incident cancer-associated venous thrombosis (CAT) location with overall and cancer-specific mortality was determined using Cox models, stratified by cancer site, and adjusted for individual characteristics. RESULTS Among 942,109 cancer patients, CAT occurred in 62,003 (6.6%): of these, 6,841 (11.0%) were iDDVT. Compared to more proximal sites of CAT, iDDVT was associated with similar risk for rVTE. IDDVT was associated with increased mortality across all cancer types when compared to patients without CAT (HR 1.56-4.60). The effect of iDDVT on mortality was similar to that of proximal DVT (pDVT) for most cancers except lung, colorectal, bladder, uterine, brain, and myeloma, where iDDVT was associated with a lesser association with mortality. CONCLUSION iDDVT represented 11% of CAT. The risk of rVTE after iDDVT was similar to other sites of CAT and rVTE occurred in more proximal locations after an incident iDDVT. IDDVT was associated with increased mortality and this effect was similar to that of PE or pDVT for most cancer types.
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Affiliation(s)
- Anjlee Mahajan
- Hematology/Oncology, University of California Davis Health System, Sacramento, United States
| | - Ann Brunson
- Hematology/Oncology, University of California Davis Health System, Sacramento, United States
| | - Joanna Eldredge
- Hematology/Oncology, University of California Davis Health System, Sacramento, United States
| | - Richard H White
- Internal Medicine, University of California Davis Health System, Sacramento, United States
| | - Theresa Keegan
- Hematology/Oncology, University of California Davis Health System, Sacramento, United States
| | - Ted Wun
- Hematology/Oncology, University of California Davis Health System, Sacramento, United States
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Anaya N, Gandhi K. SONO case series: 39-year-old man with leg swelling and pain. Emerg Med J 2021; 39:230-232. [PMID: 34815267 DOI: 10.1136/emermed-2020-209547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Nancy Anaya
- Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Kavita Gandhi
- Emergency Medicine, University of California San Francisco, San Francisco, California, USA
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Abstract
Venous thromboembolism (VTE), encompassing pulmonary embolism (PE) and deep vein thrombosis (DVT), is encountered commonly. Acute PE may present as a high-risk cardiovascular emergency, and acute DVT can cause acute and chronic vascular complications. The goal of this review is to ensure that cardiologists are comfortable managing VTE-including risk stratification, anticoagulation therapy, and familiarity with primary reperfusion therapy. Clinical assessment and determination of degree of right ventricular dysfunction are critical in initial risk stratification of PE and determination of parenteral versus oral anticoagulation therapy. Direct oral anticoagulants have emerged as preferred first-line oral anticoagulation strategy in VTE scenarios.
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Affiliation(s)
- Abby M Pribish
- Department of Medicine, Division of ADM-Housestaff, Beth Israel Deaconess Medical Center, Harvard Medical School, Deac 311, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Eric A Secemsky
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 4th Floor, 375 Longwood Avenue, Boston, MA 02215, USA
| | - Alec A Schmaier
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 4th Floor, 375 Longwood Avenue, Boston, MA 02215, USA.
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Merriman E, Chunilal S, Brighton T, Chen V, McRae S, Ockelford P, Curnow J, Tran H, Chong B, Smith M, Royle G, Crowther H, Slocombe A, Tran H. Two Weeks of Low Molecular Weight Heparin for Isolated Symptomatic Distal Vein Thrombosis (TWISTER study). Thromb Res 2021; 207:33-39. [PMID: 34530387 DOI: 10.1016/j.thromres.2021.09.004] [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: 05/02/2021] [Revised: 08/06/2021] [Accepted: 09/07/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment of low-risk patients with isolated symptomatic distal deep vein thrombi (IDDVT) is uncertain. OBJECTIVE assess whether two weeks of therapeutic anticoagulation is efficacious/safe for IDDVT. PRIMARY OUTCOME symptomatic three-month venous thromboembolism (VTE) incidence in the two-week anticoagulation group. Secondary outcomes included post-thrombotic syndrome (PTS) and bleeding. METHODS Prospective multicentre cohort study. Consecutive low-risk IDDVT patients enrolled within 72 h of diagnosis and treated with therapeutic dose enoxaparin or rivaroxaban. At two weeks, patients had repeat complete whole leg compression ultrasound (CUS)/clinical review. If resolution of leg symptoms AND no radiological evidence of thrombus extension, anticoagulation was stopped. If ongoing symptoms and/or radiographic extension within distal veins, anticoagulation was continued for four more weeks. Patients with extension into the popliteal vein on two-week ultrasound were treated off-study. Patients were reviewed at three and six months. FINDINGS/INTERPRETATION 241 eligible patients received ≥2 weeks anticoagulation. 167/241 (69%) were assigned to the 2-week anticoagulation group; 71/241 (30%) to the six-week anticoagulation group; 3/241 patients (1%) had extension into the popliteal vein on two-week CUS. Two patients in the two-week anticoagulation group had symptomatic IDDVT recurrence in ≤3 months; VTE recurrence 2/156; 1.3%(95% CI 0.05-4.85%). 69% of patients had complete resolution of symptoms within two weeks. Six-month PTS rates were 8/184, 4.4%(95% CI 2.1-8.5%). No major bleeding was reported. Our findings suggest it's safe/efficacious to stop therapeutic anticoagulation at two weeks in low-risk IDDVT patients with resolution of symptoms/no extension on ultrasound. This could replace 6-12 weeks of anticoagulation for ambulatory, low-risk IDDVT patients. TRIAL REGISTRATION ClinicalTrials.govNCT01252420.
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Affiliation(s)
- Eileen Merriman
- Haematology Department, North Shore Hospital, Auckland, New Zealand.
| | - Sanjeev Chunilal
- Department of Clinical Haematology, Monash Medical Centre, Melbourne, Australia
| | - Tim Brighton
- Department of Haematology, New South Wales Health Pathology Randwick, Prince of Wales Hospital Randwick, NSW, Australia
| | - Vivien Chen
- Department of Haematology, Concord Hospital, NW, Australia
| | - Simon McRae
- SA Pathology, Royal Adelaide Hospital, Adelaide, Australia
| | - Paul Ockelford
- Department of Haematology, Auckland City Hospital, Auckland, New Zealand
| | - Jennifer Curnow
- Department of Haematology, Westmead Hospital, NSW, Australia
| | - Huy Tran
- Department of Haematology, Frankston Hospital, Victoria, Australia
| | - Beng Chong
- Department of Haematology, St George's Hospital, NSW, Australia
| | - Mark Smith
- Department of Haematology, Christchurch Hospital, New Zealand
| | - Gordon Royle
- Department of Haematology, Middlemore Hospital, Auckland, New Zealand
| | - Helen Crowther
- Department of Haematology, Blacktown Hospital, NSW, Australia
| | - Alison Slocombe
- Department of Haematology, Box Hill Hospital, Victoria, Australia
| | - Huyen Tran
- Department of Clinical Haematology, Monash Medical Centre, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; Australian Centre for Blood Diseases, Melbourne, Australia
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Heller T, Becher M, Kröger JC, Beller E, Heller S, Höft R, Weber MA, Meinel FG. Isolated calf deep venous thrombosis: frequency on venous ultrasound and clinical characteristics. BMC Emerg Med 2021; 21:126. [PMID: 34717549 PMCID: PMC8557054 DOI: 10.1186/s12873-021-00516-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 10/12/2021] [Indexed: 11/24/2022] Open
Abstract
Background It remains controversial whether to include calf veins in the initial ultrasound evaluation of suspected deep venous thrombosis (DVT). We sought to investigate the frequency and clinical characteristics of isolated calf DVT. Materials and methods In this retrospective analysis, we investigated a cohort of 596 patients (median age 69 years, 52.3% women) who had been imaged with complete lower extremity venous duplex ultrasound for suspected acute DVT. Radiology reports were analyzed for the presence and localization of DVT. Clinical information was collected from patients’ electronic charts. Results DVT was found in 157 patients (26.3%), of which 74 patients (47.1%) had isolated calf DVT. Isolated calf DVTs were located in the posterior tibial veins (22 patients, 29.7%), peroneal veins (41 patients, 55.4%) and muscle veins (19 patients, 25.7%). There were no differences in age or sex between patients with isolated calf DVT and patients with proximal DVT. Isolated calf DVT was more commonly associated with leg pain (52.7% vs. 33.7%, p = 0.0234) and less commonly associated with subjective leg swelling (35.1% vs. 55.4%, p = 0.0158) and objectively measured difference in leg circumference (23% vs. 39.8%, p = 0.0268). D-Dimers were significantly lower in patients with isolated lower leg DVT (median 2.3 vs. 6.8 mg/L, p < 0.0001) compared to patients with proximal DVT. Conclusions Isolated calf DVT represents approximately half of DVT cases and has different clinical characteristics than proximal DVT.
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Affiliation(s)
- Thomas Heller
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Centre Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany.
| | - Mattes Becher
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Centre Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Jens-Christian Kröger
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Centre Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Ebba Beller
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Centre Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Susanne Heller
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Centre Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Raimund Höft
- Department of Emergency Medicine, University Medical Centre Rostock, Rostock, Germany
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Centre Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Felix G Meinel
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Centre Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
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Yamashita Y, Morimoto T, Kimura T. Venous thromboembolism: Recent advancement and future perspective. J Cardiol 2021; 79:79-89. [PMID: 34518074 DOI: 10.1016/j.jjcc.2021.08.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 12/21/2022]
Abstract
Clinicians have been more and more often encountering patients with venous thromboembolism (VTE), including pulmonary embolism and deep vein thrombosis, leading to the increased importance of VTE in daily clinical practice. VTE is becoming a common issue in Asian countries including Japan. The management strategies of VTE have changed dramatically in the past decade including the introduction of direct oral anticoagulants (DOACs). In addition, there have been several landmark clinical trials assessing acute treatment strategies including thrombolysis and inferior vena cava (IVC) filter. The current VTE guidelines do not recommend the routine use of thrombolysis or IVC filters based on recent evidence; Nevertheless, the prevalence of thrombolysis and IVC filter use in Japan was strikingly high. The novel profiles of DOACs with rapid onset of action and potential benefit of a lower risk for bleeding compared with vitamin K antagonist could make home treatment feasible and is safer even with extended anticoagulation therapy. One of the most clinically relevant issues for VTE treatment is optimal duration of anticoagulation for the secondary prevention of VTE. Considering recent evidence, optimal duration of anticoagulation should be determined based on the risk for recurrence as well as the risk for bleeding in an individual patient. Despite the recent advances for VTE management, there are still a number of uncertain issues that challenge clinicians in daily clinical practice, such as cancer-associated VTE and minor VTE including subsegmental pulmonary embolism and distal deep vein thrombosis, warranting future research. Several clinical trials are now ongoing for these issues, globally as well as in Japan. The current review is aimed to overview the recent advances in VTE management, describe the current status including some domestic issues in Japan, and discuss the future perspective of VTE.
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Affiliation(s)
- Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Vlazny DT, Pasha AK, Kuczmik W, Wysokinski WE, Bartlett M, Houghton D, Casanegra AI, Daniels P, Froehling DA, White LJ, Hodge DO, McBane RD. Outcome of anticoagulation in isolated distal deep vein thrombosis compared to proximal deep venous thrombosis. J Thromb Haemost 2021; 19:2206-2215. [PMID: 34060224 DOI: 10.1111/jth.15416] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Isolated, distal deep vein thrombosis (IDDVT) is thought to have low rates of propagation, embolization, and recurrence compared with proximal DVT (PDVT), but the data are limited. OBJECTIVES The objective of this study was to assess outcomes among patients with IDDVT compared with PDVT. PATIENTS/METHODS Consecutive patients with ultrasound-confirmed acute DVT (March 1, 2013-August 1, 2020) were identified by reviewing the Mayo Clinic Gonda Vascular Center and VTE Registry databases. Patients were divided into two groups depending on the DVT location (isolated, distal vs. proximal DVT). Outcomes including venous thromboembolism (VTE) recurrence, major bleeding, and death were compared by thrombus location and anticoagulant therapy, warfarin vs. direct oral anticoagulant (DOAC). RESULTS Isolated, distal deep vein thrombosis (n = 746) was more often associated with recent surgery, major trauma, or confinement (p < .001), whereas patients with PDVT (n = 1176) were more frequently unprovoked, had a prior history of VTE, or active cancer (p < .001). There was no overall difference in VTE recurrence or major bleeding between groups during follow-up. Patients with IDDVT had a higher death rate at 3 months (p = .001) and when propensity scored for cancer (p = .003). Independent predictors of mortality included warfarin (vs. DOAC) therapy, increasing age, and active cancer. DOAC therapy resulted in lower VTE recurrence, major bleeding, and death rates in both groups. CONCLUSION Outcomes of IDDVT including VTE recurrence and bleeding rates were similar to PDVT despite higher early mortality rates. Outcomes for both groups were positively influenced by the use of DOACs.
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Affiliation(s)
- Danielle T Vlazny
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | - Ahmed K Pasha
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | | | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | | | - Damon Houghton
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | - Ana I Casanegra
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | - Paul Daniels
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - David A Froehling
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | - Launia J White
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Robert D McBane
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
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Makedonov I, Galanaud JP, Kahn SR. Significance and management of isolated distal deep vein thrombosis. Curr Opin Hematol 2021; 28:331-338. [PMID: 34267078 DOI: 10.1097/moh.0000000000000670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Management of isolated distal deep vein thrombosis (IDDVT) remains controversial. We summarize recent studies regarding the natural history of IDDVT as well as pertinent therapeutic trials. We also provide our management approach. RECENT FINDINGS IDDVT is more commonly associated with transient risk factors and less often associated with permanent, unmodifiable risk factors than proximal DVT. IDDVT has a significantly lower risk of proximal extension and recurrence than proximal DVT. Cancer-associated IDDVT has a similar natural history to cancer-associated proximal DVT, with substantially less favourable outcomes than noncancer-associated IDDVT. Anticoagulant treatment reduces the risk of proximal extension and recurrence in IDDVT at the cost of increased bleeding risk. Intermediate dosing of anticoagulation may be effective for treating noncancer-associated IDDVT in patients without prior DVT. SUMMARY IDDVT with a transient risk factor can be treated for 6 weeks in patients without a prior DVT. Unprovoked IDDVT in patients without malignancy can be treated for 3 months. Outpatients without malignancy or a prior DVT can be left untreated and undergo surveillance compression ultrasound in one week to detect proximal extension, but few patients opt for this in practice. Cancer-associated IDDVT should be treated analogously to cancer-associated proximal DVT.
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Affiliation(s)
- Ilia Makedonov
- Department of Medicine, Division of General Internal Medicine, Sunnybrook Health Sciences Center
| | - Jean-Philippe Galanaud
- Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario
| | - Susan R Kahn
- Center for Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute; Division of Internal Medicine, Department of Medicine, McGill University, Montreal, Québec, Canada
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Stevens SM, Woller SC, Baumann Kreuziger L, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest 2021; 160:e545-e608. [PMID: 34352278 DOI: 10.1016/j.chest.2021.07.055] [Citation(s) in RCA: 368] [Impact Index Per Article: 122.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/11/2021] [Accepted: 07/08/2021] [Indexed: 01/06/2023] Open
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Chen Y, Zhao J, Zhang Z, Ding Z, Chen Y, Chen X, Zhang W. Construction and Validation of a Nomogram for Predicting the Risk of Deep Vein Thrombosis in Hepatocellular Carcinoma Patients After Laparoscopic Hepatectomy: A Retrospective Study. J Hepatocell Carcinoma 2021; 8:783-794. [PMID: 34322456 PMCID: PMC8312330 DOI: 10.2147/jhc.s311970] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/11/2021] [Indexed: 01/10/2023] Open
Abstract
Background The incidence of deep vein thrombosis (DVT) in hepatocellular carcinoma (HCC) patients after laparoscopic hepatectomy (LH) is unclear, and there is no effective method for DVT risk assessment in these patients. Methods The data from the total of 355 consecutive HCC patients who underwent LH were included. A DVT risk algorithm was developed using a training set (TS) of 243 patients, and its predictive performance was evaluated in both the TS and a validation set (VS) of 112 patients. The model was then used to develop a DVT risk nomogram (TRN). Results The incidence of DVT in the present study was 18.6%. Age, sex, body mass index (BMI), comorbidities and operative position were independent risk factors for DVT in the TS. The model based on these factors had a good predictive ability. In the TS, it had an area under the receiver operating characteristic (AUC) curve of 0.861, Hosmer-Lemeshow (H-L) goodness of fit p value of 0.626, sensitivity of 44.4%, specificity of 96.5%, positive predictive value (PPV) of 74.1%, negative predictive value (NPV) of 88.4%, and accuracy of 86.8%. In the VS, it had an AUC of 0.818, H-L p value of 0.259, sensitivity of 38.1%, specificity of 98.9%, PPV of 88.9%, NPV of 87.4%, and accuracy of 87.5%. The TRN performed well in both the internal and the external validation, indicating a good clinical application value. The TRN had a better predictive value of DVT than the Caprini score (p < 0.001). Conclusion The incidence of DVT after LH was high, and should not be neglected in HCC patients. The TRN provides an efficacious method for DVT risk evaluation and individualized pharmacological thromboprophylaxis.
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Affiliation(s)
- Yao Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, People's Republic of China
| | - Jianping Zhao
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, People's Republic of China
| | - Zhanguo Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, People's Republic of China
| | - Zeyang Ding
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, People's Republic of China
| | - Yifa Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, People's Republic of China
| | - Xiaoping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, People's Republic of China
| | - Wanguang Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, People's Republic of China
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Mazzolai L, Ageno W, Alatri A, Bauersachs R, Becattini C, Brodmann M, Emmerich J, Konstantinides S, Meyer G, Middeldorp S, Monreal M, Righini M, Aboyans V. Second consensus document on diagnosis and management of acute deep vein thrombosis: updated document elaborated by the ESC Working Group on aorta and peripheral vascular diseases and the ESC Working Group on pulmonary circulation and right ventricular function. Eur J Prev Cardiol 2021; 29:1248-1263. [PMID: 34254133 DOI: 10.1093/eurjpc/zwab088] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/25/2021] [Accepted: 05/07/2021] [Indexed: 12/14/2022]
Abstract
This consensus document is proposed to clinicians to provide the whole spectrum of deep vein thrombosis management as an update to the 2017 consensus document. New data guiding clinicians in indicating extended anticoagulation, management of patients with cancer, and prevention and management of post-thrombotic syndrome are presented. More data on benefit and safety of non-vitamin K antagonists oral anticoagulants are highlighted, along with the arrival of new antidotes for severe bleeding management.
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Affiliation(s)
- Lucia Mazzolai
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, Chemin de Mont-Paisible 18, CH-1011 Lausanne, Switzerland
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Via Ravasi 2, 21100 Varese, Italy
| | - Adriano Alatri
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, Chemin de Mont-Paisible 18, CH-1011 Lausanne, Switzerland
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Grafenstraße 9, 64283 Darmstadt, Germany.,Departement of Vascular Medicine, Center for Thrombosis and Hemostasis, University Medical Center Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Cecilia Becattini
- Departement of Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Marianne Brodmann
- Département of Internal Medicine, Division of Angiology, Medical University Graz, Graz, Austria
| | - Joseph Emmerich
- Department of Vascular Medicine, Groupe Hospitalier Paris Saint-Joseph and University of Paris, Paris, France
| | - Stavros Konstantinides
- Departement of Vascular Medicine, Center for Thrombosis and Hemostasis, University Medical Center Mainz, Langenbeckstr. 1, 55131 Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | | | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona, Barcelona, Spain
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Internal Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital and Inserm 1094, Tropical Neuroepidemiology, School of Medicine, 2 avenue martin Luther-King 87042 Limoges, France
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Khan F, Tritschler T, Kahn SR, Rodger MA. Venous thromboembolism. Lancet 2021; 398:64-77. [PMID: 33984268 DOI: 10.1016/s0140-6736(20)32658-1] [Citation(s) in RCA: 236] [Impact Index Per Article: 78.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 11/06/2020] [Accepted: 12/04/2020] [Indexed: 12/11/2022]
Abstract
Venous thromboembolism, comprising both deep vein thrombosis and pulmonary embolism, is a chronic illness that affects nearly 10 million people every year worldwide. Strong provoking risk factors for venous thromboembolism include major surgery and active cancer, but most events are unprovoked. Diagnosis requires a sequential work-up that combines assessment of clinical pretest probability for venous thromboembolism using a clinical score (eg, Wells score), D-dimer testing, and imaging. Venous thromboembolism can be considered excluded in patients with both a non-high clinical pretest probability and normal D-dimer concentrations. When required, ultrasonography should be done for a suspected deep vein thrombosis and CT or ventilation-perfusion scintigraphy for a suspected pulmonary embolism. Direct oral anticoagulants (DOACs) are the first-line treatment for almost all patients with venous thromboembolism (including those with cancer). After completing 3-6 months of initial treatment, anticoagulation can be discontinued in patients with venous thromboembolism provoked by a major transient risk factor. Patients whose long-term risk of recurrent venous thromboembolism outweighs the long-term risk of major bleeding, such as those with active cancer or men with unprovoked venous thromboembolism, should receive indefinite anticoagulant treatment. Pharmacological venous thromboembolism prophylaxis is generally warranted in patients undergoing major orthopaedic or cancer surgery. Ongoing research is focused on improving diagnostic strategies for suspected deep vein thrombosis, comparing different DOACs, developing safer anticoagulants, and further individualising approaches for the prevention and management of venous thromboembolism.
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Affiliation(s)
- Faizan Khan
- School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Tobias Tritschler
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada; Division of Internal Medicine and Division of Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | - Marc A Rodger
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of Medicine, McGill University, Montreal, QC, Canada.
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Ochiai Y, Yamaguchi T, Komiyama C, Kodama T. Impact of Anticoagulation Therapy on the Risk of Pulmonary Embolism and Bleeding Events in Patients with Isolated Distal Deep-Vein Thrombosis. Int Heart J 2021; 62:601-606. [PMID: 33952809 DOI: 10.1536/ihj.20-726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The efficacy of anticoagulation for isolated distal DVT (id-DVT) is still uncertain and controversial. The aim of this study was to elucidate the risk of pulmonary embolism (PE) from id-DVT and to investigate the need for anticoagulants.We identified hospitalized patients with id-DVT diagnosed by lower-extremity ultrasonography (LEUS) from January 2013 to December 2013 in our institute. The exclusion criteria were the simultaneous detection of PE, a history of PE and/or DVT, and administration of anticoagulants before DVT detection. We retrospectively investigated the patient characteristics, treatments, occurrence of PE, and bleeding events between the groups with and without anticoagulation.A total of 151 patients met the criteria. The median (IQR) age was 74 (67, 80) years old, and there were 60 (39.7%) men. The median (IQR) observation period was 571 (160, 721) days. Significant differences in patient characteristics were observed for hypertension, operation time, consultation with experts, and follow-up LEUS. During the observation period, only one patient in the no-anticoagulation group who had traumatic cerebral hemorrhaging and was bedridden developed PE (non-massive type). However, there was no statistically significant difference in the occurrence of PE between the groups (log-rank P = 0.569). Bleeding episodes were observed in 9 of 151 (6.0%) patients, and all patients with bleeding events were taking anticoagulants (log-rank P < 0.001).The present retrospective single center study suggests that anticoagulation for id-DVT in inpatients with various backgrounds has a low efficacy to prevent the occurrence of PE and may increase bleeding events.
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Kuczmik W, Wysokinski WE, Macedo T, Froehling D, Daniels P, Casanegra A, Houghton D, Vlazny D, Meverden R, Lang T, White L, Hodge D, McBane RD. Calf Vein Thrombosis Outcomes Comparing Anticoagulation and Serial Ultrasound Imaging Management Strategies. Mayo Clin Proc 2021; 96:1184-1192. [PMID: 33840522 DOI: 10.1016/j.mayocp.2021.01.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/09/2020] [Accepted: 01/06/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare outcomes among patients with calf deep vein thrombosis (DVT) stratified by management strategy because distal or calf DVT is said to have low rates of propagation, embolization, and recurrence and, as such, guideline recommendations include provisions for serial imaging without treatment. PATIENTS AND METHODS Consecutive patients with ultrasound-confirmed acute DVT involving the calf veins (January 1, 2016, to August 1, 2018) were identified by scrutinizing the Gonda Vascular Center Ultrasound database. Patients were segregated into 2 categories depending on management strategy; anticoagulation vs serial surveillance ultrasound without anticoagulation. Outcomes including venous thromboembolism (VTE) recurrence, bleeding, death, and net clinical benefit were compared by treatment strategy. RESULTS There were 483 patients with calf DVT identified; 399 were treated with anticoagulation therapy and 84 were managed with surveillance ultrasound. Patients in the surveillance group were older (70.0±13.9 vs 63.0±14.9 years; P<.001) and more likely to have had a recent hospitalization (76.2% [64/84] vs 45.4% [181/399]; P<.001). Common reasons for choosing ultrasound surveillance included guideline prescriptive (58.3% [49/84]), active bleeding (21.4% [18/84]), and recent surgery (17.9% [15/84]). The VTE recurrence composite was lower for patients treated with anticoagulants (7.3% [29/399]) compared with surveillance (14.3% [12/84]; P=.04). The DVT propagation was less frequent in the treated group (2.8% [11/399] vs 8.3% [7/84]; P=.01). There was no difference in bleeding or mortality outcomes by management strategy. Net clinical benefit (VTE recurrence plus major bleeding) favored anticoagulant therapy (9.8% [39/399] vs 20.2% [17/84]; P<.01). CONCLUSION Patients with calf DVT treated with anticoagulants had significantly better outcomes compared with those managed by a strategy of serial ultrasound surveillance without increasing bleeding outcomes.
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Affiliation(s)
| | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Thanila Macedo
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Department of Radiology, Mayo Clinic, Rochester, MN
| | - David Froehling
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Paul Daniels
- Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Ana Casanegra
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Damon Houghton
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | | | - Ryan Meverden
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Teresa Lang
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Launia White
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - David Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - Robert D McBane
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN.
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Li Y, Ding J, Shen L, Yang J, Wang H, Zhou Y, Jiang G, Zhu Y, Wang Y. Risk Factors and Anticoagulation Therapy in Patients With Isolated Distal Deep Vein Thrombosis in the Early Post-operative Period After Thoracic Surgery. Front Surg 2021; 8:671165. [PMID: 33996889 PMCID: PMC8113622 DOI: 10.3389/fsurg.2021.671165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/01/2021] [Indexed: 12/21/2022] Open
Abstract
Background: Isolated distal deep vein thrombosis (IDDVT) accounts for ~50% of all patients diagnosed with deep venous thrombosis (DVT), but the diagnosis and optimal management of IDDVT remains unclear and controversial. The aim of this study was to explore potential risk factors and predictors of IDDVT, and to evaluate different strategies of anticoagulation therapy. Methods: A total of 310 consecutive patients after thoracic surgery, who underwent whole-leg ultrasonography as well as routine measurements of D-dimer levels before and after surgery were evaluated. The general clinical data, anticoagulant therapy, pre- and postoperative D-dimer levels were collected. Differences between IDDVT, DVT and non-DVT groups were calculated. Logistic regression analysis was used to analyze risk factors of postoperative IDDVT. Results: Age and postoperative D-dimer levels were significantly higher in IDDVT group than in non DVT group (p = 0.0053 and p < 0.001, respectively). Logistic regression analysis showed that postoperative D-dimer level was a significant independent predictor of IDDVT even when adjusted for age and operation method (p = 0.0003). There were no significant side effects associated with both full-dose and half-dose anticoagulation regimens. Half-dose therapy was associated with a significant decrease in the requirement for anticoagulation medications after discharge (p = 0.0002). Conclusion: Age and D-dimer levels after surgery are strong predictors of IDDVT following thoracic surgery. Half-dose therapeutic anticoagulation has the same efficiency in preventing IDDVT progression, is not associated with any additional risks of adverse effects compared to a full-dose regimen, and may be adopted for treating IDDVT patients after thoracic surgery.
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Affiliation(s)
- Yuping Li
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Junrong Ding
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lei Shen
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jian Yang
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Haifeng Wang
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yiming Zhou
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Gening Jiang
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuming Zhu
- Department of General Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yin Wang
- Department of Ultrasound, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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Hong J, Ahn SY, Lee YJ, Lee JH, Han JW, Kim KH, Yhim HY, Nam SH, Kim HJ, Song J, Kim SH, Bang SM, Kim JS, Mun YC, Bae SH, Kim HK, Jang S, Park R, Choi HS, Kim I, Oh D. Updated recommendations for the treatment of venous thromboembolism. Blood Res 2021; 56:6-16. [PMID: 33627521 PMCID: PMC7987480 DOI: 10.5045/br.2021.2020083] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 01/06/2021] [Accepted: 01/06/2021] [Indexed: 12/13/2022] Open
Abstract
Venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis, is a condition characterized by abnormal blood clot formation in the pulmonary arteries and the deep venous vasculature. It is often serious and sometimes even fatal if not promptly and appropriately treated. Moreover, the later consequences of VTE may result in reduced quality of life. The treatment of VTE depends on various factors, including the type, cause, and patient comorbidities. Furthermore, bleeding may occur as a side effect of VTE treatment. Thus, it is necessary to carefully weigh the benefits versus the risks of VTE treatment and to actively monitor patients undergoing treatment. Asian populations are known to have lower VTE incidences than Western populations, but recent studies have shown an increase in the incidence of VTE in Asia. A variety of treatment options are currently available owing to the introduction of direct oral anticoagulants. The current VTE treatment recommendation is based on evidence from previous studies, but it should be applied with careful consideration of the racial, genetic, and social characteristics in the Korean population.
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Affiliation(s)
- Junshik Hong
- Division of Hematology-Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Department of Hematology-Oncology, Korea
| | - Seo-Yeon Ahn
- Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Yoo Jin Lee
- Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Ji Hyun Lee
- Division of Hematology and Oncology, Department of Internal Medicine, Dong-A University College of Medicine, Dong-A University Hospital, Busan, Korea
| | - Jung Woo Han
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Jeonju, Korea
| | - Kyoung Ha Kim
- Department of Oncology and Hematology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Department of Internal Medicine, Jeonju, Korea
| | - Ho-Young Yhim
- Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
| | | | - Hee-Jin Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jaewoo Song
- Department of Laboratory Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Sung-Hyun Kim
- Division of Hematology and Oncology, Department of Internal Medicine, Dong-A University College of Medicine, Dong-A University Hospital, Busan, Korea
| | - Soo-Mee Bang
- Division of Hematology-Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Department of Internal Medicine, Seoul, Korea
| | - Yeung-Chul Mun
- Ewha Womans University College of Medicine, Seoul, Korea
| | - Sung Hwa Bae
- Daegu Catholic University School of Medicine, Daegu Catholic University Hospital, Daegu, Department of Laboratory Medicine, Korea
| | - Hyun Kyung Kim
- Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seongsoo Jang
- University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Rojin Park
- Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Hyoung Soo Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Inho Kim
- Division of Hematology-Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Department of Hematology-Oncology, Korea
| | - Doyeun Oh
- Division of Hematology-Oncology, Department of Internal Medicine, CHA University School of Medicine, Seongnam, Korea
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