Recurrence in isolated distal DVT after anticoagulation: a systematic review and meta-analysis of axial and muscular venous thrombosis

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.

Incidence of bleeding and recurrence in isolated distal deep vein thrombosis: findings from the Venous Thrombosis Registry in Østfold Hospital

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.

Development of Risk Prediction Model for Muscular Calf Vein Thrombosis with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Purpose

This study aims to establish a risk prediction model for muscular calf vein thrombosis (MCVT) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Methods

The research sample consisted of 248 patients with AECOPD and all of them underwent vascular ultrasounds of both lower limbs in this retrospective study. Univariate analysis and multivariate logistic regression analysis were conducted on factors with significant group differences to screen for the independent risk factors of MCVT. A nomogram to predict the risk of MCVT was constructed and validated with bootstrap resampling.

Results

According to the exclusion criteria, 240 patients were included for analysis, divided into the MCVT group (n = 81) and the non-MCVT group (n = 159). Multivariate logistic regression analyses showed that hypertension, elevated MPV, reduced albumin (ALB), elevated D-dimer and bed rest ≥3 days were independent risk factors for MCVT in AECOPD. A nomogram model for predicting AECOPD with MCVT was established based on them. The area under the curve (AUC) of receiver operating characteristic (ROC) curve for the prediction model and the simplified Wells score was 0.784 (95% CI: 0.722–0.847) and 0.659 (95% CI: 0.583–0.735), respectively. The cut-off value and Youden index of prediction model were 0.248 and 0.454, respectively. At the same time, the sensitivity, specificity, positive predictive value, and negative predictive value of the prediction model were 85.9%, 59.5%, 84.6%, and 77.4%, respectively. The sensitivity and specificity of the simplified Wells score were 67.9% and 56.3%, respectively. Validation by the use of bootstrap resampling revealed optimal discrimination and calibration, and the decision analysis curve (DAC) suggested that this prediction model involved high clinical practicability.

Conclusion

We developed a nomogram that can predict the risk of MCVT for AECOPD patients. This model has the potential to assist clinicians in making treatment recommendations and formulating corresponding prevention measures.

The anatomic distribution and pulmonary embolism complications of hospital-acquired lower extremity deep venous thrombosis

OBJECTIVE

The anatomic distribution of lower extremity deep venous thrombosis (LEDVT) plays an important role in its prevention and treatment. This study aimed to evaluate the anatomic distribution of hospital-acquired LEDVT (HA-LEDVT) and its probable role in the occurrence of pulmonary embolism (PE).

METHODS

We retrospectively analyzed the demographic data, ultrasound results, and PE-related findings of inpatients with HA-LEDVT in 28 clinical departments at Peking University People's Hospital between January 1, 2007, and December 31, 2018.

RESULTS

This study included 1431 HA-LEDVT events: 35.8%, 31%, and 33.3% were left, right, and bilateral LEDVT. Isolated distal, proximal, and blended DVT were detected in 83.4%, 7.3%, and 9.3% of the patients, respectively. The distribution of HA-LEDVT in the left and right lower extremities were not significantly different except in patients aged ≥40 years (left: 2.07 vs right: 1.88 per 1000 extremities, P = .04). For anatomic types of HA-LEDVT, isolated distal HA-LEDVT was 5.02 times more prevalent than proximal HA-LEDVT (1.24 vs 0.26 per 1000 extremities, P ＜ .01). The involvement rates of specific deep veins by HA-LEDVT were highest in the muscular calf vein (87.5%) followed by the popliteal vein (10.1%), superficial femoral vein (9.3%), and common femoral vein (9.2%). HA-LEDVT involving multiple vein segments simultaneously occurred in 338 extremities. HA-LEDVT involving the muscular calf vein and at least one of three connected axial veins of the muscular calf vein occurred most frequently. Eighty-eight patients with HA-LEDVT (6.15%) had PE. The frequency of PE among patients with proximal and distal DVT (7.89% vs 6.23% P = .275) was not significantly different. The incidence of PE was highest in patients with bilateral proximal DVT (15.4%) and lowest in patients with a single right distal DVT (4.5%). PE occurred in 6% of muscular calf vein HA-LEDVT. In isolated muscular calf vein DVT cases, PE were more likely to occur in cases with a ＞6.05-mm-diameter thrombus than in those with a ＜6.05-mm-diameter thrombus (10.3% vs 4.2%, P ＜ .0001).

CONCLUSIONS

HA-LEDVT is characterized by a significantly high percentage of DVT in the muscular calf vein. Muscular calf vein thrombosis may be the primary origin of lower extremity deep vein thrombosis. The diameter of the thrombus in the muscular calf vein may be associated with the occurrence of PE. More prospective studies are needed to more fully determine the natural history of HA-LEDVT and develop prevention and treatment guidelines for HA-LEDVT.

Calf deep vein thrombosis: frequency, therapeutic management, early outcomes and all-causes mortality in a cohort of hospitalized patients

BACKGROUND

Isolated distal deep vein thromboses (IDDVT) are frequent; however, their optimal management is still controversial.

METHODS

We performed a retrospective study on inpatients undergoing ultrasound for suspected deep vein thrombosis (DVT) or with a particular risk profile, during 2016. This study aimed to assess the frequency of proximal deep vein thromboses (PDVT) and IDDVT; to evaluate therapeutic management and identify variables associated with early outcomes and mortality among IDDVT patients; to compare all-causes mortality between subjects with PDVT and IDDVT.

RESULTS

Among 21594 patients hospitalized in the study period 251 IDDVT and 149 PDVT were diagnosed; the frequency was 1.2% and 0.7% respectively. 19% of IDDVT patients died compared to 25.5% of PDVT subjects (OR=0.72; 95% CI=0.44-1.17; P=0.19). In IDDVT patients, age ≥80, cancer and intracranial bleeding increased the risk of death (OR=2; 95% CI=1.07-3.75, P=0.001; OR=8.47; 95% CI=3.28-21.88, P=0.0000003; OR=2.33; 95% CI=1.18-4.58, P=0.0003). A significant association between intracranial hemorrhage and both proximal extension by using the Fisher's exact test (P=0.031; OR=16.11; 95% CI=0.80-321.2), and composite of propagation to popliteal or to other calf veins (OR=8.28, 95% CI=2.07-33 P=0.001) was observed. Standard anticoagulation significantly reduced the composite of propagation to popliteal or to other calf veins (OR=0.07; 95% CI=0.009-0.61, P=0.007), and all-causes mortality (OR=0.37; 95% CI=0.17-0.8; P=0.02), without a significant increase of bleeding.

CONCLUSIONS

Among inpatients, IDDVT exceeded 60% of DVT. Mortality was not significantly different between IDDVT and PDVT subjects. Intracranial bleeding significantly increased the risk of propagation and death. Although standard anticoagulation decreased both these complications, further targeted studies are needed.