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Kang SY, Jo IJ, Heo S, Chang H, Lee G, Park JE, Kim T, Lee SU, Kim MJ, Yoon H. Emergency medicine residents' learning curve in diagnosing deep vein thrombosis with 3-point venous point-of-care ultrasound. Int J Emerg Med 2024; 17:75. [PMID: 38886639 PMCID: PMC11181670 DOI: 10.1186/s12245-024-00645-x] [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: 01/12/2024] [Accepted: 05/14/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Many cases of deep vein thrombosis (DVT) are diagnosed in the emergency department, and abbreviated lower extremity venous point-of-care ultrasound (POCUS) has already shown an accuracy comparable to that of specialists. This study aimed to identify the learning curve necessary for emergency medicine (EM) residents to achieve expertise-level accuracy in diagnosing DVT through a 3-point lower extremity venous POCUS. METHODS This prospective study was conducted at an emergency department between May 2021 and October 2022. Four EM residents underwent a one-hour POCUS training session and performed DVT assessments in participants with DVT symptoms or confirmed pulmonary embolism. POCUS was performed at three proximal lower extremity sites to evaluate the thrombi presence and vein compressibility, with results validated by specialized radiology ultrasound. Cumulative sum (CUSUM) and the Bush and Mosteller models were used to analyze the learning curve, while generalized estimating equations were used to identify factors affecting diagnostic accuracy. RESULTS 91 POCUS scans were conducted in 49 patients, resulting in 22% DVT confirmed by specialized venous ultrasound. In the CUSUM analysis, all four EM residents attained a 90% success rate at the common femoral vein, whereas only half achieved this rate when all three sites were considered. According to Bush and Mosteller models, 13-18 cases are required to attain 90-95% diagnostic accuracy. After 10-16 cases, the examination time for each resident decreased, and a 20% increase in examiner confidence was linked to a 2.506-fold increase in the DVT diagnosis accuracy. CONCLUSION EM residents generally required 13-18 cases for 90-95% DVT diagnostic accuracy, but proficiency varied among individuals, particularly requiring more cases for regions outside the common femoral vein.
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Affiliation(s)
- Soo Yeon Kang
- Department of Emergency Medicine, Chung-Ang University Gwangmyeong Hospital, Chung- Ang University School of Medicine, Gwangmyeong, Gyeonggi-do, 14353, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Gangwon-do, 24341, Republic of Korea
| | - Ik Joon Jo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Sejin Heo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Hansol Chang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Guntak Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jong Eun Park
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Taerim Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Se Uk Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Min Ji Kim
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, 06351, Republic of Korea
| | - Hee Yoon
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 115 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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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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Galanaud JP, Sevestre MA, Pernod G, Vermorel C, Rolland C, Soudet S, Laroche JP, Bosson JL. Isolated distal deep vein thrombosis: What have we learnt from the OPTIMEV study? JOURNAL DE MEDECINE VASCULAIRE 2023; 48:3-10. [PMID: 37120268 DOI: 10.1016/j.jdmv.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/20/2023] [Indexed: 05/01/2023]
Abstract
The OPTIMEV (OPTimisation de l'Interrogatoire dans l'évaluation du risque throMbo-Embolique Veineux) study has provided some important and innovative information for the management of lower extremity isolated distal deep vein thrombosis (distal DVT). Indeed, if distal deep-vein thrombosis (DVT) therapeutic management is nowadays still debated, before the OPTIMEV study, the clinical relevance of these DVT itself was questioned. Via the publication of 6 articles, between 2009 and 2022, assessing risk factors, therapeutic management, and outcomes of 933 patients with distal DVT we were able to demonstrate that: - When distal deep veins are systematically screened for suspicion of DVT, distal DVT are the most frequent clinical presentation of the venous thromboembolic disease (VTE). This is also true in case of combined oral contraceptive related VTE. - Distal DVT share the same risk factors as proximal DVT and constitute two different clinical expressions of the same disease: the VTE disease. However, the weight of these risk factors differs: distal DVT are more often associated with transient risk factors whereas proximal DVT are more associated with permanent risk factors. - Deep calf vein and muscular DVT share the same risk factors, short and long-term prognoses. - In patients without history of cancer, risk of unknown cancer is similar in patients with a first distal or proximal DVT. - After 3years and once anticoagulation has been stopped, distal DVT recur twice less as proximal DVT and mainly as distal DVT; However, in cancer patients, prognosis of distal and proximal DVT appear similar in terms of death and VTE recurrence.
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Affiliation(s)
- J-P Galanaud
- Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada.
| | - M-A Sevestre
- Department of Vascular Medicine, Amiens University Hospital, Amiens, France
| | - G Pernod
- Department of Vascular Medicine, Grenoble-Alpes University Hospital, Grenoble, France
| | - C Vermorel
- University Grenoble Alpes, CNRS, Department of Public Health, Grenoble-Alpes University Hospital and, TIMC-IMAG, 38000 Grenoble, France
| | - C Rolland
- University Grenoble Alpes, CNRS, Department of Public Health, Grenoble-Alpes University Hospital and, TIMC-IMAG, 38000 Grenoble, France
| | - S Soudet
- Department of Vascular Medicine, Amiens University Hospital, Amiens, France
| | - J-P Laroche
- Vascular Medicine Physician, Private practice office, Avignon, France
| | - J-L Bosson
- University Grenoble Alpes, CNRS, Department of Public Health, Grenoble-Alpes University Hospital and, TIMC-IMAG, 38000 Grenoble, France
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4
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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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Zhou C, Yi Q, Ge H, Wei H, Liu H, Zhang J, Luo Y, Pan P, Zhang JR, Peng L, Aili A, Liu Y, Wang MY, Tang YJ, Wang L, Zhong X, Wang Y, Zhou H. Validation of risk assessment models predicting venous thromboembolism in inpatients with AECOPD: a multicenter cohort study. Thromb Haemost 2021; 122:1177-1185. [PMID: 34758489 DOI: 10.1055/a-1693-0063] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND As inpatients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) are at increased risk for venous thromboembolism (VTE), identifying high-risk patients requiring thromboprophylaxis is critical to reduce the mortality and morbidity associated with VTE. This study aimed to evaluate and compare the validities of the Padua Prediction Score and Caprini risk assessment model (RAM) in predicting the risk of VTE in inpatients with AECOPD. METHODS The inpatients with AECOPD were prospectively enrolled from seven medical centers of China between September 2017 and January 2020. Caprini and Padua scores were calculated on admission, and the incidence of 3-month VTE was investigated. RESULTS Among the 3277 eligible patients with AECOPD, 128 patients (3.9%) developed VTE within 3 months after admission. The distribution of the study population by the Caprini risk level was as follows: high, 53.6%; moderate, 43.0%; and low, 3.5%. The incidence of VTE increased by risk level as high, 6.1%; moderate, 1.5%; and low, 0%. According to the Padua RAM, only 10.9% of the study population was classified as high risk and 89.1% as low risk, with the corresponding incidence of VTE 7.9% and 3.4%, respectively. The Caprini RAM had higher area under curve (AUC) compared with the Padua RAM (0.713 0.021 vs 0.644 ± 0.023, P = 0.029). CONCLUSION The Caprini RAM was superior to the Padua RAM in predicting the risk of VTE in inpatients with AECOPD and might better guide thromboprophylaxis in these patients.
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Affiliation(s)
- Chen Zhou
- West China School of Medicine, Sichuan University West China Hospital, Chengdu, China
| | - Qun Yi
- Department of Respiratory and Critical Care Medicine, Sichuan University West China Hospital, Chengdu, China
| | - Huiqing Ge
- Department of Respiratory and Critical Care Medicine, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, China
| | - Hailong Wei
- Department of Respiratory and Critical Care Medicine, People's Hospital of Leshan, Leshan, China
| | - Huiguo Liu
- Department of Respiratory and Critical Care Medicine, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Jianchu Zhang
- Respiratory and Critical Care Medicine, Wuhan Union Hospital, Wuhan, China
| | - Yuanming Luo
- State Key Laboratory of Respiratory Disease, Guangzhou Medical University, Guangzhou, China
| | - Pinhua Pan
- Department of Respiratory and Critical Care Medicine, Xiangya Hospital Central South University, Changsha, China
| | - Jia-Rui Zhang
- Department of Respiratory and Critical Care Medicine, Sichuan University West China Hospital, Chengdu, China
| | - Lige Peng
- Department of Respiratory and Critical Care Medicine, Sichuan University West China Hospital, Chengdu, China
| | - Adila Aili
- Department of Respiratory and Critical Care Medicine, Sichuan University West China Hospital, Chengdu, China
| | - Yu Liu
- Department of Respiratory and Critical Care Medicine, Sichuan University West China Hospital, Chengdu, China
| | - Mao-Yun Wang
- Department of Respiratory and Critical Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yong-Jiang Tang
- Department of Respiratory and Critical Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lan Wang
- Department of Respiratory and Critical Care Medicine, Sichuan University West China Hospital, Chengdu, China
| | - Xia Zhong
- West China School of Medicine, Sichuan University West China Hospital, Chengdu, China
| | - Yixi Wang
- West China School of Medicine, Sichuan University West China Hospital, Chengdu, China
| | - Haixia Zhou
- Department of Respiratory and Critical Care Medicine, Sichuan University West China Hospital, Chengdu, China
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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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Di Vilio A, Vergara A, Desiderio A, Iodice F, Serio A, Palermi S, Gambardella F, Sperlongano S, Gioia R, Acitorio M, D'Andrea A. Incremental value of compression ultrasound sonography in the emergency department. World J Crit Care Med 2021; 10:194-203. [PMID: 34616656 PMCID: PMC8462022 DOI: 10.5492/wjccm.v10.i5.194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/13/2021] [Accepted: 07/05/2021] [Indexed: 02/06/2023] Open
Abstract
The quick evaluation of venous thromboembolism is a key point of modern medicine since the delayed diagnosis is associated with a worse prognosis. Venous ultrasound (VU) is a sensitive and rapidly performed test in cases of suspected deep venous thrombosis. Various protocols have been proposed for its execution, such as the study of the whole deep venous circulation of the lower limb or the analysis of the femoral-popliteal area. The aim is to detect a vessel thrombus and the most sensitive element is the non-compressibility with the probe. Initially, the thrombus is hypoechogenic and adherent to the vessel; later, it tends to organize and recanalize. Usually, in the early stages, the risk of embolism is higher. The role of studying the iliac axis and calf veins is still uncertain. VU is not useful for assessing response to anticoagulation therapy and it is unclear whether the persistence of thrombotic abnormalities can guide on a possible prolongation of therapy.
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Affiliation(s)
- Alessandro Di Vilio
- Unit of Cardiology and Intensive Coronary Care, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples 80131, Italy
| | - Andrea Vergara
- Unit of Cardiology and Intensive Coronary Care, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples 80131, Italy
| | - Alfonso Desiderio
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore 84014, Italy
| | - Franco Iodice
- Unit of Cardiology and Intensive Coronary Care, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples 80131, Italy
| | - Alessandro Serio
- Human Anatomy and Sport Medicine Division, Department of Public Health, University of Naples “Federico II”, Naples 80131, Italy
| | - Stefano Palermi
- Human Anatomy and Sport Medicine Division, Department of Public Health, University of Naples “Federico II”, Naples 80131, Italy
| | - Francesco Gambardella
- Human Anatomy and Sport Medicine Division, Department of Public Health, University of Naples “Federico II”, Naples 80131, Italy
| | - Simona Sperlongano
- Unit of Cardiology and Intensive Coronary Care, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples 80131, Italy
| | - Renato Gioia
- Department of Medicine, Surgery, and Dentistry, University of Salerno, Salerno 84084, Italy
| | - Maria Acitorio
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore 84014, Italy
| | - Antonello D'Andrea
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore 84014, Italy
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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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Liu X, Tan AHC. Incidence of venous thromboembolism in Asian patients undergoing anterior cruciate ligament reconstruction without the use of mechanical or chemical prophylaxis. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2021. [DOI: 10.1177/2210491721994314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Venous thromboembolism (VTE) is a clinically relevant complication of major orthopedic surgeries. The prevalence of VTE and the indications for VTE thromboprophylaxis in Asian patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction are not clear. This study aims to evaluate the prevalence of clinically significant venous thromboembolic events (VTE) in Asian patients undergoing arthroscopic ACL reconstruction without mechanical or chemical thromboprophylaxis. Methods: All patients who underwent ACL reconstruction by a single surgeon from 2006 to 2018 in a single tertiary institution were reviewed. The inclusion criteria for the study included Asian patients of common ethnic groups in Singapore (Chinese, Malay, Indian) and underwent primary or revision ACL reconstruction, or ACL reconstruction combined with meniscal surgery. The exclusion criteria were patients with incomplete medical records, pre-existing anticoagulant treatment within 1 year prior to the surgery and additional procedures that altered the standard rehabilitation protocol, less than 6 months of follow-up duration. All patients received general anesthesia. The single-bundle ACL technique with autologous hamstring tendon reconstruction was performed. No chemical DVT prophylaxis was given. The patients were screened for clinically for VTE. Symptomatic patients were referred for ultrasonography. Results: Of the 581 patients reviewed, 3 patients had a clinical suspicion of deep vein thrombosis, but subsequent ultrasonography showed no thrombosis. Hence, the prevalence of clinically significant VTE was 0%. Conclusion: Given the low prevalence of clinically significant VTE, there is no need for routine mechanical or chemical thromboprophylaxis or radiologic screening in Asian patients undergoing arthroscopic ACL reconstruction.
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Affiliation(s)
- Xuan Liu
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Lapébie FX, Minville V, Ribes A, Combis B, Thery A, Geeraerts T, Silva S, Bura-Rivière A, Vardon-Bounes F. Systematic Screening for Deep Vein Thrombosis in Critically Ill Inpatients With COVID-19: Impact on the Incidence of Venous Thromboembolism. Front Med (Lausanne) 2021; 7:624808. [PMID: 33521028 PMCID: PMC7840698 DOI: 10.3389/fmed.2020.624808] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/03/2020] [Indexed: 12/20/2022] Open
Abstract
Background: Several studies suggest an increased incidence of thrombosis in COVID-19 patients. However, evidence on how to prevent and even treat it is scarce. The aim of this study was to compare the cumulative incidence of venous thromboembolism (VTE) of two different methods for lower extremity deep vein thrombosis (LE-DVT) diagnosis: systematic vs. clinically guided complete compression venous ultrasonography (CCUS). We conducted a monocentric, prospective, open-label, non-randomized study. All consecutive patients admitted in three intensive care units (ICUs) of University Hospital of Toulouse for COVID-19 pneumonia were included: one performed systematic screening for LE-DVT, the others did not. The primary outcome was the 21-day cumulative incidence of VTE. The secondary end points were the 21-day cumulative incidences of major bleeding and death. Results: Among the 78 patients included, 27 (34.6%) underwent systematic screening for DVT 7 ± 2 days after ICU admission. Thirty-two patients (41.0%) were diagnosed with VTE, with a 21-day cumulative incidence of 42.3% (95% CI, 31.4–55.2), without difference between screened and non-screened patients (hazard ratio 1.45, 95% CI, 0.72–2.93). In the screened group, the frequency of isolated DVT was higher (25.9 vs. 5.9%, p-value = 0.027), but the frequency of pulmonary embolism was not reduced (25.9 vs. 29.4%, p-value = 0.745). The 21-day cumulative incidences of major bleeding and death were 9.6% (95% CI, 4.7–19.2) and 10.3% (95% CI, 5.0–20.8), respectively, without difference between the two groups. Conclusions: A systematic screening for DVT in patients hospitalized in ICU was not associated with a higher diagnosis of VTE or a reduced diagnosis of PE.
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Affiliation(s)
- François-Xavier Lapébie
- Department of Vascular Medicine, Toulouse University Hospital, Toulouse, France.,UMR 1027 INSERM, Toulouse III - Paul Sabatier University, Toulouse, France
| | - Vincent Minville
- Department of Anesthesiology and Critical Care, Toulouse University Hospital, Toulouse, France.,UMR 1048 INSERM, I2MC, Toulouse III - Paul Sabatier University, Toulouse, France
| | - Agnès Ribes
- UMR 1048 INSERM, I2MC, Toulouse III - Paul Sabatier University, Toulouse, France.,Laboratory of Hematology, Toulouse University Hospital, Toulouse, France
| | - Bertrand Combis
- Department of Anesthesiology and Critical Care, Toulouse University Hospital, Toulouse, France
| | - Arthur Thery
- Department of Vascular Medicine, Toulouse University Hospital, Toulouse, France
| | - Thomas Geeraerts
- Department of Anesthesiology and Critical Care, Toulouse University Hospital, Toulouse, France.,ToNIC (Toulouse Neuro-Imaging Center) INSERM, Toulouse III - Paul Sabatier University, Toulouse, France
| | - Stein Silva
- Department of Anesthesiology and Critical Care, Toulouse University Hospital, Toulouse, France.,ToNIC (Toulouse Neuro-Imaging Center) INSERM, Toulouse III - Paul Sabatier University, Toulouse, France
| | - Alessandra Bura-Rivière
- Department of Vascular Medicine, Toulouse University Hospital, Toulouse, France.,UMR 1031 INSERM, StromaLab, Toulouse III - Paul Sabatier University, Toulouse, France
| | - Fanny Vardon-Bounes
- Department of Anesthesiology and Critical Care, Toulouse University Hospital, Toulouse, France.,UMR 1048 INSERM, I2MC, Toulouse III - Paul Sabatier University, Toulouse, France
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Ye Y, He X, Huang C, Shi C, Deng W, Luo W, Liang J, He Z, Mao H, Liang Q, Chen D, Chen H, Xie G. Comparison Between the Diagnostic Performance of 1.5 T and 3.0 T field Strengths for Detecting Deep Vein Thrombosis Using Magnetic Resonance Black-Blood Thrombus Imaging. Clin Appl Thromb Hemost 2021; 26:1076029620921235. [PMID: 32320276 PMCID: PMC7288798 DOI: 10.1177/1076029620921235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Magnetic resonance (MR) black-blood thrombus imaging (BTI) is an accurate diagnostic technique for detecting deep vein thrombosis (DVT) but to date there have been no studies comparing the diagnostic performance and consistency of this technique at different field strengths. In this study, we evaluated and compared the diagnostic performance of BTI for detecting DVT at 1.5 T and 3.0 T field strengths. METHODS A total of 40 patients with DVT were enrolled in this study from November 2015 up to October 2018. All patients underwent BTI, a contrast-free T1-weighted MR imaging technique for detecting DVT, and contrast-enhanced MR venography (CE-MRV) at 1.5 T or 3.0 T field strengths. The MR data analyses used 1160 segments from the venous lumen of the 40 patients. The signal-to-noise ratio and contrast-to-noise ratio between thrombus and muscle/lumen were calculated to compare BTI at 1.5 T or 3.0 T to determine the image performance for thrombus detection at 1.5 T or 3.0 T. Two physicians blinded to the study evaluated all BTI images and calculated the overall sensitivity (SE), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV), accuracy, and diagnostic consistency at 1.5 T and 3.0 T. These images and values were compared to control CE-MRV images that had been obtained by 2 senior physicians and used as reference standards. In addition, the reliability and consistency of diagnoses between observers were also evaluated. RESULTS Two study-blind physicians reviewed all BTI images to diagnose thrombus and to determine SE, SP, PPV, NPV, and accuracy. There were no statistical differences in SE, SP, PPV, NPV, or accuracy between the 1.5 T and 3.0 T groups. CONCLUSIONS Black-blood thrombus imaging has high SE, SP, and accuracy for DVT diagnosis both at 1.5 T and 3.0 T field strengths. This noninvasive diagnostic technique, which does not require the use of contrast agents, can be widely used in the clinical screening of DVT and follow-up after treatment.
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Affiliation(s)
- Yufeng Ye
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, China
- Medical Imaging Institute of Panyu, Guangzhou, China
- Department of Radiology, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Xueping He
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, China
- Medical Imaging Institute of Panyu, Guangzhou, China
| | - Chen Huang
- Medical Imaging Institute of Panyu, Guangzhou, China
- Department of Minimally Invasive Interventional Radiology, Guangzhou Panyu Central Hospital, Guangzhou, China
| | - Caiyun Shi
- Paul C. Lauterbur Research Centre for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Science, Shenzhen, China
- Shenzhen College of Advanced Technology, University of Chinese Academy of Sciences, Shenzhen, China
| | - Wei Deng
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, China
- Medical Imaging Institute of Panyu, Guangzhou, China
| | - Wenfeng Luo
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, China
- Medical Imaging Institute of Panyu, Guangzhou, China
| | - Jianke Liang
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, China
- Medical Imaging Institute of Panyu, Guangzhou, China
| | - Zhuonan He
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, China
- Medical Imaging Institute of Panyu, Guangzhou, China
| | - Huan Mao
- Department of Biomedical Engineering, School of Basic Medical Sciences, The Sixth Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Qiwei Liang
- Medical Imaging Institute of Panyu, Guangzhou, China
- Department of Minimally Invasive Interventional Radiology, Guangzhou Panyu Central Hospital, Guangzhou, China
| | - Dongya Chen
- Physical Examination Section, Guangzhou Panyu Central Hospital, Guangzhou, China
| | - Hanwei Chen
- Medical Imaging Institute of Panyu, Guangzhou, China
- Department of Radiology, The First Affiliated Hospital, Jinan University, Guangzhou, China
- Department of Minimally Invasive Interventional Radiology, Guangzhou Panyu Central Hospital, Guangzhou, China
- Hanwei Chen, Guangzhou Panyu Central Hospital, 8 East Fuyu Road Qiaonan Street, Panyu District, Guangzhou 511400, China.
| | - Guoxi Xie
- Department of Biomedical Engineering, School of Basic Medical Sciences, The Sixth Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
- Guoxi Xie, Guangzhou Medical University, Xinzao, Panyu District, Guangzhou, 511436, China.
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14
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Elmi G, Rinaldi ER, Domanico A, Aluigi L. Calf deep vein thrombosis – clinical relevance, diagnostic approaches and therapeutic options. VASA 2020; 49:359-366. [DOI: 10.1024/0301-1526/a000869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Summary. Isolated distal deep vein thromboses (IDDVT) represent up to 50 % of legs deep vein thromboses (DVT). However, since their natural history is to date unknown, the need to diagnose and treat them is a matter of debate. The diagnostic strategy based on the assessment of pre-test probability and D-dimer demonstrated a scarse efficiency for IDDVT. The choice between a proximal and a complete ultrasonographic approach should be guided by the clinical context, the local expertise and the patient characteristics. Randomized and observational studies have analyzed the need of therapy and compared different regimens of anticoagulation, with conflicting results. Systematic reviews and meta-analyses tend to support the usefulness of an anticoagulant treatment, even if the optimal dose and duration are not still defined. A careful stratification of the patient’s profile, taking into account risk factors for proximal extension, recurrence and bleeding should address the therapeutic approach, which must always be discussed with an adequately informed patient. Further studies aimed to clarify the natural history of IDDVT, and to assess safety and efficacy of lower intensity and shorter duration protocols are urgently needed.
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Affiliation(s)
- Giovanna Elmi
- Medical Department, Ultrasound Program, Maggiore Hospital, Azienda USL of Bologna, Italy
| | - Elisa Rebecca Rinaldi
- Medical Department, Ultrasound Program, Maggiore Hospital, Azienda USL of Bologna, Italy
| | - Andrea Domanico
- Medical Department, Ultrasound Program, Maggiore Hospital, Azienda USL of Bologna, Italy
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15
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Moumneh T, Riou J, Douillet D, Henni S, Mottier D, Tritschler T, Le Gal G, Roy PM. Validation of risk assessment models predicting venous thromboembolism in acutely ill medical inpatients: A cohort study. J Thromb Haemost 2020; 18:1398-1407. [PMID: 32168402 DOI: 10.1111/jth.14796] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Because hospital-acquired venous thromboembolism (VTE) represents a frequent cause of preventable deaths in medical inpatients, identifying at-risk patients requiring thromboprophylaxis is critical. We aimed to externally assess the Caprini, IMPROVE, and Padua VTE risk scores and to compare their performance to advanced age as a stand-alone predictor. METHODS We performed a retrospective analysis of patients prospectively enrolled in the PREVENU trial. Patients aged 40 years and older, hospitalized for at least 2 days on a medical ward were consecutively enrolled and followed for 3 months. Critical ill patients were not recruited. Patients diagnosed with VTE within 48 hours from admission, or receiving full dose anticoagulant treatment or who underwent surgery were excluded. All suspected VTE and deaths occurring during the 3-month follow-up were adjudicated by an independent committee. The three scores were retrospectively assessed. Body mass index, needed for the Padua and Caprini scores, was missing in 44% of patients. RESULTS Among 14 910 eligible patients, 14 660 were evaluable, of which 1.8% experienced symptomatic VTE or sudden unexplained death during the 3-month follow-up. The area under the receiver operating characteristic curves (AUC) were 0.60 (95% confidence interval [CI] 0.57-0.63), 0.63 (95% CI 0.60-0.66) and 0.64 (95% CI 0.61-0.67) for Caprini, IMPROVE, and Padua scores, respectively. None of these scores performed significantly better than advanced age as a single predictor (AUC 0.61, 95% CI 0.58-0.64). CONCLUSION In our study, Caprini, IMPROVE, and Padua VTE risk scores have poor discriminative ability to identify not critically ill medical inpatients at risk of VTE, and do not perform better than a risk evaluation based on patient's age alone.
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Affiliation(s)
- Thomas Moumneh
- Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC, UMR CNRS 6015, UMR INSERM 1083, InnoVTE F-CRIN, Université d'Angers, Angers, France
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jérémie Riou
- Unité de Formation-Recherche Santé, MINT UMR INSERM 1066, CNRS 6021, Université d'Angers, Angers, France
| | - Delphine Douillet
- Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC, UMR CNRS 6015, UMR INSERM 1083, InnoVTE F-CRIN, Université d'Angers, Angers, France
| | - Samir Henni
- Service des explorations fonctionnelles vasculaires, CHU d'Angers, Institut MITOVASC, UMR CNRS 6015, UMR INSERM 1083, Université d'Angers, Angers, France
| | - Dominique Mottier
- Département de Médecine Interne et Pneumologie, CHU de la Cavale Blanche, EA3878 (GETBO), CIC INSERM 1412, InnoVTE F-CRIN, Université de Bretagne Occidentale, Brest, France
| | - 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
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Pierre-Marie Roy
- Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC, UMR CNRS 6015, UMR INSERM 1083, InnoVTE F-CRIN, Université d'Angers, Angers, France
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16
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Poudel SK, Park DY, Jia X, Wilks M, Pinkava V, O'Brien M, Tripp B, Song JM, McCrae KR, Khorana AA, Angelini DE. Clinical outcomes of isolated distal deep vein thrombosis versus proximal venous thromboembolism in cancer patients: The Cleveland Clinic experience. J Thromb Haemost 2020; 18:651-659. [PMID: 31808607 DOI: 10.1111/jth.14700] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 11/25/2019] [Accepted: 11/27/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Previous studies suggest isolated distal deep vein thrombosis (IDDVT) has a self-limited clinical course. However, these studies excluded cancer patients, who remain a high-risk population. In addition, studies to evaluate the long-term clinical outcomes of IDDVT in cancer patients have been limited. Here, we report outcomes from our experience in treating cancer-associated IDDVT versus proximal venous thromboembolism (VTE). METHODS We prospectively evaluated a cohort of patients referred to our cancer-associated thrombosis clinic from August 2014 through May 2018. We compared clinical characteristics, anticoagulation prescription, VTE recurrence, overall survival, major bleeding, and subsequent hospital admission between cancer patients with IDDVT and proximal VTE. A propensity score matching method was used to reduce bias from confounding variables. RESULTS Of 1100 patients referred to the clinic, 124 IDDVT and 178 proximal VTE events were analyzed. After propensity score matching, 96 patients were included in each cohort. There was no difference in the rate of recurrent VTE between cancer patients with proximal VTE vs IDDVT, with or without matching (matched: hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.31-1.92; P = .58). There was no difference in overall survival between cancer patients with proximal VTE vs. IDDVT with or without matching (matched: HR, 1.18; 95% CI, 0.77-1.82; P = .45). Furthermore, subsequent hospital admissions and major bleeding events were similar between patients with proximal VTE events versus IDDVT. CONCLUSIONS Cancer patients with IDDVT have similar outcomes as their proximal counterparts, including rate of recurrence and overall survival. These findings suggest treatment of cancer-associated IDDVT should mirror treatment of proximal events.
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Affiliation(s)
- Shyam K Poudel
- Department of Internal Medicine, Western Reserve Health Education, Youngstown, Ohio
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Deborah Y Park
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Xuefei Jia
- Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mailey Wilks
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vicki Pinkava
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Meghan O'Brien
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Barbara Tripp
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jung-Min Song
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Keith R McCrae
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alok A Khorana
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dana E Angelini
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
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17
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McHale S, Williams M, O'Mahony C, Hockings M. Should we use dabigatran or aspirin thromboprophylaxis in total hip and knee arthroplasty? A natural experiment. J Orthop 2019; 16:563-568. [PMID: 31660024 DOI: 10.1016/j.jor.2019.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/05/2019] [Accepted: 05/26/2019] [Indexed: 01/21/2023] Open
Abstract
Background Despite long clinical experience some authorities recommend against the use of aspirin for perioperative VTE prophylaxis and favour alternatives such as dabigatran. A change from Dabigatran to an Aspirin based protocol in a British district general hospital created the conditions of a natural experiment. Methods We conducted a single centre, retrospective study of 6-months using a dabigatran based protocol (THA n = 191, TKA n = 155) and 6-months using and aspirin based protocol (THA n = 165, TKA n = 136). Outcomes addressed include: VTE used, VTE events within 90-days, 30-day return to theatre (RTT) rates, and 90-day mortality. Results Pre-intervention, the dabigatran prescription rate was 73% (n = 139) and 78% (n = 123) with aspirin prescription post-intervention in 67% (n = 110) and 70% (n = 90) for THA and TKA respectively. We found a similar VTE rate when comparing dabigatran and aspirin groups for THA (2.2% vs. 0%, p = 0.17) and TKA (0.64% vs. 0%, p = 0.32). Similarly, no difference in the RTT rate was seen for THA (0.7% vs.2.7%, p = 0.23) or TKA (1.6% vs. 3.2%, p = 0.38). Conclusion No significant differences in safety were found comparing aspirin to dabigatran for VTE prophylaxis for lower limb arthroplasty which, has not been previously reported and represents significant cost saving implications.
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Affiliation(s)
- Stephen McHale
- Department of Trauma and Orthopaedics, Torbay and South Devon NHS Foundation Trust, Torbay Hospital, Torquay, TQ2 7AA, UK
| | - Mark Williams
- Department of Trauma and Orthopaedics, Torbay and South Devon NHS Foundation Trust, Torbay Hospital, Torquay, TQ2 7AA, UK
| | - Canice O'Mahony
- Department of Trauma and Orthopaedics, Torbay and South Devon NHS Foundation Trust, Torbay Hospital, Torquay, TQ2 7AA, UK
| | - Michael Hockings
- Department of Trauma and Orthopaedics, Torbay and South Devon NHS Foundation Trust, Torbay Hospital, Torquay, TQ2 7AA, UK
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18
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Systemic and Local Factors’ Influence on the Topological Differences in Deep Vein Thrombosis. Medicina (B Aires) 2019; 55:medicina55100691. [PMID: 31623212 PMCID: PMC6843345 DOI: 10.3390/medicina55100691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/09/2019] [Accepted: 10/15/2019] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives: Deep vein thrombosis (DVT) is a common cause of intra-hospital morbidity and mortality, and its most severe complication is pulmonary thromboembolism. The risk factors that influence the apparition of DVT are generally derived from Virchow’s triad. Since the most severe complications of DVT occur in proximal rather than distal deep vein thrombosis, the aim of this study was to identify the factors influencing the apparition of proximal DVT. Materials and Methods: This was a transversal, cohort study. The study included 167 consecutive patients with lower limb DVT over a two-year period. The following data were recorded or determined: general data, conditions that are known to influence DVT, medical history and coagulation or thrombophilia-related genetic variations. Results: In the univariate analysis, male gender, neoplasia, previous DVT and mutated factor V Leiden were all associated with proximal DVT, while bed rest was associated with distal DVT. In the multivariate analysis, male gender, previous DVT and factor V Leiden mutation were independently correlated with proximal DVT, while bed rest was independently associated with distal deep vein thrombosis. Conclusion: Our observations point out that the factors indicating a systemic involvement of coagulation were correlated with proximal DVT, while local factors were associated with distal DVT.
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Gianesini S, Obi A, Onida S, Baccellieri D, Bissacco D, Borsuk D, Campisi C, Campisi CC, Cavezzi A, Chi YW, Chunga J, Corda D, Crippa A, Davies A, De Maeseneer M, Diaz J, Ferreira J, Gasparis A, Intriago E, Jawien A, Jindal R, Kabnick L, Latorre A, Lee BB, Liew NC, Lurie F, Meissner M, Menegatti E, Molteni M, Morrison N, Mosti G, Narayanan S, Pannier F, Parsi K, Partsch H, Rabe E, Raffetto J, Raymond-Martimbeau P, Rockson S, Rosukhovski D, Santiago FR, Schul A, Schul M, Shaydakov E, Sibilla MG, Tessari L, Tomaselli F, Urbanek T, van Rijn MJ, Wakefield T, Wittens C, Zamboni P, Bottini O. Global guidelines trends and controversies in lower limb venous and lymphatic disease: Narrative literature revision and experts' opinions following the vWINter international meeting in Phlebology, Lymphology & Aesthetics, 23-25 January 2019. Phlebology 2019; 34:4-66. [PMID: 31495256 DOI: 10.1177/0268355519870690] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Guidelines are fundamental in addressing everyday clinical indications and in reporting the current evidence-based data of related scientific investigations. At the same time, a spatial and temporal issue can limit their value. Indeed, variability in the recommendations can be found both among the same nation different scientific societies and among different nations/continents. On the other side, Garcia already published in 2014 data showing how, after three years in average, one out of five recommendations gets outdated (Martinez Garcia LM, Sanabria AJ, Garcia Alvarez E, et al. The validity of recommendations from clinical guidelines: a survival analysis. CMAJ 2014;186(16):1211–1219). The present document reports a narrative literature revision on the major international recommendations in lower limb venous and lymphatic disease management, focusing on the different countries’ guidelines, trends and controversies from all the continents, while identifying new evidence-based data potentially influencing future guidelines. World renowned experts’ opinions are also provided. The document has been written following the recorded round tables scientific discussions held at the vWINter international meeting (22–26 January 2019; Cortina d’Ampezzo, Italy) and the pre- and post-meeting literature search performed by the leading experts.
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Affiliation(s)
| | - Andrea Obi
- 2 University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Denis Borsuk
- 6 Clinic of Phlebology and Laser Surgery, 'Vasculab' Ltd, Chelyabinsk, Russia
| | | | | | - Attilio Cavezzi
- 9 Eurocenter Venalinfa, San Benedetto del Tronto (AP), Italy
| | - Yung-Wei Chi
- 10 University of California, Davis Vascular Center, Sacramento, CA, USA
| | | | | | | | | | | | - Josè Diaz
- 15 Vanderbilt University Medical Center, Nashville, TN, USA
| | - Julio Ferreira
- 16 Instituto Brasilerio de Flebologia, Sao Paulo, Brazil
| | | | | | - Arkadiusz Jawien
- 19 Collegium Medicum, University of Nicolaus Copernicus, Bydgoszcz, Poland
| | | | | | | | | | - N C Liew
- 24 Putra University, Serdang, Malaysia
| | - Fedor Lurie
- 25 Jobst Vascular Institute, Toledo, OH, USA
| | | | | | | | | | | | | | | | - Kurosh Parsi
- 32 St. Vincent's Hospital, University of NSW, Sydney, Australia
| | | | | | | | | | - Stanley Rockson
- 37 Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Cees Wittens
- 44 Maastricht University Medical Center, Maastricht, Netherlands.,45 Uniklinik Aachen, Aachen, Germany
| | | | - Oscar Bottini
- 46 Universidad de Buenos Aires, Buenos Aires, Argentina
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Righini M, Robert-Ebadi H, Glauser F, Blondon M, Ouvry P, Diamand JM, Tissot A, Frappe P, Quere I, Kahn SR, Galanaud JP, Le Gal G. Effect of anticoagulant treatment on pain in distal deep vein thrombosis: an ancillary analysis from the cactus trial. J Thromb Haemost 2019; 17:507-510. [PMID: 30656824 DOI: 10.1111/jth.14387] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Indexed: 02/04/2023]
Abstract
Essentials Management of patients with calf deep vein thrombosis remains controversial. We conducted a post-hoc analysis of a placebo controlled LMWH randomized clinical trial. Pain was assessed using visual analogue scale at inclusion, one and six weeks. There was no difference in pain control between the two arms. SUMMARY: Background The optimal management of distal deep vein thrombosis (DVT) is highly debated. The only available placebo-controlled trial suggested the absence of clear benefit of anticoagulation. Many physicians feel that, beyond preventing thromboembolic complications, anticoagulation with low-molecular-weight heparin (LMWH) has the potential to improve pain control. Objectives To analyze whether LMWHs decrease pain in patients with distal deep vein thrombosis. Patients and methods Two-hundred and fifty-two patients included in a multicenter, placebo-controlled, randomized clinical trial of LMWH in patients with acute distal DVT and who were asked to rate their pain at inclusion and at each medical visit, using a visual analogue pain scale (VAS). Results One hundred and thirty patients were randomized in the therapeutic nadroparin arm and 122 patients were randomized in the placebo arm. Mean VAS values were 4.6 (standard deviation [SD] 2.5) at inclusion, 2.1 (SD 2.0) at 1 week and 0.4 (SD 1.2) at 6 weeks. We calculated the individual variation in VAS between inclusion and 1 week in patients in whom VAS was available at the two study time-points. There was no difference in the mean VAS reduction between patients treated with therapeutic nadroparin (n = 106) and with placebo (n = 109): -2.6 (SD 2.4) vs. -2.3 (SD 2.0) after 1 week and -4.4 (SD 2.8) vs. -4.0 (SD 2.4) after 6 weeks, respectively. The use of compression stockings was associated with a reduction in pain. Conclusion These data suggests that LMWH use does not improve pain control as compared with placebo in patients with acute distal DVT.
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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
| | - Frédéric Glauser
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Marc Blondon
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | | | | | | | - Paul Frappe
- Département de Médecine Générale and EA 3065, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Isabelle Quere
- Clinical Investigation Centre and Department of Internal and Vascular Medicine, Montpellier University Hospital, Montpellier, France
| | - Susan R Kahn
- Department of Medicine and Lady Davis Institute, Jewish General Hospital, Montreal, Canada
| | - Jean-Philippe Galanaud
- Clinical Investigation Centre and Department of Internal and Vascular Medicine, Montpellier University Hospital, Montpellier, France
- Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Canada
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22
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Obi A, Wakefield T. The Management of Venous Thromboembolic Disease: New Trends in Anticoagulant Therapy. Adv Surg 2018; 52:43-56. [PMID: 30098620 DOI: 10.1016/j.yasu.2018.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Andrea Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, 5372 Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA.
| | - Thomas Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, 5463 Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA
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Chen H, He X, Xie G, Liang J, Ye Y, Deng W, He Z, Liu D, Li D, Liu X, Fan Z. Cardiovascular magnetic resonance black-blood thrombus imaging for the diagnosis of acute deep vein thrombosis at 1.5 Tesla. J Cardiovasc Magn Reson 2018; 20:42. [PMID: 29936910 PMCID: PMC6016134 DOI: 10.1186/s12968-018-0459-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 05/16/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The aim was to investigate the feasibility of a cardiovascular magnetic resonance (CMR) black-blood thrombus imaging (BBTI) technique, based on delay alternating with nutation for tailored excitation black-blood preparation and a variable flip angle turbo-spin-echo readout, for the diagnosis of acute deep vein thrombosis (DVT) at 1.5 T. METHODS BBTI was conducted in 15 healthy subjects and 30 acute DVT patients. Contrast-enhanced CMR venography (CE-CMRV) was conducted for comparison and only performed in the patients. Apparent contrast-to-noise ratios between the thrombus and the muscle/lumen were calculated to determine whether BBTI could provide an adequate thrombus signal for diagnosis. Two blinded readers assessed the randomized BBTI images from all participants and made independent decisions on the presence or absence of thrombus at the segment level. Images obtained by CE-CMRV were also randomized and assessed by the two readers. Using the consensus CE-CMRV as a reference, the sensitivity, specificity, positive and negative predictive values, and accuracy of BBTI, as well as its diagnostic agreement with CE-CMRV, were calculated. Additionally, diagnostic confidence and interobserver diagnostic agreement were evaluated. RESULTS The thrombi in the acute phase exhibited iso- or hyperintense signals on the BBTI images. All the healthy subjects were correctly identified from the participants based on the segment level. The diagnostic confidence of BBTI was comparable to that of CE-CMRV (3.69 ± 0.52 vs. 3.70 ± 0.47). High overall sensitivity (95.2%), SP (98.6%), positive predictive value (96.0%), negative predictive value (98.3%), and accuracy (97.7%), as well as excellent diagnostic and interobserver agreements, were achieved using BBTI. CONCLUSION BBTI is a reliable, contrast-free technique for the diagnosis of acute DVT at 1.5 T.
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Affiliation(s)
- Hanwei Chen
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, 511400 Guangdong China
- Medical Imaging Institute of Panyu, Guangzhou, 511400 Guangdong China
| | - Xueping He
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, 511400 Guangdong China
- Medical Imaging Institute of Panyu, Guangzhou, 511400 Guangdong China
| | - Guoxi Xie
- The Sixth Affiliated Hospital, Guangzhou Medical University, Xinzao, Panyu District, Qingyuan, 511518 Guangdong China
- Department of Biomedical Engineering of Basic Medical School, Guangzhou Medical University, Guangzhou, 511436 Guangdong China
| | - Jianke Liang
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, 511400 Guangdong China
| | - Yufeng Ye
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, 511400 Guangdong China
| | - Wei Deng
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, 511400 Guangdong China
| | - Zhuonan He
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, 511400 Guangdong China
| | - Dexiang Liu
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, 511400 Guangdong China
| | - Debiao Li
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048 USA
| | - Xin Liu
- Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055 Guangdong China
| | - Zhaoyang Fan
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048 USA
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Effects of Natural Hirudin and Low Molecular Weight Heparin in Preventing Deep Venous Thrombosis in Aged Patients with Intertrochanteric Fracture. Sci Rep 2018; 8:8847. [PMID: 29891906 PMCID: PMC5995864 DOI: 10.1038/s41598-018-27243-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/29/2018] [Indexed: 02/05/2023] Open
Abstract
Our objective was to evaluate the efficacy and safety of natural hirudin and low molecular weight heparin (LMWH) in the prevention of perioperative deep venous thrombosis (DVT) in elderly patients with intertrochanteric fracture. From June 2014 to June 2017, 96 patients with intertrochanteric fractures were treated with proximal femoral nail antirotation (PFNA) were randomly divided into two groups. For DVT prevention, 45 patients were treated with oral natural hirudin and subcutaneous LMWH-calcium (test group) and 51 patients were treated with subcutaneous LMWH-calcium (control group). The mean intraoperative bleeding, wound drainage and incisional hematoma were higher in the test group, with no significant differences between the groups. There were significant differences in distal intramuscular venous thrombosis (P = 0.043). Both activated partial thromboplastin time (APTT), thrombin time (TT), and prothrombin time (PT) lengthened in both groups postoperatively, and there was a significant difference between the two groups two weeks postoperatively. D-dimer were significantly different and platelet count (PLT) did not differ between groups two weeks postoperatively. In elderly patients with unilateral intertrochanteric fracture after PFNA on anticoagulant therapy, the combination of natural hirudin and LMWH was more effective than that of LMWH-calcium alone, with no significant difference with regard to safety.
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Needleman L, Cronan JJ, Lilly MP, Merli GJ, Adhikari S, Hertzberg BS, DeJong MR, Streiff MB, Meissner MH. Ultrasound for Lower Extremity Deep Venous Thrombosis. Circulation 2018; 137:1505-1515. [DOI: 10.1161/circulationaha.117.030687] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Venous ultrasound is the standard imaging test for patients suspected of having acute deep venous thrombosis (DVT). There is variability and disagreement among authoritative groups regarding the necessary components of the test. Some protocols include scanning the entire lower extremity, whereas others recommend scans limited to the thigh and knee supplemented with serial testing. Some protocols use gray-scale ultrasound alone, whereas others include Doppler interrogation. Point-of-care ultrasound is recommended in some settings, and there is heterogeneity of these protocols as well. Heterogeneity of recommendations can lead to errors including incorrect application of guidelines, confusion among requesting physicians, and incorrect follow-up. In October 2016, the Society of Radiologists in Ultrasound convened a multidisciplinary panel of experts to evaluate the current evidence to develop recommendations regarding ultrasound protocols for DVT and the terminology used to communicate results to clinicians. Recommendations were made after open discussion and by unanimous consensus.
The panel recommends a comprehensive duplex ultrasound protocol from thigh to ankle with Doppler at selected sites rather than a limited or complete compression-only examination. This protocol is currently performed in many facilities and is achievable with standard ultrasound equipment and personnel. The use of these recommendations will increase the diagnosis of calf DVT and provide better data to explain the presenting symptoms. The panel recommends a single point-of-care protocol that minimizes underdiagnoses of proximal DVT.
The panel recommends the term chronic postthrombotic change to describe the residual material that persists after the acute presentation of DVT to avoid potential overtreatment of prior thrombus.
Adoption of a single standardized comprehensive duplex ultrasound and a single point-of-care examination will enhance patient safety and clinicians’ confidence.
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Affiliation(s)
| | - John J. Cronan
- Department of Diagnostic Imaging, Brown University, Providence, RI (J.J.C.)
| | - Michael P. Lilly
- Department of Surgery, University of Maryland School of Medicine, Baltimore (M.P.L.)
| | - Geno J. Merli
- Department of Medicine (G.J.M.), Thomas Jefferson University, Philadelphia, PA
| | - Srikar Adhikari
- Department of Emergency Medicine, University of Arizona, Tucson (S.A.)
| | - Barbara S. Hertzberg
- Department of Radiology, Duke University School of Medicine, Durham, NC (B.S.H.)
| | | | - Michael B. Streiff
- Department of Medicine (M.B.S.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Mark H. Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle (M.H.M.)
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26
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Riopel C, Bounameaux H. Doppler ultrasound and D-dimer. Hamostaseologie 2017; 32:28-36. [DOI: 10.5482/ha-1182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 11/07/2011] [Indexed: 01/16/2023] Open
Abstract
SummaryThe diagnosis of venous thromboembolism has evolved considerably with the development of standardized diagnostic algorithms that include clinical probability assessment, D-dimer measurement and the use of non-invasive imaging modalities such as compression ultrasonography and computed tomography angiography. The implementation of these strategies aims to improve resource allocation and patient outcome. The judicious use of these diagnostic tools requires a thorough knowledge of the appropriate clinical setting in which every test and strategy is efficient and can be used safely. For this purpose, D-dimer measurement and compression ultrasonography are complementary: the former is mainly used to exclude VTE in selected patients, while the latter is used to confirm the presence of an underlying DVT.This review provides an appraisal of the features and use of D-dimer and compression ultrasonography in the context of suspected venous thromboembolism.
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Robert-Ebadi H, Righini M. Should we diagnose and treat distal deep vein thrombosis? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:231-236. [PMID: 29222260 PMCID: PMC6142559 DOI: 10.1182/asheducation-2017.1.231] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Ultrasound series report that isolated distal deep vein thrombosis (DVT), also known as calf DVT, represents up to 50% of all lower-limb DVTs and, therefore, is a frequent medical condition. Unlike proximal DVT and pulmonary embolism, which have been studied extensively and for which management is well standardized, much less is known about the optimal management of isolated calf DVT. Recent data arising from registries and nonrandomized studies have suggested that most distal DVTs do not extend to the proximal veins and have an uneventful follow-up when left untreated. These data had some impact on the international recommendations that recently stated that ultrasound surveillance instead of systematic therapeutic anticoagulation might be an option for selected low-risk patients. However, robust data from randomized studies are scarce. Only 5 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. The only randomized placebo-controlled trial included low-risk patients (outpatients without cancer or previous venous thromboembolism [VTE]) and was hampered by limited statistical power. Nevertheless, data from this trial confirmed 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 significantly higher risk of bleeding. Further randomized studies are needed to define the best therapy for high-risk patients (inpatients, patients with active cancer, or patients with previous VTE) and the optimal dose and duration of treatment.
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Affiliation(s)
- Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
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28
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Goldfisher R. Lower-extremity venous ultrasound - past, present and future. Pediatr Radiol 2017; 47:1209-1213. [PMID: 28779202 DOI: 10.1007/s00247-017-3933-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 05/30/2017] [Accepted: 06/19/2017] [Indexed: 10/19/2022]
Abstract
Deep vein thrombosis is a frequent clinical concern and imaging request in the pediatric population. There has been increased awareness of deep venous thrombosis in the pediatric population and sonography is now utilized more liberally and frequently to evaluate for thrombosis in the extremities. In this review the author discusses various aspects of deep vein thrombosis in the lower extremity including the pathophysiology, background, and morbidity in children. The current ultrasound guidelines and techniques, and the controversy over treatment are discussed as well.
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Affiliation(s)
- Rachelle Goldfisher
- Department of Radiology, Hofstra-Northwell School of Medicine, 270-05 76th Ave., New Hyde Park, NY, 11040, USA.
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29
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El-Menyar A, Asim M, Jabbour G, Al-Thani H. Clinical implications of the anatomical variation of deep venous thrombosis. Phlebology 2017; 33:97-106. [DOI: 10.1177/0268355516687863] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Little is known about the anatomic variation and its implication in patients with lower limb deep venous thrombosis (DVT). We studied the clinical presentation, site of thrombosis and risk factors based on the anatomic distribution of lower limb DVT. Methods A retrospective analysis of clinically suspected DVT cases was conducted between 2008 and 2012. DVT was categorized by the location of the thrombosed segment and limb involved. The DVT anatomic segments were assessed according to left-to-right ratio, predisposing factors and clinical presentations. Results A total of 637 patients with DVT were included with a mean age of 50 ± 17 years (51%; females). The most frequently thrombosed segments were popliteal, posterior tibial and profunda femoris veins. DVT was more common at the left side, with a left-to-right ratio of 1.5:1. Bilateral DVT cases (38.5%) had more prior history of DVT as compared to left- (20.3%) and right-sided DVTs (22.6%); p = 0.01. Bilateral DVT was complicated more with post-thrombotic syndrome (leg ulcer) ( p = 0.02). The rates of pulmonary embolism (25%) and mortality (23.1%) were significantly higher for bilateral DVT in comparison to left- and right-sided DVT. Abnormal coagulation profile was significantly associated with posterior tibial DVT (81% vs. 71.4%; p = 0.01) as compared to patients with normal coagulation profile. Conclusion Lower limb DVTs are more common at the left side; however, patients with bilateral DVT have higher frequency of recurrence, post-thrombotic syndrome, pulmonary embolism and mortality. The anatomic segments of DVT show specific distribution depending on the predisposing factors. These findings could improve our understanding of the pathophysiology and management of DVT patients.
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Affiliation(s)
- Ayman El-Menyar
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
- Clinical Research, Trauma Surgery, Hamad General Hospital, Doha, Qatar
- Cardiology Unit, Internal Medicine, Ahmed Maher Teaching Hospital, Cairo, Egypt
| | - Mohammad Asim
- Clinical Research, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Gaby Jabbour
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma & Vascular Surgery, Hamad General Hospital, Doha, Qatar
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30
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Anticoagulant therapy for symptomatic calf deep vein thrombosis (CACTUS): a randomised, double-blind, placebo-controlled trial. LANCET HAEMATOLOGY 2016; 3:e556-e562. [DOI: 10.1016/s2352-3026(16)30131-4] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 08/19/2016] [Accepted: 08/31/2016] [Indexed: 11/20/2022]
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31
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Robert-Ebadi H, Righini M. Management of distal deep vein thrombosis. Thromb Res 2016; 149:48-55. [PMID: 27889688 DOI: 10.1016/j.thromres.2016.11.009] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 11/07/2016] [Accepted: 11/09/2016] [Indexed: 12/22/2022]
Abstract
Isolated distal deep vein thrombosis (DVT), also known as calf DVT, represents up to 50% of all lower limb DVT in ultrasound series and is therefore a frequent medical condition. Unlike proximal DVT and pulmonary embolism (PE), which have been extensively studied and for which management is well standardized, much less is known on the optimal management of isolated calf DVT. Recent 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 the international recommendations which recently stated that ultrasound surveillance instead of systematic therapeutic anticoagulation might be an option for selected low-risk patients. However, robust data arising from randomized studies are scarce. Indeed, only five 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. The only randomized placebo-controlled trial included low-risk patients (outpatients without cancer or previous venous thromboembolic events (VTE)) and was hampered by a limited statistical power. 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 significantly higher risk of bleeding. Further randomized studies are needed to define the best therapy for high-risk patients (inpatients, patients with active cancer or previous VTE), and the optimal dose and duration of treatment.
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Affiliation(s)
- Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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32
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King DAL, Pow RE, Dickison DM, Vale PR. Apixaban versus enoxaparin in the prevention of venous thromboembolism following total knee arthroplasty: a single-centre, single-surgeon, retrospective analysis. Intern Med J 2016; 46:1030-7. [DOI: 10.1111/imj.13139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 03/12/2016] [Accepted: 05/19/2016] [Indexed: 12/30/2022]
Affiliation(s)
- D. A. L. King
- School of Medicine, The University of Notre Dame; Sydney New South Wales Australia
| | - R. E. Pow
- School of Medicine, The University of Notre Dame; Sydney New South Wales Australia
| | - D. M. Dickison
- Department of Orthopaedic Surgery, Mater Hospital; Sydney New South Wales Australia
| | - P. R. Vale
- School of Medicine, The University of Notre Dame; Sydney New South Wales Australia
- Department of Cardiovascular Medicine, Mater Hospital; Sydney New South Wales Australia
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33
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Dronkers CEA, Klok FA, Huisman MV. Current and future perspectives in imaging of venous thromboembolism. J Thromb Haemost 2016; 14:1696-710. [PMID: 27397899 DOI: 10.1111/jth.13403] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Indexed: 01/16/2023]
Abstract
Several thrombus imaging techniques for the diagnosis of venous thromboembolism (VTE) are available. The most prevalent forms of VTE are deep vein thrombosis of the lower extremities and pulmonary embolism. However, VTE may also occur at unusual sites such as deep veins of the upper extremity and the splanchnic and cerebral veins. Currently, the imaging techniques most widely used in clinical practice are compression ultrasonography and computed tomography (CT) pulmonary angiography. Moreover, single-photon emission CT, CT venography, positron emission tomography, and different magnetic resonance imaging (MRI) techniques, including magnetic resonance direct thrombus imaging, have been evaluated in clinical studies. This review provides an overview of the technique, diagnostic accuracy and potential pitfalls of these established and emerging imaging modalities for the different sites of venous thromboembolism.
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Affiliation(s)
- C E A Dronkers
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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34
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Porfidia A, Carnicelli A, Bonadia N, Pola R, Landolfi R. Controversies in venous thromboembolism: the unique case of isolated distal deep vein thrombosis. Intern Emerg Med 2016; 11:775-9. [PMID: 27126683 DOI: 10.1007/s11739-016-1453-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/07/2016] [Indexed: 01/08/2023]
Abstract
Venous thromboembolism (VTE) represents the third leading cause of cardiovascular mortality, and it is the main cause of preventable mortality in hospitalized patients. Among VTE, there is the unique case of isolated distal deep vein thrombosis (IDDVT), which still lacks an agreement in terms of optimal therapeutic strategy. Although most IDDVTs are self-limiting and associated with a very low risk of embolic complications, still not all IDDVTs can be safely identified as stable. Lack of strong scientific evidence, fear of thromboembolic complications, and risk of bleeding upon initiation of anticoagulant treatment result in very heterogeneous therapeutic strategies among physicians. Here, we provide a comprehensive review of the literature, highlight the many controversial issues regarding IDDVTs, and call for a consensus of experts aimed to shed new light on the gray areas of IDDVT management and therapy.
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Affiliation(s)
- Angelo Porfidia
- Division of Internal Medicine and Vascular Diseases, Department of Medicine, A. Gemelli University Hospital, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Annamaria Carnicelli
- Division of Internal Medicine and Vascular Diseases, Department of Medicine, A. Gemelli University Hospital, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Nicola Bonadia
- Division of Internal Medicine and Vascular Diseases, Department of Medicine, A. Gemelli University Hospital, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Roberto Pola
- Division of Internal Medicine and Vascular Diseases, Department of Medicine, A. Gemelli University Hospital, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Raffaele Landolfi
- Division of Internal Medicine and Vascular Diseases, Department of Medicine, A. Gemelli University Hospital, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy.
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35
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Arabi YM, Alsolamy S, Al-Dawood A, Al-Omari A, Al-Hameed F, Burns KEA, Almaani M, Lababidi H, Al Bshabshe A, Mehta S, Al-Aithan AM, Mandourah Y, Almekhlafi G, Finfer S, Abdukahil SAI, Afesh LY, Dbsawy M, Sadat M. Thromboprophylaxis using combined intermittent pneumatic compression and pharmacologic prophylaxis versus pharmacologic prophylaxis alone in critically ill patients: study protocol for a randomized controlled trial. Trials 2016; 17:390. [PMID: 27488380 PMCID: PMC4972959 DOI: 10.1186/s13063-016-1520-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 07/22/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) remains a common problem in critically ill patients. Pharmacologic prophylaxis is currently the standard of care based on high-level evidence from randomized controlled trials. However, limited evidence exists regarding the effectiveness of intermittent pneumatic compression (IPC) devices. The Pneumatic compREssion for preventing VENous Thromboembolism (PREVENT trial) aims to determine whether the adjunct use of IPC with pharmacologic prophylaxis compared to pharmacologic prophylaxis alone in critically ill patients reduces the risk of VTE. METHODS/DESIGN The PREVENT trial is a multicenter randomized controlled trial, which will recruit 2000 critically ill patients from over 20 hospitals in three countries. The primary outcome is the incidence of proximal lower extremity deep vein thrombosis (DVT) within 28 days after randomization. Radiologists interpreting the scans are blinded to intervention allocation, whereas the patients and caregivers are unblinded. The trial has 80 % power to detect a 3 % absolute risk reduction in proximal DVT from 7 to 4 %. DISCUSSION The first patient was enrolled in July 2014. As of May 2015, a total of 650 patients have been enrolled from 13 centers in Saudi Arabia, Canada and Australia. The first interim analysis is anticipated in July 2016. We expect to complete recruitment by 2018. TRIAL REGISTRATION Clinicaltrials.gov: NCT02040103 (registered on 3 November 2013). Current controlled trials: ISRCTN44653506 (registered on 30 October 2013).
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Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.
| | - Sami Alsolamy
- Emergency Medicine and Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Abdulaziz Al-Dawood
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia
| | - Awad Al-Omari
- Alfaisal University, Riyadh, Kingdom of Saudi Arabia
| | - Fahad Al-Hameed
- Intensive Care Department, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Mohammed Almaani
- Department of Pulmonary and Critical Care Medicine, King Fahad Medical City, ᅟRiyadh, ᅟSaudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Hani Lababidi
- Department of Pulmonary and Critical Care Medicine, King Fahad Medical City, ᅟRiyadh, ᅟSaudi Arabia
| | - Ali Al Bshabshe
- Department of Critical Care Medicine, King Khalid University, Assir Central Hospital, Abha, Kingdom of Saudi Arabia
| | - Sangeeta Mehta
- Medical/Surgical ICU, University of Toronto, Mount Sinai Hospital, Toronto, ON, Canada
| | | | - Yasser Mandourah
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia.,International Extended Care Centers, ᅟJeddah, ᅟSaudi Arabia
| | - Ghaleb Almekhlafi
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Simon Finfer
- Intensive Care Royal North Shore Hospital of Sydney and Sydney Adventist Hospital, The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | | | - Lara Y Afesh
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Maamoun Dbsawy
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Musharaf Sadat
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
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36
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Qureshi W, Ali Z, Amjad W, Alirhayim Z, Farooq H, Qadir S, Khalid F, Al-Mallah MH. Venous Thromboembolism in Cancer: An Update of Treatment and Prevention in the Era of Newer Anticoagulants. Front Cardiovasc Med 2016; 3:24. [PMID: 27517038 PMCID: PMC4963402 DOI: 10.3389/fcvm.2016.00024] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 07/06/2016] [Indexed: 12/23/2022] Open
Abstract
Cancer patients are at major risk of developing venous thromboembolism (VTE), resulting in increased morbidity and economic burden. While a number of theories try to explain its pathophysiology, its risk stratification can be broadly done in cancer-related, treatment–related, and patient-related factors. Studies report the prophylactic use of thrombolytic agents to be safe and effective in decreasing VTE-related mortality/morbidity especially in postoperative cancer patients. Recent data also suggest the prophylactic use of low molecular weight Heparins (LMWHs) and Warfarin to be effective in reducing VTEs related to long-term central venous catheter use. In a double-blind, multicenter trial, a new ultra-LMWH Semuloparin has shown to be efficacious in preventing chemotherapy-associated VTE’s along with other drugs, such as Certoparin and Nadoparin. LMWHs are reported to be very useful in preventing recurrent VTEs in advanced cancers and should be preferred over full dose Warfarin. However, their long-term safety beyond 6 months has not been established yet. Furthermore, this paper discusses the safety and efficacy of different drugs used in the treatment and prevention of recurrent VTEs, including Bemiparin, Semuloparin, oral direct thrombin inhibitors, parenteral and direct oral factor Xa inhibitors.
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Affiliation(s)
- Waqas Qureshi
- Department of Internal Medicine, Division of Cardiovascular Epidemiology and Cardiology, Wake Forest University , Winston Salem, NC , USA
| | - Zeeshan Ali
- Department of Internal Medicine, University of Maryland , Baltimore, MD , USA
| | - Waseem Amjad
- Allama Iqbal Medical College , Lahore , Pakistan
| | - Zaid Alirhayim
- Department of Internal Medicine, Henry Ford Hospital, Wayne State University , Detroit, MI , USA
| | - Hina Farooq
- Rawalpindi Medical College , Rawalpindi , Pakistan
| | | | - Fatima Khalid
- Department of Internal Medicine, Division of Nephrology and Hypertension, Wake Forest University , Winston Salem, NC , USA
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Kitchen L, Lawrence M, Speicher M, Frumkin K. Emergency Department Management of Suspected Calf-Vein Deep Venous Thrombosis: A Diagnostic Algorithm. West J Emerg Med 2016; 17:384-90. [PMID: 27429688 PMCID: PMC4944794 DOI: 10.5811/westjem.2016.5.29951] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/31/2016] [Accepted: 05/03/2016] [Indexed: 11/22/2022] Open
Abstract
Introduction Unilateral leg swelling with suspicion of deep venous thrombosis (DVT) is a common emergency department (ED) presentation. Proximal DVT (thrombus in the popliteal or femoral veins) can usually be diagnosed and treated at the initial ED encounter. When proximal DVT has been ruled out, isolated calf-vein deep venous thrombosis (IC-DVT) often remains a consideration. The current standard for the diagnosis of IC-DVT is whole-leg vascular duplex ultrasonography (WLUS), a test that is unavailable in many hospitals outside normal business hours. When WLUS is not available from the ED, recommendations for managing suspected IC-DVT vary. The objectives of the study is to use current evidence and recommendations to (1) propose a diagnostic algorithm for IC-DVT when definitive testing (WLUS) is unavailable; and (2) summarize the controversy surrounding IC-DVT treatment. Discussion The Figure combines D-dimer testing with serial CUS or a single deferred FLUS for the diagnosis of IC-DVT. Such an algorithm has the potential to safely direct the management of suspected IC-DVT when definitive testing is unavailable. Whether or not to treat diagnosed IC-DVT remains widely debated and awaiting further evidence. Conclusion When IC-DVT is not ruled out in the ED, the suggested algorithm, although not prospectively validated by a controlled study, offers an approach to diagnosis that is consistent with current data and recommendations. When IC-DVT is diagnosed, current references suggest that a decision between anticoagulation and continued follow-up outpatient testing can be based on shared decision-making. The risks of proximal progression and life-threatening embolization should be balanced against the generally more benign natural history of such thrombi, and an individual patient’s risk factors for both thrombus propagation and complications of anticoagulation.
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Affiliation(s)
- Levi Kitchen
- Naval Medical Center Portsmouth, Emergency Department, Portsmouth, Virginia
| | - Matthew Lawrence
- Naval Medical Center Portsmouth, Emergency Department, Portsmouth, Virginia
| | - Matthew Speicher
- Naval Medical Center Portsmouth, Emergency Department, Portsmouth, Virginia
| | - Kenneth Frumkin
- Naval Medical Center Portsmouth, Emergency Department, Portsmouth, Virginia
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Guss D, DiGiovanni CW. Venous Thromboembolic Disease in Foot and Ankle Surgery. JBJS Rev 2015; 3:01874474-201512000-00006. [PMID: 27490995 DOI: 10.2106/jbjs.rvw.o.00012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Daniel Guss
- Foot and Ankle Center, Massachusetts General Hospital/Newton-Wellesley Hospital, 52 2nd Avenue, Waltham, MA 02451
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39
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Almosni J, Meusy A, Frances P, Pontal D, Quéré I, Galanaud JP. Practice variation in the management of distal deep vein thrombosis in primary vs. secondary cares: A clinical practice survey. Thromb Res 2015; 136:526-30. [DOI: 10.1016/j.thromres.2015.06.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 06/01/2015] [Accepted: 06/11/2015] [Indexed: 11/25/2022]
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40
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Granziera S, Hasan A, Cohen A(AT. Direct Oral Anticoagulants and Their Use in Treatment and Secondary Prevention of Acute Symptomatic Venous Thromboembolism. Clin Appl Thromb Hemost 2015; 22:209-21. [DOI: 10.1177/1076029615600791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have been compared with standard therapy in large phase III studies to assess their safety and efficacy in the treatment of deep vein thrombosis and/or pulmonary embolism and in the secondary prevention of recurrent venous thromboembolism. Although the mean population age and the gross inclusion and exclusion criteria were similar across these studies, they differed in other aspects such as overall study design and acute treatment strategies. The 4 DOACs examined in phase III trials (apixaban, edoxaban, rivaroxaban, and dabigatran) showed noninferiority compared with standard therapy for the treatment of deep vein thrombosis and/or pulmonary embolism and for the prevention of recurrent venous thromboembolism. Furthermore, these DOACs exhibited a similar safety profile to standard therapy, with the risk of major bleeding significantly reduced in some of these studies. Rivaroxaban and apixaban were tested as a single-drug approach, whereas in the dabigatran and edoxaban studies, initial bridging with parenteral agents was employed. The purpose of this review is to compare the phase III studies of DOACs in this indication, to highlight the differences, and to discuss a series of clinically relevant issues, including the management of key patient subgroups (eg, fragile patients, those with cancer or renal impairment), extended treatment, use of comedications, heparin pretreatment versus a single-drug approach, and the bleeding profiles of the DOACs.
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Affiliation(s)
- Serena Granziera
- Vascular Medicine, King’s College Hospital, London, United Kingdom
- Department of Medicine—DIMED, University of Padova, Padova, Italy
| | - Arjumand Hasan
- Geriatric Medicine, Kingston Hospital, Surrey, United Kingdom
| | - Alexander (Ander) T. Cohen
- Department of Haematological Medicine, Guys and St Thomas’ NHS Foundation Trust, King’s College London, London, United Kingdom
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41
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Horner D, Hogg K, Body R. Should we be looking for and treating isolated calf vein thrombosis? Emerg Med J 2015; 33:431-7. [PMID: 26101406 DOI: 10.1136/emermed-2014-204230] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 05/31/2015] [Indexed: 11/03/2022]
Affiliation(s)
- Daniel Horner
- Emergency Department, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Kerstin Hogg
- Department of Medicine, Thrombosis and Emergency Medicine, McMaster University, West Hamilton, Ontario, Canada
| | - Richard Body
- Emergency Department, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK The University of Manchester, Manchester, UK
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Li AY, Woulfe T, Rolfe-Vyson V, Rowland V, Simpson D, Merriman E. Management and outcomes of axial isolated distal deep vein thrombosis at North Shore Hospital, New Zealand: a retrospective audit. Intern Med J 2015; 45:177-82. [DOI: 10.1111/imj.12664] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 11/20/2014] [Indexed: 12/01/2022]
Affiliation(s)
- A. Y. Li
- Haematology Department; North Shore Hospital; Auckland New Zealand
| | - T. Woulfe
- Haematology Department; North Shore Hospital; Auckland New Zealand
| | - V. Rolfe-Vyson
- Haematology Department; North Shore Hospital; Auckland New Zealand
| | - V. Rowland
- Haematology Department; North Shore Hospital; Auckland New Zealand
| | - D. Simpson
- Haematology Department; North Shore Hospital; Auckland New Zealand
| | - E. Merriman
- Haematology Department; North Shore Hospital; Auckland New Zealand
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Horner D, Hogg K, Body R, Nash MJ, Baglin T, Mackway-Jones K. The Anticoagulation of Calf Thrombosis (ACT) Project. Chest 2014; 146:1468-1477. [DOI: 10.1378/chest.14-0235] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Roberts C, Horner D, Coleman G, Maitland L, Curl-Roper T, Smith R, Wood E, Mackway-Jones K. Guidelines in Emergency Medicine Network (GEMNet): guideline for the use of thromboprophylaxis in ambulatory trauma patients requiring temporary limb immobilisation. Emerg Med J 2014; 30:968-82. [PMID: 24142947 DOI: 10.1136/emermed-2013-203134] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The Guidelines in Emergency Medicine Network (GEMNet) has been created to promote best medical practice in a range of conditions presenting to emergency departments (EDs) in the UK. This guideline presents a summary of the best available evidence to guide the use of thromboprophylaxis in adult ambulatory outpatients who present to the ED following acute limb trauma and require temporary immobilisation. The document has been developed following discussion among emergency physicians and collegiate fellows to decide which topics would benefit from the development of clinical guidelines. The document is intended as a guideline for use in the ED by emergency physicians and is based on the review of the best existing evidence for treatments used in this setting. The document is summarised as a Clinical Decision Support Guideline that has been presented as an easy to follow algorithm. The intention is for each guideline to be updated and reviewed as further evidence becomes available. The formal revision date has been set at 5 years from publication, though the guideline is subject to continuous informal review.
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45
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Schulman S. Distal deep vein thrombosis--a benign disease? Thromb Res 2014; 134:5-6. [PMID: 24780081 DOI: 10.1016/j.thromres.2014.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 04/01/2014] [Accepted: 04/01/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Sam Schulman
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Canada and Karolinska Institutet, Stockholm, Sweden.
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Galanaud JP, Sevestre MA, Genty C, Kahn SR, Pernod G, Rolland C, Diard A, Dupas S, Jurus C, Diamand JM, Quere I, Bosson JL. Incidence and predictors of venous thromboembolism recurrence after a first isolated distal deep vein thrombosis. J Thromb Haemost 2014; 12:436-43. [PMID: 24450376 DOI: 10.1111/jth.12512] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 01/16/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Isolated distal deep vein thrombosis (iDDVT) (i.e. without proximal DVT or pulmonary embolism) represents half of all cases of lower limb DVT. Its clinical significance and management are controversial. Data on long-term follow-up are scarce, especially concerning risk and predictors of venous thromboembolism (VTE) recurrence. METHODS Using data from the OPTIMEV (OPTimisation de l'Interrogatoire dans l'évaluation du risque throMbo-Embolique Veineux) study, a prospective, observational, multicenter study, we compared, 3 years after an index VTE event and after discontinuation of anticoagulants, (i) the incidence and type of recurrence in patients without cancer with a first iDDVT vs. a first isolated proximal DVT (iPDVT) and (ii) predictors of recurrence after iDDVT. RESULTS Compared with patients with iPDVT (n = 259), patients with an iDDVT (n = 490) had a lower annualized incidence of overall VTE recurrence (5.2% [95% confidence interval 3.6-7.6] vs. 2.7% [1.9-3.8], respectively; P = 0.02) but a similar incidence of pulmonary embolism recurrence (1.0% [0.5-2.3] vs. 0.9% [0.5-1.6], respectively; P = 0.83). An age of > 50 years, unprovoked character of index iDDVT, and involvement of more than one vein in one or both legs each independently tripled the risk of recurrence, with the latter then being ≥ 3% per patient-year. Neither muscular vein nor deep-calf vein location of iDDVT nor clot diameter with compression influenced the risk of recurrence. CONCLUSIONS After stopping anticoagulants, patients with iDDVT have a significantly lower risk of overall VTE recurrence than did patients with iPDVT but a similar risk of serious recurrent VTE. Age > 50 years, unprovoked iDDVT, and number of thrombosed veins (more than one) influenced the risk of recurrence and may help to define patients at significant risk of recurrence.
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Affiliation(s)
- J-P Galanaud
- Clinical Investigation Center and Department of Internal Medicine, Montpellier University Hospital, Montpellier, France
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Long A, Zhang L, Zhang Y, Jiang B, Mao Z, Li H, Zhang S, Xie Z, Tang P. Efficacy and safety of rivaroxaban versus low-molecular-weight heparin therapy in patients with lower limb fractures. J Thromb Thrombolysis 2014; 38:299-305. [DOI: 10.1007/s11239-013-1046-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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48
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Variations in ultrasound scanning protocols in the UK for suspected deep vein thrombosis in outpatients. Phlebology 2013; 28:397-403. [DOI: 10.1177/0268355513501608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims To assess current ultrasound scanning protocol in outpatients with suspected deep vein thrombosis (DVT), in particular whether practitioners routinely scanned calf veins. Methods A standard questionnaire was sent out via post to all radiology departments in the United Kingdom (UK) and via the British Medical Ultrasound Society (BMUS) website in 2010. Responses were entered into Access® and database queries were run to analyse responses. Free-text comments were taken into account in our analysis. Results A total of 277 responses (50 through the BMUS website) were received (46% postal response rate). Of them, six were excluded as these were incomplete. Thus, 97 (36%) were consultants, 13 (5%) accredited vascular scientists (AVSs), 153 (56%) sonographers and six (2%) higher radiology trainees. All AVSs scanned the whole limb and used all three modalities of compression, colour and pulse wave Dopplers. Practice across other healthcare professionals varied. In all, 120/176 (68%) of other health-care professionals trained in vascular ultrasound scanned the whole limb routinely and 82/120 of these used all three scanning modalities. Trained sonographers scanned the whole limb significantly more than the medical cohort (P = 0.017). The use of all three modalities varied significantly between AVS and the non-AVS trained professionals (P = 0.0194), the trained medical cohort of consultants and sonographers (P = 0.0001), and trained and non-trained respondents (P = 0.0113). The commonly chosen reason for not scanning the whole limb was that it had poor sensitivity for calf vein DVTs. Free-text reasons for not scanning the whole limb routinely included local protocols prohibiting it. Conclusions There is a discrepancy between the scanning protocols of medically trained and allied health-care professionals, trained or otherwise in vascular ultrasound, and between these groups and AVSs. This is likely to have an impact on clinical governance.
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Crowhurst TD, Dunn RJ. Sensitivity and specificity of three-point compression ultrasonography performed by emergency physicians for proximal lower extremity deep venous thrombosis. Emerg Med Australas 2013; 25:588-96. [DOI: 10.1111/1742-6723.12155] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Thomas D Crowhurst
- School of Medicine; Faculty of Health Sciences; University of Adelaide; Adelaide South Australia Australia
| | - Robert J Dunn
- Discipline of Acute Care Medicine; School of Medicine; Faculty of Health Sciences; University of Adelaide; Adelaide South Australia Australia
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50
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Graham WC, Flanigan DC. Venous Thromboembolism Following Arthroscopic Knee Surgery: A Current Concepts Review of Incidence, Prophylaxis, and Preoperative Risk Assessment. Sports Med 2013; 44:331-43. [DOI: 10.1007/s40279-013-0121-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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