D-dimer testing is useful to exclude deep vein thrombosis in elderly outpatients

The role of D-dimer and fibrinogen testing in catheter-directed thrombolysis with urokinase for deep venous thrombosis

BACKGROUND

During catheter-directed thrombolysis (CDT), D-dimer (D-D) are generated in large quantities and fibrinogen (FIB) is continuously consumed. Reduction of FIB increases the risk of bleeding. However, there are currently few studies on the relationship between D-D and FIB concentrations during CDT.

OBJECTIVES

To evaluate the relationship of D-D and FIB concentrations during CDT with urokinase for deep venous thrombosis (DVT).

METHOD

17 patients with lower limb DVT were enrolled and treated with CDT. The concentrations of plasma D-D and FIB were measured every 8 h during thrombolysis. The degree of thrombolysis was evaluated, the change rules of D-D and FIB concentrations were analyzed, and the change curve graphs were drawn. The "thrombus volume," "thrombolysis time," "thrombolysis ratio," "D-D peak," "D-D rising speed," "FIB falling speed," and "duration of D-D elevation" were calculated in each patient. The mixed model was used to simulate the time change trend of the plasma D-D and FIB concentrations. Pearson method and linear regression were used to analyze the correlation and linear relationship, respectively.

RESULTS

The D-D concentration first increased rapidly and then decreased gradually, and the FIB concentration continued to decrease during thrombolysis. The rate of the decline of FIB varies with the urokinase dose. The thrombus volume is positively correlated with D-D rising speed, duration of D-D elevation, D-D peak, and FIB falling speed; the D-D rising speed is positively correlated with the D-D peak and FIB falling speed; and the D-D peak is positively correlated with the FIB falling speed. The correlation coefficients were all statistically significant (p < 0.05). Efficacy reached level I-II in 76.5% patients. No major bleeding occurred in any of the patients.

CONCLUSION

During CDT with urokinase for DVT, the concentrations of D-D and FIB show specific changes, and there are some specific relationships between each other. Understanding these changes and relationships may be helpful to adjust the thrombolysis time and urokinase dose more rationally.

Association between hyperglycemia on admission and preoperative deep venous thrombosis in patients with femoral neck fractures

Background

Elevated blood glucose is the most frequent electrolyte disturbance in acutely ill patients. This study aimed to determine whether admission hyperglycemia is associated with the incidence of preoperative deep venous thrombosis (DVT) in patients with femoral neck fractures.

Methods

This retrospective study was conducted on consecutive patients with femoral neck fractures admitted to our institution from March 2018 to March 2022. Blood glucose levels were measured within 24 h of admission and categorized into quartiles (Q1 = 5.30; Q2 = 5.70; Q3 = 6.60). Patients were divided into four groups (Group1-4) based on the quartiles. Preoperative DVT was diagnosed using venous compression ultrasonography. Multivariable logistic regression models and propensity score matching analysis evaluated the association between blood glucose and preoperative DVT in patients.

Results

Of 217 patients included in this study, 21(9.7%) had preoperative DVT in hospital, and admission hyperglycemia was observed in 83 (38.2%). Preoperative DVT was higher in patients with hyperglycemia (n = 15) than patients without hyperglycemia (n = 6) in the multivariable logistic regression models (OR 3.03, 95% CI 0.77–11.87). Propensity scores matching analyses manifested that compared with patients with group 2 (5.30 – 5.70 mmol/L) of glucose levels, the odds of preoperative DVT were slightly higher (OR 1.94, 95% CI 0.31–12.12) in patients with group 3 (5.70 – 6.60 mmol/L), substantially higher (OR 6.89, 95% CI 1.42–33.44, P trend < 0.01) in patients with the group 4 (> 6.60 mmol/L) of glucose levels.

Conclusions

In patients hospitalized for femoral neck fracture, markedly elevated blood glucose is associated with increased preoperative DVT in patients. The development of this biomarker could help in guiding patient counseling, risk assessment, and future management decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05862-0.

Septicaemia with deep venous thrombosis and necrotising pneumonia caused by acute community-acquired methicillin-resistant Staphylococcus aureus in an infant with a three-year follow-up: a case report

BACKGROUND

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is a common pathogen that usually causes bacteraemia, osteomyelitis, as well as skin and soft tissue infections. However, deep venous thrombosis (DVT) and necrotising pneumonia are rare in infants.

CASE PRESENTATION

We report the case of a one-month-five-day-old girl who was hospitalised for DVT and necrotising pneumonia due to septicaemia associated with Staphylococcus aureus. She recovered after treatment with intravenous antibiotics and multiple anticoagulant therapy, but DVT persisted at the three-year follow-up. Collateral circulation around the DVT was well-formed. Post thrombotic syndrome was not observed.

CONCLUSIONS

Staphylococcus aureus complicated by DVT and necrotising pneumonia is rare and can be successfully treated.

A Retrospective cohort study on the risk factors of deep vein thrombosis (DVT) for patients with traumatic fracture at Honghui Hospital

OBJECTIVE

To explore the risk factors of perioperative deep vein thrombosis (DVT) in patients with traumatic fracture after orthopaedic surgery and their potential diagnostic values in clinical.

DESIGN

Retrospective cohort study.

SETTING

Clinical Laboratory of Honghui Hospital, Xi'an JiaoTong University College of Medicine, Xi'an, Shaanxi, China.

MATERIALS AND METHODS

A retrospective cohort study was conducted with surgically treated fracture patients in Honghui Hospital from 1 May 2016 to 31 February 2017. χ² test, independent sample t test and regression analysis were applied to examine the correlation between perioperative DVT and the factors of preoperative time, fracture sites, D-dimer value and chronic diseases (hypertension, diabetes and coronary disease).

RESULTS

462 patients were enrolled for analysis. The preoperative time of patients with DVT was significantly longer than that of non-DVT patients (7.14±5.51 vs 5.45±3.75) (P<0.01). χ² test showed the significant differences in the rate of DVT among patients with different fracture sites (P<0.01). By the receiver-operating characteristic curve analysis, the cut-off value of preoperative D-dimer and postoperative D-dimer in diagnosing perioperative DVT was 4.01 µg/mL and 5.03 µg/mL, respectively. Area under the curve was 0.593 (95% CI 0.533 to 0.652) and 0.728 (95% CI 0.672 to 0.780), respectively. The sensitivity and specificity of preoperative D-dimer for DVT diagnosis were 71.30% and 44.83%, and as for postoperative D-dimer were 63.90% and 70.51%.

CONCLUSIONS

Fracture site was correlated to the incidence of DVT; prolonged preoperative time and increased D-dimer value were independent risk factors for DVT in patients with lower extremity traumatic fractures.

Correlation of Interleukin-18 and High-Sensitivity C-Reactive Protein with Perioperative Deep Vein Thrombosis in Patients with Ankle Fracture

BACKGROUND

In the present study, we aimed to inspect the correlation of interleukin-18 (IL-18) and high-sensitivity C-reactive protein (hs-CRP), if any present, with the occurrence of perioperative deep vein thrombosis (DVT) in patients suffering from an ankle fracture (AF).

METHODS

Sixty-seven AF patients with complicated DVT (DVT group) and 448 AF patients without DVT (non-DVT group) were enrolled in the present study. To begin with, hemorheological indexes were detected. Turbidimetric immunoassay and enzyme-linked immunosorbent assay were used for the determination of the expressions of hs-CRP and IL-18, respectively. Coagulation method was used to detect prothrombin time (PT), thrombin time (TT), fibrinogen, and activated partial thromboplastin time (APTT). Logistic regression analysis was used to analyze the independent risk factors for DVT occurrence in AF patients after operation.

RESULTS

The results revealed that the DVT group presented an increased expression of hs-CRP and IL-18 1 day before operation and 1, 3, and 7 days after operation in comparison with the non-DVT group. The DVT group also had increased levels of PT, APTT, and prolonged TT and fibrinogen at 3 and 7 days after operation compared to the non-DVT group. After operation, it was observed that the patients in the DVT group had increased plasma viscosity, whole blood reduced viscosity, red blood cell (RBC) aggregation index, RBC deformation index, erythrocyte sedimentation rate, and declined erythrocrit. The independent risk factors for the occurrence of DVT were identified to be high-energy injury, TT, fibrinogen, hs-CRP, and IL-18 in AF patients after operation.

CONCLUSIONS

Based on the results obtained from the study, it was concluded that AF patients with DVT have higher levels of IL-18 and hs-CRP expressions, which is associated with the occurrence and development of DVT. These results may be particularly useful for diagnosis and treatment on DVT occurrence in AF patients.

Consensus among Chinese experts on standard interventional therapy for deep venous thrombosis of lower extremity (second edition)

This is an update on the first edition of the expert consensus. This document discusses the indications and contraindications of interventional treatment methods for deep venous thrombosis such as anticoagulation, catheter-directed thrombolysis, percutaneous mechanical thrombectomy, percutaneous transluminal angioplasty and stent implantation. The operational procedures, considerations, preoperative management, and prevention of complications were also updated, supplemented, and revised. Emphasis is placed on the interventional treatment of acute and subacute deep venous thrombosis to effectively reduce the incidence of post-thrombosis syndrome.

Risk factors for deep venous thrombosis in women with ovarian cancer

We aim to clarify the incidence of deep venous thrombosis (DVT) before treatment in women with ovarian cancer and identify risk factors for DVT.In this prospective study, 110 women underwent venous ultrasonography before cancer treatment and D-dimer levels were measured. We investigated factors predicting DVT by logistic regression.DVT was detected in 25 of 110 women (22.7%) and pulmonary thromboembolism was coexisted in 2 women (1.8%). A total of 21 women (84.4%) with DVT were asymptomatic. D-dimer levels in women with DVT (median, 10.9; range, <0.5-98.2 μg/mL) were significantly higher than those in women without DVT (2.0; <0.5-60.8 μg/mL; P < .01). When 10.9 μg/mL was used as a cutoff value for D-dimer levels to predict DVT, specificity, sensitivity, and positive and negative predictive values were 92.9%, 52.0%, 68.4%, and 86.8%, respectively. The multivariate analysis demonstrated that D-dimer level (odds ratio [OR], 19.7; 95% confidence interval [CI], 5.89-76.76) and clear cell histology (OR, 7.1; 95% CI, 2.12-25.67) were independent factors predicting DVT.Asymptomatic DVT occurred with great frequency before treatment in patients with ovarian cancer. High D-dimer level and clear cell pathology is associated with a higher DVT risk.

The preoperative incidence of deep vein thrombosis (DVT) and its correlation with postoperative DVT in patients undergoing elective surgery for femoral neck fractures

INTRODUCTION

Data on the incidence of preoperative deep vein thrombosis (DVT) in patients, who are waiting for elective hip replacement for femoral neck fractures, are limited. Our primary goal was to determine the prevalence and risk factors of preoperative DVT in acute hip fracture patients awaiting hemi- or total hip arthroplasty using venography. The secondary objective was to find a possible relationship between preoperative and postoperative DVT.

METHODS

We enrolled 119 consecutive patients with subcapital femoral neck fracture, who were awaiting hip replacement at our institution. All of them received venography before and after surgery. We used univariate analysis and multivariate logistic regression analysis to identify the risk factors for preoperative DVT.

RESULTS

Of the patients, 35 patients (29.4 %) developed DVT in affected limbs before surgery. Both long duration of immobilization and increased level of D-dimer were associated with preoperative DVT independently. Intriguingly, 66.7 % of patients who were diagnosed with DVT after surgery had thrombus in the same location, as they did before surgery.

CONCLUSIONS

We identified the high incidence and risk factors of preoperative DVT in patients awaiting elective surgery for femoral neck fractures. The majority of patients diagnosed with DVT postoperatively had already had thrombus before surgery.

D-dimer: An Overview of Hemostasis and Fibrinolysis, Assays, and Clinical Applications

D-dimer is the smallest fibrinolysis-specific degradation product found in the circulation. The origins, assays, and clinical use of D-dimer will be addressed. Hemostasis (platelet and vascular function, coagulation, fibrinolysis, hemostasis) is briefly reviewed. D-dimer assays are reviewed. The D-dimer is very sensitive to intravascular thrombus and may be markedly elevated in disseminated intravascular coagulation, acute aortic dissection, and pulmonary embolus. Because of its exquisite sensitivity, negative tests are useful in the exclusion venous thromboembolism. Elevations occur in normal pregnancy, rising two- to fourfold by delivery. D-dimer also rises with age, limiting its use in those >80 years old. There is a variable rise in D-dimer in active malignancy and indicates increased thrombosis risk in active disease. Elevated D-dimer following anticoagulation for a thrombotic event indicates increased risk of recurrent thrombosis. These and other issues are addressed.

Effectiveness of d-dimer as a screening test for venous thromboembolism: an update

Venous thromboembolism (VTE) is the leading cause of morbidity and mortality among hospitalized patients. We searched the PubMed database and reviewed the articles published until June 2011. Articles related to the D-dimer and VTE were considered to write this paper. Many factors play a key role in changing the sensitivity and specificity of D-dimer testing, including the extent of thrombosis and fibrinolytic activity, duration of symptoms, anticoagulant therapy, comorbidity due to surgical or medical illnesses, inflammatory diseases, cancer, elderly age, pregnancy and the postpartum period, and previous VTE. Many previous studies have shown that the D-dimer test is highly sensitive (>95%) in acute deep venous thrombosis or pulmonary embolism, usually with a cut-off value of 500 μg FEU/l, which reasonably rules out acute VTE, particularly in patients with low clinical probability (LCP) or intermediate clinical probability. Patients with high D-dimer levels upon presentation may prompt a more intense diagnostic approach, irrespective of pretest probability. Studies performed after a negative D-dimer for 3 months proved the high negative predictive value (NPV) of D-dimer testing together with LCP in patients with suspected VTE. Among oncology patients, D-dimer testing has the highest sensitivity and NPV in excluding VTE. The new cutoff values of D-dimer testing were analyzed in a recent prospective study of pregnant women; they are 286 ng DDU/ml, 457 ng DDU/ml, and 644 ng DDU/ml for the first, second, and third trimesters, respectively.

Relative Risk of Deep Vein Thrombosis in Very Elderly Patients Compared With Elderly Patients

Deep vein thrombosis (DVT) and pulmonary embolism are major causes of morbidity and mortality in patients during hospitalization; previous studies have proposed that an advanced age of more than 60 years is a risk factor for these conditions. This study analyzes the relative risk of DVT in very elderly patients older than 90 years of age compared with elderly patients aged 80 to 89 years. The study was performed at the Department of Internal Medicine, University Hospital of Saarland, Homburg/Saar, Germany, between 2004 and 2012. After completing ultrasound examinations, 20 (64.52%, 12 [60%] female patients, mean age 91.8 ± 1.83 years) of the 31 patients in the study group and 132 (62.26%, 87 [65.91%] female patients, mean age 83.84 ± 2.66 years) of the 212 patients in the control group were diagnosed with DVT. An increased relative risk of DVT was not discovered in the very elderly patients (relative risk, 1.04; P = .80).

Postoperative plasma D-dimer value for predicting deep venous thrombosis following hip arthroplasty with nadroparin prophylaxis

The aim of the study was to assess the value of D-dimer as an event predicitor for deep vein thrombosis (DVT) in patients given low molecular weight heparin (LMWH) after total hip arthroplasty (THA). Plasma D-dimer levels were obtained preoperatively and at days 1, 3, and 7 postoperatively in 83 consecutive patients undergoing THA treated with nadroparin prophylaxis plus intermittent pneumatic compression. Unilateral ascending venography was performed at postoperative day 7 or 8. There was a significant difference between the D-dimer levels in the DVT group (28 patients) and non-DVT group (55 patients) on each day (P<0.01). ROC analysis showed the AUC on postoperative days 1, 3 and 7 was 0.706, 0.712 and 0.772 respectively. The D-dimer concentration on postoperative day 1, day 3 or day 7 is of moderate predicting value of DVT in patients undergoing THA, treated with nadroparin prophylaxis plus intermittent pneumatic compression.

Cut-off value of D-dimer for prediction of deep venous thrombosis before treatment in ovarian cancer

Objective

The purpose of the present study was to elucidate the incidence of deep venous thrombosis (DVT) before treatment in ovarian cancer and the appropriate cut-off value of D-dimer (DD) for the diagnosis of DVT.

Methods

Between July 2007 and October 2008, eighty seven patients with presumed ovarian cancer (final diagnosis: ovarian cancer, n=59; borderline malignancy, n=28) were enrolled. Measurement of DD levels and subsequent venous ultrasonography were performed before treatment.

Results

The mean DD level was 4.1 µg/mL. Subsequent venous ultrasonography revealed DVT in 14 of 87 (16.1%) patients (ovarian cancer, 12 cases; borderline malignancy, 2 cases). None were found to have developed DVT if they had a DD level of <1.5 µg/mL. If 1.5 µg/mL was used as a cut-off value for DD levels to diagnose DVT, sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 61.6%, 33.3%, and 100%. There was noclinical onset of postoperative pulmonary thromboembolism.

Conclusion

Our data suggest that presumed ovarian cancer patients with at least more than 1.5 µg/mL should be examined using venous ultrasonogaphy to detect DVT.

Systematic review: diagnostic accuracy of clinical decision rules for venous thromboembolism in elderly

BACKGROUND

Physicians committed to the care of elderly patients, are challenged with the diagnosis of venous thromboembolism (VTE: deep venous thrombosis and pulmonary embolism) due to a higher incidence, co-morbidities masking signs and symptoms and burdening referrals. Clinical decision rules (CDRs) have been developed and implemented for VTE. Yet, until now, no study has evaluated the existing evidence of the diagnostic accuracy of CDRs for VTE in elderly.

PURPOSE

To assess the effect of increasing age on diagnostic accuracy of CDRs for VTE in elderly.

DATA SOURCES

A computerized systematic search was performed in Medline and Embase from 1950 to 2010. After checking reference lists and field experts, all key journals were hand searched.

STUDY SELECTION

After review of 1538 eligible citations, nine articles were included and critically appraised on methodological quality by two reviewers using the QUADAS criteria.

DATA EXTRACTION

Data on age subgroups, type of CDRs, sensitivity, specificity, safety, efficiency and the prevalence of deep venous thrombosis (DVT) and pulmonary embolism (PE) were extracted.

DATA SYNTHESIS

Although sensitivity and safety of the CDRs for VTE in elderly remained high, the specificity and efficiency decreased substantially in older age groups.

LIMITATIONS

A limited number of studies met our inclusion criteria. Possible referral bias due to inclusion of relatively high risk elderly patients.

CONCLUSIONS

This diagnostic review demonstrates an increase of prevalence of PE with age and a strong decrease of specificity and efficiency for CDRs of VTE in older patients. Moreover, due to referral bias the decrease in specificity in the elderly may even be underestimated. Although the safety of CDRs for VTE is high, adapting these rules for elderly is much needed to make them more efficient for aged patients.

Venous thromboembolism following vigorous deep tissue massage

Venous thromboembolism (VTE) is an increasing public health concern, in part because of lack of awareness among patients and physicians. Nonpenetrating trauma to the legs may be an under-recognized potential risk factor for VTE. We report a case of VTE following vigorous deep tissue massage in a previously healthy 67-year-old man with no other identifiable risk factors. The etiology, risk factors, and implications for the prevention and detection of VTE are reviewed. There are few other published reports of VTE associated with massage, but under-reporting seems likely. Vigorous massage or any equivalent trauma to the legs should be considered and evaluated as a possible risk factor for VTE, especially in older adults. Additional research is needed to clarify the risks associated with nonpenetrating trauma to the legs in older adults and other susceptible groups. Improved awareness of VTE, including its risk factors and symptoms, is an urgent priority for more effective prevention, detection, and treatment.

The use of D-dimer in specific clinical conditions: a narrative review

The use of D-dimer in combination with a clinical decision rule has been widely investigated in pulmonary embolism and deep venous thrombosis. Although it has been shown to be safe in excluding venous thromboembolism, the clinician is often faced with specific situations in which the use of D-dimer is controversial. We review the best available evidence on these patients. We conclude that it is not safe to use D-dimer testing in patients with symptoms of a venous thromboembolism for over 14 days, patients receiving therapeutic heparin treatment and patients with suspected deep venous thrombosis during oral anticoagulant therapy. In these populations the levels of D-dimer can be lower then expected giving rise to false-negative results. It is safe to use D-dimer testing in combination with a clinical decision rule in patients of all ages, patients presenting with a suspected recurrent venous thromboembolism or inpatients with suspected pulmonary embolism. As patients with recurrent venous thromboembolism, elderly patients and inpatients have higher levels of D-dimer, D-dimer testing has a low specificity and the need for additional radiological testing is increased.

An age-adapted approach for the use of D-dimers in the exclusion of deep venous thrombosis

A normal D-dimer (DD) concentration for the exclusion of deep venous thrombosis (DVT) has a low specificity in older patients and compression ultrasonography is often required. Three D-dimer assays, STA Liatest, Tina-quant, and Innovance, are evaluated in symptomatic outpatients suspected for DVT with emphasis on its performance in older patients by using different cut-off levels. This study includes 466 outpatients suspected for having DVT. The diagnostic accuracy, measured as sensitivity and area under the curve of the receiver operation characteristic curve is good for all DD assays. The specificity of the DD assays combined with a low pretest probability varies from 42.6 to 51.5%. The specificity of the three DD assays in patients > or = 60 years varies, however, between 24.6 and 40.9%. Several cut-off values in different age-subgroups are studied. For patients < 60 years, the most accurate cut-off value is 500 microg/L for all DD assays. For patients > or = 60 years, a threshold of 750 microg/L has the best results with NPV of 100% for all assays and specificity of 48.5% (STA Liatest), 60.6% (Tina-quant), and 49.2% (Innovance), respectively. For the three assays, the number needed to test (NNT) decreases in both subgroups of patients compared to the standard algorithm. A cut-off level of 750 microg/L for patients > or = 60 years improves the clinical performance of DD assays in combination with the PTP score without the loss of NPV. The NNT improves substantially with an age-adapted algorithm.