Should we look for silent pulmonary embolism in patients with deep venous thrombosis?

Cohort study of prediction of venous thromboembolism in emergency department patients with extremity symptoms

Despite diagnostic algorithms, identification of venous thromboembolism (VTE) in emergency departments (ED) remains a challenge. We evaluated symptoms, background, and laboratory data in 27,647 ED patients presenting with pain, swelling, or other symptoms from the extremities, and identified predictors of VTE diagnosis within one year. Predictors of a clinical decision to perform phlebography, ultrasound, or computer tomography (CT) angiography of pelvic, lower, or upper extremity veins, CT of pulmonary arteries, or pulmonary scintigraphy at the ED or within 30 days, and the results of such investigations were also evaluated. A total of 3195 patients (11.6%) were diagnosed with VTE within one year. In adjusted analysis of patients in whom all laboratory data were available, a d-dimer value ≥ 0.5 mg/l (odds ratio [OR]: 2.602; 95% confidence interval [CI] 1.894-3.575; p < 0.001) at the ED and a previous diagnosis of VTE (OR: 6.037; CI 4.465-8.162; p < 0.001) independently predicted VTE within one year. Of diagnosed patients, 2355 (73.7%) had undergone imaging within 30 days after the ED visit and 1730 (54.1%) were diagnosed at this examination. Lower age (OR: 0.984; CI 0.972-0.997; p = 0.014), higher blood hemoglobin (OR: 1.023; CI 1.010-1.037; p < 0.001), C-reactive protein (OR: 2.229; CI 1.433-3.468; p < 0.001), d-dimer (OR: 8.729; CI 5.614-13.574; p < 0.001), and previous VTE (OR: 7.796; CI 5.193-11.705; p < 0.001) predicted VTE on imaging within 30 days, whereas female sex (OR 0.602 [95% CI 0.392-0.924]; p = 0.020) and a previous diagnosis of ischemic heart disease (OR 0.254 [95% CI 0.113-0.571]; p = 0.001) were negative predictors of VTE. In conclusion, analysis of 27,647 ED patients with extremity symptoms confirmed the importance of well-established risk factors for VTE. Many patients developing VTE within one year had initial negative imaging, highlighting the importance of continued symptom vigilance.

Can Routine Investigation for Occult Pulmonary Embolism Be Justified in Patients with Deep Vein Thrombosis?

Purpose

This study aims to investigate whether routine screening for silent pulmonary embolism (PE) can be justified in patients with deep vein thrombosis (DVT).

Materials and Methods

We retrospectively analyzed the medical records of 201 patients with lower-extremity DVT admitted to the vascular surgery department of a single tertiary university center between 2019 and 2023. All patients underwent clinical evaluation, basic laboratory exams, a whole-leg colored duplex ultrasound, and a computed tomography pulmonary angiography (CTPA), to screen for an occult, underlying PE.

Results

The overall incidence of silent PE was 48.8%. The median admission D-dimer level was significantly higher in patients with silent PE than in those without PE (9.60 vs. 5.51 mg/L, P=0.001). A D-dimer value ≥5.14 mg/L was discriminant for predicting silent PE, with a sensitivity of 68.2% and a specificity of 59.3%. Silent PE was significantly more common on the right side, with the embolus located at the main pulmonary, lobar, segmental, and subsegmental arteries in 29.6%, 32.7%, 20.4%, and 17.3%, respectively. A higher incidence of occult PE was observed in patients with iliofemoral DVT (P=0.037), particularly when the thrombus extended to the inferior vena cava (P=0.003). Moreover, iliofemoral DVT was associated with a larger size and a more proximal location of the embolus (P=0.041). Multivariate logistic regression showed that male sex (odds ratio [OR]=2.46, 95% confidence interval [CI]: 1.39-3.53; P=0.026), cancer (OR=2.76, 95% CI: 1.45-4.07; P=0.017), previous venous thromboembolism (VTE) history (OR=2.67, 95% CI: 1.33-4.01; P=0.022), D-dimer value ≥5.14 mg/L (OR=2.24, 95% CI: 1.10-3.38; P=0.033), iliofemoral DVT (OR=2.13, 95% CI: 1.19-3.07; P=0.041), and thrombus extension to the IVC (OR=2.95, 95% CI: 1.43-4.47; P=0.009) served as independent predictors for silent PE.

Conclusion

A high incidence of silent PE was observed in patients with lower-extremity DVT. Screening of patients with DVT who have the aforementioned predictive risk factors using CTPA for silent PE may be needed and justified for the efficient management of VTE and its long-term complications.

Oral Rivaroxaban Versus Warfarin After inferior Vena cava Filter Implantation: A Retrospective Cohort Study

OBJECTIVES

To assess the efficacy and safety of rivaroxaban compared to warfarin after inferior vena cava (IVC) filter implantation.

METHOD

This retrospective analysis includes data from 100 patients with deep vein thrombosis (DVT) who underwent IVC filter implantation due to a free-floating thrombus (n = 64), thrombus propagation (n = 8), or acute bleeding (n = 8) on therapeutic anticoagulation, catheter-directed thrombolysis (n = 8), or had previously implanted filter with DVT recurrence. Patients were treated with warfarin (n = 41) or rivaroxaban (n = 59) for 3-12 months. Symptomatic venous thromboembolism (VTE) recurrence and bleeding events were assessed at 12 months follow-up.

RESULTS

Three (7.3%) cases of VTE recurrence without IVC filter occlusion occurred on warfarin and none on rivaroxaban. The only (2.4%) major bleeding occurred on warfarin. Three (5.1%) clinically relevant non-major bleedings were detected on rivaroxaban. No significant differences existed between groups when full and propensity scores matched datasets were compared.

CONCLUSIONS

Rivaroxaban seems not less effective and safe than warfarin after IVC filter implantation.

Comparison of international guideline recommendations for the diagnosis of pulmonary embolism

Pulmonary embolism is one of the leading causes of death due to cardiovascular disease. Timely diagnosis is crucial, but challenging, as the clinical presentation of pulmonary embolism is unspecific and easily mistaken for other common medical emergencies. Clinical prediction rules and D-dimer measurement allow stratification of patients into groups of expected prevalence and are key elements in adequate selection of patients for diagnostic imaging; however, the strengths and weaknesses of the multiple proposed prediction rules, when to measure D-dimer, and which cutoff to apply might be elusive to a significant proportion of physicians. 13 international guidelines authored by medical societies or expert author groups provide recommendations on facets of the diagnostic investigations in suspected pulmonary embolism, some of which are hallmarked by pronounced heterogeneity. This Review summarises key recommendations of each guideline, considers the most recent evidence on the topic, compares guideline recommendations on each facet of the diagnosis of pulmonary embolism, and provides a synthesis on the most common recommendations.

Preoperative risk factors for deep vein thrombosis in knee osteoarthritis patients undergoing total knee arthroplasty

BACKGROUND

To analyze the risk factors for preoperative deep vein thrombosis (DVT) in knee osteoarthritis (OA) patients undergoing total knee arthroplasty (TKA).

METHODS

In this retrospective study, a total of 584 knee OA patients undergoing TKA were enrolled. General information, medical records and preoperative laboratory examination results of the patients were collected. According to the results of Doppler ultrasonography for the lower extremities, the patients were divided into DVT group and non-DVT group. Univariate and multivariate logistic regression were used to identify independent risk factors for preoperative DVT in knee OA patients undergoing TKA.

RESULTS

The incidence of DVT before TKA was 6.85% (40 cases). The increase of ESR (Erythrocyte Sedimentation Rate), platelet crit, IL-6 (Interleukin-6), and PCT (Procalcitonin) were associated with the development of DVT before TKA. Factors as coronary heart disease (CHD), diabetes mellitus (DM), Chronic Kidney Disease (CKD), NLR (ratio of neutrophils to lymphocytes), lower limb venous blood stasis, the time from onset to admission, RBC, PLT were identified by multivariate logistic regression to be the independent risk factors for preoperative DVT in knee OA patients undergoing TKA.

CONCLUSIONS

DM, CKD, CHD, increased in ESR, IL-6 and PCT, blood stasis of the lower extremities, increased in PLT, platelet crit and the time from onset to admission, decreased in RBC, were high risk factors for preoperative DVT in knee OA patients undergoing TKA.

Silent Pulmonary Embolism in Deep Vein Thrombosis: Relationship and Risk Factors

PURPOSE

This study aimed to evaluate risk factors for silent pulmonary embolism (PE) in symptomatic deep vein thrombosis (DVT) and investigate the relationship between DVT and silent PE.

METHODS

This was a single-centre, retrospective cohort study. Between 5 January 2015 and 31 December 2021, consecutive patients with symptomatic DVT received CT pulmonary angiography and CT venography were analyzed. Patient demographics, comorbidities, risk factors, and image findings were analyzed. The group differences were compared using a Chi-square test, Fisher's exact test, independent t test, or Mann-Whitney U test. Multivariant regression was used to determine predictive factors for silent PE.

RESULTS

A total of 355 patients (mean age, 60.5 ± 16.6 years) were included. The incidence of silent PE was 43.1%. The main or lobar pulmonary arteries were affected in 53.6% of patients, which is more often found in iliofemoral DVTs (56.6% vs 26.7%, p = .027). The multivariant analysis showed male patients (p = .042; OR 1.59; 95% CI, 1.02-2.50), inferior vena cava involvement (p = .043; OR 1.81; 95% CI, 1.02-3.20) and D-dimer value > 3.82 μg/ml (p < .001; OR 2.32; 95% CI, 1.43-3.77) were risk factors for silent PE. Unilateral DVT patients with ipsilateral iliac vein compression had a lower incidence of silent PE (28.8% vs 52.9%, p < .001).

CONCLUSION

Iliofemoral DVT was associated with a more proximal PE. The male patients, inferior vena cava involvement, and D-dimer > 3.82 μg/ml were risk factors for silent PE. Ipsilateral iliac vein compression reduced the incidence of silent PE.

Impact of Systemic Atherosclerosis on Clinical Characteristics and Short-term Outcomes in Patients with Deep Venous Thrombosis or Thrombophlebitis

BACKGROUND

Venous thromboembolism (VTE) and atherosclerosis are accompanied by substantial cardiovascular mortality; links between both disease entities were reported. We aimed to investigate the impact of systemic atherosclerosis on adverse outcomes in patients with deep venous thrombosis or thrombophlebitis (DVT) and to identify differences in DVT patients with and without systemic atherosclerosis.

METHODS

The German nationwide inpatient sample was used for this analysis. Patients admitted for DVT were included in this study and stratified by systemic atherosclerosis (composite of coronary artery disease, myocardial infarction, ischemic stroke, and/or atherosclerotic arterial diseases). We compared DVT patients with (DVT+Athero) and without (DVT-Athero) systemic atherosclerosis and analysed the impact of systemic atherosclerosis on adverse outcomes.

RESULTS

Overall, 489,679 patients with DVT (55.7% females) were included in this analysis. Among these, 53,309 (10.9%) were coded with concomitant systemic atherosclerosis with age-dependent incline. Concomitant PE (4.1% vs.3.8%, P=0.001) was more frequently in DVT-Athero and risk for PE in DVT patients was independently associated with absence of systemic atherosclerosis (OR 0.87 [95%CI 0.83-0.91], P<0.001). In-hospital mortality (3.4% vs.1.4%, P<0.001) and adverse in-hospital events (2.2% vs.0.8%,P<0.001) were more prevalent in DVT+Athero compared to DVT-Athero; both, in-hospital mortality (OR 1.52 [95%CI 1.41-1.63], P<0.001) and adverse in-hospital events (OR 1.49 [95%CI 1.40-1.58], P<0.001) were affected independently of sex, age and comorbidities by systemic atherosclerosis.

CONCLUSIONS

Systemic atherosclerosis in DVT patients was accompanied by poorer outcomes. Systemic atherosclerosis was associated with higher bleeding rate and with isolated DVT (without concomitant PE).

Diagnosis and Treatment of Deep Vein Thrombosis in the Emergency Department: Results of an Italian Nominal Group Technique Study

Early diagnosis and treatment of deep vein thrombosis (DVT) is a main issue in the Emergency setting. With the aim of assisting clinicians in the diagnosis and the subsequent management of DVT in the Emergency Departments, a Nominal Group Technique (NGT) study was conducted. A panel of 5 Italian experts developed 21 consensus statements based on available evidence and their clinical experience. The agreed consensus statements may assist clinicians in applying the results of clinical studies and clinical experience to routine care settings, providing guidance on all aspects of the risk assessment, prophylaxis, early diagnosis and appropriate treatment of DVT in the EDs.

Is routine screening for silent pulmonary embolism justified in patients with deep vein thrombosis?

The incidence of asymptomatic pulmonary embolism (PE) exceeds 70% in patients with deep venous thrombosis (DVT), even in cases of distal deep vein thrombosis. We report the case of a patient with a diagnosis of DVT in the lower left limb associated with asymptomatic PE who presented late symptoms due to this same PE. The absence of acute symptoms and the late onset of symptoms could have provoked doubts about the most appropriate treatment, resulting in unnecessary interventions, if pulmonary embolism had not already been diagnosed with tomography. In the present case, we demonstrate that computed tomography angiography conducted at the time of DVT diagnosis accurately diagnosed PE and prevented any misinterpretation of recurrent DVT in a patient already being medicated, which could have been mistakenly interpreted as demonstrating failure of anticoagulant therapy. Such a situation could lead to unnecessary intervention to fit an inferior vena cava filter. We cannot suggest that a classic medical conduct should be reformulated simply on the basis of a case report. However, we would be remiss not to suggest that well-designed studies should be carried out in the future to assess the need for this examination in the acute phase.

In-Hospital Risks and Management of Deep Venous Thrombosis According to Location of the Thrombus

BACKGROUND

Whether deep venous thrombosis involving the pelvic veins or inferior vena cava is associated with higher in-hospital mortality or higher prevalence of in-hospital pulmonary embolism than proximal or distal lower extremity deep venous thrombosis is not known.

METHODS

This was a retrospective cohort study based on administrative data from the Nationwide Inpatient Sample, 2016, 2017. Patients hospitalized with a primary diagnosis of deep venous thrombosis at known locations were identified by International Classification of Diseases-10-Clinical Modification codes.

RESULTS

In-hospital all-cause mortality with deep venous thrombosis involving the inferior vena cava in patients treated only with anticoagulants was 2.2% versus 0.8% with pelvic vein deep venous thrombosis (p<0.0001), 0.7% with proximal deep venous thrombosis (p<0.0001) and 0.2% with distal deep venous thrombosis (p<0.0001).  Mortality with anticoagulants was similar with pelvic vein deep venous thrombosis compared with proximal lower extremity deep venous thrombosis, 0.8% versus 0.7% (p=0.39). Lower mortality was shown with pelvic vein deep venous thrombosis treated with thrombolytics than with anticoagulants, 0% versus 0.8% (p<0.0001). In-hospital pulmonary embolism occurred in 11% to 23%, irrespective of the site of deep venous thrombosis.

CONCLUSION

Patients with deep venous thrombosis involving the inferior vena cava had higher in-hospital mortality than patients with deep venous thrombosis at other locations. Pelvic vein deep venous thrombosis did not result in higher mortality or more in-hospital pulmonary embolism than proximal lower extremity deep venous thrombosis.  The incidence of in-hospital pulmonary embolism was considerable with deep venous thrombosis at all sites.

Risk Factors and Outcomes for Preoperative Asymptomatic Pulmonary Embolism in Patients Aged 60 Years and Over with Hip Fracture

Objective

To investigate the risk factors for, and outcomes of, preoperative asymptomatic pulmonary embolism (PE) in patients ≥60 years old following delayed operation for hip fracture.

Methods

From March 2017 to December 2018, 90 patients aged ≥60 years with hip fracture who suffered a delay in surgery were recruited to this prospective study following admission to our hospital. Computed tomography pulmonary angiography (CTPA) was used to detect preoperative asymptomatic PE and calculated its incidence. Time from injury to admission, baseline characteristics, medical comorbidities, and blood biomarker levels were evaluated as potential risk factors. Logistic regression analysis was used to identify risk factors. Mortality and major bleeding events were recorded and compared between individuals with PE and without. Data were analyzed by t‐test, Mann–Whitney U test, χ² test, Fisher's exact test, and logistic regression analysis.

Results

The incidence of preoperative asymptomatic PE was 18.9% (17/90 patients). In the univariate analysis, the risk factors for preoperative asymptomatic PE were male sex, hypertension, cerebrovascular accident, smoking, plasma D‐dimer level, potassium level, urea level, creatinine level, and cysteine level. Multivariate logistic regression analysis showed that the risk of preoperative asymptomatic PE was higher in patients with hypertension (odds ratio [OR] = 10.048; 95% confidence interval [CI], 1.118–90.333), cerebrovascular accident (OR = 20.135; 95% CI, 1.875–216.164), smoking (OR = 48.741; 95% CI, 4.155–571.788), high plasma D‐dimer levels (OR = 1.200; 95% CI, 1.062–157.300), and high plasma potassium levels (OR = 12.928; 95% CI, 1.062–157.300). All patients were followed up for 21.0 months (range, 2 to 36 months). Mortality within the first year postoperatively was higher in patients with PE (29.41% vs 9.59%, P = 0.046).

Conclusions

In view of the high incidence of preoperative asymptomatic PE and the inferior prognosis in individuals with PE, routine CTPA examination for preoperative asymptomatic PE could be useful for patients aged ≥60 years with hip fracture for whom surgery is delayed.

Teaching limited compression ultrasound to general practitioners reduces referrals of suspected DVT to a hospital: a retrospective cross-sectional study

BACKGROUND

The aim of this study was to retrospectively determine whether teaching limited compression ultrasound (LCUS) to general practitioners (GP) would reduce the number of patients with a suspected lower extremity DVT referred to a hospital for ultrasound (US) examination. According to the current literature, an LCUS protocol is a safe way to diagnose or exclude lower extremity deep venous thrombosis (DVT) and a good option to radiologist-performed whole-leg ultrasound (US), especially in remote health care units where there may be a limited availability of radiological services.

METHODS

Between 2015 and 2016, altogether 13 GPs working in the same primary care unit were trained in LCUS for DVT diagnostics. The number of annual referrals due to a suspected DVT from Saarikka primary care unit to the closest hospital was evaluated before and after training. The incidence of DVT was considered to be constant. Thus, the reduction of referrals was attributed to the fact that these patients were diagnosed and treated in primary health care. Incidence rate ratio of hospital referrals was calculated. As a measure of safety, all patients diagnosed with a pulmonary embolism in the nearest hospital were evaluated to determine if they had undergone LCUS by a GP in primary care.

RESULTS

Before training in 2014, there were 60 annual referrals due to a suspected DVT; in 2017, after training, the number was reduced to 16, i.e., a 73.3% decrease. The incidence of referrals decreased from 3.21 to 0.89 per 1000 person-years. (IRR 3.58, 95% CI 2.04-6.66, p < 0.001). No patient with a pulmonary embolism diagnosis had LCUS performed previously, indicating that there were no false negatives, resulting in pulmonary embolism.

CONCLUSIONS

Teaching LCUS to GPs can safely reduce the number of patients with a suspected DVT referred to a hospital substantially.

Crucial considerations: Sex differences in the epidemiology, diagnosis, treatment, and outcomes of acute pulmonary embolism in non-pregnant adult patients

Acute pulmonary embolism (PE) affects over 600,000 Americans per year and is a common diagnostic consideration among emergency department patients. Although there are well-documented differences in the diagnosis, treatment, and outcomes of cardiovascular conditions, such as ischemic heart disease and stroke, the influence of sex and gender on PE remains poorly understood. The overall age-adjusted incidence of PE is similar in women and men, but women have higher relative rates of PE during early and mid-adulthood (ages 20-40 years); whereas, men have higher rates of PE after age 60 years. Women are tested for PE at far higher rates than men, yet women who undergo computed tomography pulmonary angiography are ultimately diagnosed with PE 35%-55% less often than men. Among those diagnosed with PE, women are more likely to have severe clinical features, such as hypotension and signs of right ventricular dysfunction. When controlled for PE severity, women are less likely to receive reperfusion therapies, such as thrombolysis. Finally, women have more bleeding complications for all types of anticoagulation. Further investigation of possible sex-specific diagnostic and treatment algorithms is necessary in order to more accurately detect and treat acute PE in non-pregnant adults.

Association between risk stratification for pulmonary embolism and deep vein thrombosis of lower extremities

BACKGROUND

The association of clinical risk factors, in particular deep vein thrombosis (DVT), with risk stratification for pulmonary embolism (PE) remains to be identified. We therefore aimed to establish the relationship between risk stratification of PE patients and DVT of lower extremities.

METHODS

In this retrospective study, 93 out of 485 PE patients with uncompleted clinical data were excluded, resulting in 392 patients included for analysis. Based on the ESC criteria, 24, 171, and 197 patients were categorized into high (6.1%), intermediate (43.6%), and low risk (50.3%) subgroups, respectively.

RESULTS

DVT was detected in 304 patients (77.6%). The incidence of DVT in patients with high and intermediate risk PE was much lower than in those patients with low risk PE (67.2% vs 87.8%, P < .0001). Further analyses of the 304 patients with DVT showed higher incidence of high and intermediate risk PE in patients with isolated distal DVT than proximal DVT (59.0% vs 39.1%, P = .005), with asymptomatic DVT than symptomatic DVT (63.0% vs 36.8%, P < .0001), and with bilateral DVT than unilateral DVT (54.5% vs 39.9%, P = .03). Stepwise logistic regression showed that symptomatic or asymptomatic DVT was an independent risk factor for risk stratification of PE patients with DVT (0.320, 95% confidence interval, 0.186-0.550).

CONCLUSIONS

Patients with high and intermediate risk PE presented lower incidence of DVT compared with patients with low risk PE. In PE patients with comorbid DVT, asymptomatic DVT is an independent risk factor for high and intermediate risk of PE.

[Comparison of the effects of two cephalomedullary nails (zimmer natural nail and proximal femoral nail antirotation) in treatment of elderly intertrochan teric fractures]

OBJECTIVE

To explore the effect of cephalomedullary nails for elderly intertrochanteric fractures: proximal femoral nail antirotation (PFNA) versus zimmer natural nail (ZNN) to provide the data support for clinical perioperative management.

METHODS

A retrospective study was used to analyze the clinical data of elderly intertrochanteric fractures cases which were treated with PFNA or ZNN fixation from May 2016 to May 2017. In the study, 59 cases were followed up completely, in which 28 cases accepted PFNA, and the other 31 cases accepted ZNN. The operation time, amount of bleeding, fracture healing time, postoperative complication, postoperative radiographic measurement (tip apex distance, TAD) and the last follow-up of hip function score were analyzed.

RESULTS

The patients were followed up for 6 to 19 months, with an average (10.8±4.0) months. In PFNA group, the operation time was (62.7±14.2) min, the amount of bleeding was (56.8±20.6) mL, the fracture healing time was (4.6±0.8) months, the postoperative complication was 3.6%, the TAD was (17.7±5.5) mm, and the last follow-up hip function score was 91.8±3.6. In ZNN group, the operation time was (73.6±18.3) min, the amount of bleeding was (68.7±31.6) mL, the fracture healing time was (4.5±0.7) months, the postoperative complication was 3.2%, the TAD was (16.5±4.7) mm, and the last follow-up hip function score was 92.2±3.8. The two groups of comparative experiments were carried out, the operation time of the PFNA group was less than that of the ZNN group (P<0.05). There was no significant difference in the amount of bleeding, fracture healing time, postoperative complication, TAD, postoperative hip score between the two groups (P>0.05).

CONCLUSION

Although group ZNN had significant longer operation time than group PFNA, both implants were useful tools in the treatment of elderly intertrochanteric fractures. The operation of PFNA was simpler,while the design of the anterior bow of ZNN might be more suitable for the patients with a large femoral anterior bow.

[Comparison of the effects of two cephalomedullary nails (zimmer natural nail and proximal femoral nail antirotation) in treatment of elderly intertrochan teric fractures]

OBJECTIVE

To explore the effect of cephalomedullary nails for elderly intertrochanteric fractures: proximal femoral nail antirotation (PFNA) versus zimmer natural nail (ZNN) to provide the data support for clinical perioperative management.

METHODS

A retrospective study was used to analyze the clinical data of elderly intertrochanteric fractures cases which were treated with PFNA or ZNN fixation from May 2016 to May 2017. In the study, 59 cases were followed up completely, in which 28 cases accepted PFNA, and the other 31 cases accepted ZNN. The operation time, amount of bleeding, fracture healing time, postoperative complication, postoperative radiographic measurement (tip apex distance, TAD) and the last follow-up of hip function score were analyzed.

RESULTS

The patients were followed up for 6 to 19 months, with an average (10.8±4.0) months. In PFNA group, the operation time was (62.7±14.2) min, the amount of bleeding was (56.8±20.6) mL, the fracture healing time was (4.6±0.8) months, the postoperative complication was 3.6%, the TAD was (17.7±5.5) mm, and the last follow-up hip function score was 91.8±3.6. In ZNN group, the operation time was (73.6±18.3) min, the amount of bleeding was (68.7±31.6) mL, the fracture healing time was (4.5±0.7) months, the postoperative complication was 3.2%, the TAD was (16.5±4.7) mm, and the last follow-up hip function score was 92.2±3.8. The two groups of comparative experiments were carried out, the operation time of the PFNA group was less than that of the ZNN group (P<0.05). There was no significant difference in the amount of bleeding, fracture healing time, postoperative complication, TAD, postoperative hip score between the two groups (P>0.05).

CONCLUSION

Although group ZNN had significant longer operation time than group PFNA, both implants were useful tools in the treatment of elderly intertrochanteric fractures. The operation of PFNA was simpler,while the design of the anterior bow of ZNN might be more suitable for the patients with a large femoral anterior bow.

Cardiac arrest due to pulmonary embolism

Pulmonary embolism (PE) is a potentially life threatening clinical condition that is fairly non-specific in presentation. Massive pulmonary embolism (PE) without cardiac arrest has been associated with a mortality rate of 30%. However, when cardiac arrest ensues, mortality may be as high as 95%. Since outcomes of cardiac arrest following PE are generally dismal, any available potentially life-saving measure must be instituted when the diagnosis of PE is suspected. Despite a lack of randomized controlled trials guiding the management of suspected PE in the cardiac arrest victim, thrombolysis and other therapies have been associated with good outcomes in the handful of published case reports and other small studies.

Asymptomatic Pulmonary Embolism after Ablation

Background: Pulmonary embolism (PE) is a life-threatening event with a broad presentation spectrum ranging from asymptomatic cases to sudden cardiac arrest. It is unclear if right atrial emboli cause PE in patients with atrial fibrillation (AF) or if mild PE itself increases right cardiac pressure provoking AF. Objective: To determine the incidence and predictors of asymptomatic PE in patients undergoing AF ablation. Method and Results: Patients (n = 93) were screened and those with previous or current symptomatic PE or venous thromboembolism, pulmonary hypertension, increased right heart pressures detected on echocardiography, a history of stroke, transient ischemic attack, coagulopathy or cancer and inappropriate contrast for the evaluation of pulmonary arterial tree were excluded. The remaining AF patients (n = 71) underwent guided ablation controlled with 3-dimensional, left atrial and pulmonary venous computed tomography. The asymptomatic PE was defined by using the modified Miller score by 2 independent assessors in 6 patients. Univariate logistic regression showed that age (OR: 1.094, 95% CI 1.007-1.188, p = 0.033), diabetes (OR: 12.000, 95% CI 1.902-75.716, p = 0.008), CHA2DS2-VASc score (OR: 2.800, 95% CI 1.304-6.013, p = 0.008), and pulmonary artery diameter (OR: 1.221, 95% CI 1.033-1.444, p = 0.019) were significantly associated with PE. However, multivariate analysis revealed that the CHA2DS2-VASc score (p = 0.047) remained the exclusive significant predictor for asymptomatic PE. Conclusion: The incidence of random asymptomatic PE in AF patients is high (>8%). The CHA2DS2-VASc score can predict silent PE. Since patients with a high CHA2DS2-VASc score are already anticoagulated, our results do not change clinical practice but are noteworthy in terms of the cause-effect relationship between AF and PE.

Cost of Treating Venous Thromboembolism With Heparin and Warfarin Versus Home Treatment With Rivaroxaban

BACKGROUND

Target-specific anticoagulants such as rivaroxaban facilitate immediate discharge of low-risk venous thromboembolism (VTE; including deep vein thrombosis [DVT] and pulmonary embolism [PE]) allowing treatment at home instead of hospitalization.

OBJECTIVES

The objective was to compare costs accrued over 6 months by patients diagnosed with low-risk VTE and treated at home with rivaroxaban versus usual care with heparin-warfarin.

METHODS

This case-control study calculated costs using the established charge-to-cost ratio from UB-04 billing claims of patients diagnosed at two metropolitan hospitals. Patients were defined as low risk by the Hestia criteria. All patients were anticoagulated for 6 months. Control patients were treated with usual care using low-molecular-weight heparin (LMWH) and then warfarin. Case patients were treated with an initial dose of rivaroxaban in the ED followed by same-day discharge home with rivaroxaban. Medians were compared by Mann-Whitney U-test.

RESULTS

Fifty cases and 47 controls were identified. Groups were well matched according to mean age, Charlson comorbidity score, and proportions by sex and location of thrombus. For all VTEs, median hospital charges for 6 months after diagnosis were $11,128 (interquartile range [IQR] = $8,110 to $23,390) for controls, compared with $4,787 (IQR = $3,042 to $7,596) for cases (Mann-Whitney U-test p < 0.001). Subgroup analyses of the first week of therapy, PE, DVT, and inpatient pharmacy costs retained significance, with costs for rivaroxaban-treated PE patients 57% lower than control PE patients (p < 0.001) and 56% lower for DVT patients (p = 0.003).

CONCLUSIONS

Cost of medical care was lower for low-risk VTE patients discharged immediately from the ED with rivaroxaban therapy compared with patients treated with LMWH-warfarin.

Symptomatic venous thromboembolism following circular frame treatment for tibial fractures

INTRODUCTION

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality following tibial fractures. The risk is as high as 77% without prophylaxis and around 10% with prophylaxis. Within the current literature there are no figures reported specifically for those individuals treated with circular frames. Our aim was to evaluate the VTE incidence within a single surgeon series and to evaluate potential risk factors.

METHODS

We retrospectively reviewed our consecutive single surgeon series of 177 patients admitted to a major trauma unit with tibial fractures. All patients received standardised care, including chemical thromboprophylaxis within 24h of injury until independent mobility was achieved. We comprehensively reviewed our prospective database and medical records looking at demographics and potential risk factors.

RESULTS

Seven patients (4.0% ± 2.87%) developed symptomatic VTE during the course of frame treatment; three deep vein thrombosis (DVTs) and four pulmonary embolisms (PEs). Those with a VTE event had significantly increased body mass index (BMI) (p = 0.01) when compared to those without symptomatic VTE. No differences (p > 0.05) were observed between the groups in age, gender, smoking status, fracture type (anatomical allocation or open/closed), delay to frame treatment, weight bearing status post-frame, inpatient stay or total duration of frame treatment.

CONCLUSION

This study suggests that increased BMI is a statistically significant risk factor for VTE, as reported in current literature. In addition, we calculated the true risk of VTE following circular frame treatment for tibial fracture in our series is from 1.13% to 6.87%, which is at least comparable to other forms of treatment.