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Ariyanti F, Sukrisman L, Antono D, Harimurti K. The risk for post-thrombotic syndrome of subjects with deep vein thrombosis in an Indonesian referral hospital: a retrospective cohort study. Thromb J 2023; 21:38. [PMID: 37020240 PMCID: PMC10074643 DOI: 10.1186/s12959-023-00482-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/29/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Post-thrombotic syndrome (PTS) is a complication of deep vein thrombosis (DVT) and affects 20-40% of DVT subjects. The risk factor of PTS after DVT is difficult to determine. We aimed to evaluate the incidence of PTS after 3 months of DVT diagnosis and to determine the risk of PTS. METHODS A retrospective cohort study of subjects who developed DVT confirmed by Doppler ultrasound in Cipto Mangunkusumo Hospital from April 2014 until June 2015. The presence of PTS was assessed after 3 months of completed DVT treatment using the Villalta score. Risk factors for PTS were evaluated from medical records. RESULTS There were 91 subjects with DVT with mean age of 58 years. 56% were female. It was dominated by subjects aged ≥ 60 years (45.1%). Hypertension (30.8%) and diabetes mellitus (26.4%) were the major comorbidities in this study. Deep vein thrombosis occurred commonly in unilateral side (79.1%), proximal localization (87.9%), and unprovoked DVT (47.3%). The cumulative incidence of PTS after DVT was 53.8%, 69% of subjects had mild PTS. Heaviness of the leg (63.2%) and edema (77.5%) were the most common symptoms. RESULTS There were 91 subjects with DVT with mean age of 58 years. 56% were female. It was dominated by subjects aged ≥ 60 years (45.1%). Hypertension (30.8%) and diabetes mellitus (26.4%) were the major comorbidities in this study. Deep vein thrombosis occurred commonly in unilateral side (79.1%), proximal localization (87.9%), and unprovoked DVT (47.3%). The cumulative incidence of PTS after DVT was 53.8%, 69% of subjects had mild PTS. Heaviness of the leg (63.2%) and edema (77.5%) were the most common symptoms. Significant risk factors for PTS were unprovoked DVT (adjusted RR 1.67; 95%CI: 1.17-2.04; p = 0.01) and female gender (adjusted RR 1.55; 95%CI: 1.03-1.94; p = 0.04). Age, body mass index, thrombus location, immobilization, malignancy and surgery was not associated with PTS. CONCLUSION We conclude that 53.8% of subjects suffered PTS after 3 months of DVT. Unprovoked DVT and female gender were significant risk factors for PTS.
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Affiliation(s)
- Farieda Ariyanti
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Lugyanti Sukrisman
- Division of Hematology - Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.
| | - Dono Antono
- Cardiovascular Division- Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Kuntjoro Harimurti
- Clinical Epidemiology Unit, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
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Flumignan CD, Nakano LC, Baptista-Silva JC, Flumignan RL. Antiplatelet agents for the treatment of deep venous thrombosis. Cochrane Database Syst Rev 2022; 7:CD012369. [PMID: 35876829 PMCID: PMC9311262 DOI: 10.1002/14651858.cd012369.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Antiplatelet agents may be useful for the treatment of deep venous thrombosis (DVT) when used in addition to best medical practice (BMP), which includes anticoagulation, compression stockings, and clinical care such as physical exercise, skin hydration, etc. Antiplatelet agents could minimise complications such as post-thrombotic syndrome (PTS) and pulmonary embolism (PE). They may also reduce the recurrence of the disease (recurrent venous thromboembolism (recurrent VTE)). However, antiplatelet agents may increase the likelihood of bleeding events. OBJECTIVES To assess the effects of antiplatelet agents in addition to current BMP compared to current BMP (with or without placebo) for the treatment of DVT. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 7 December 2021. The review authors searched LILACS and IBECS databases (15 December 2021) and also checked the bibliographies of included trials for further references to relevant trials, and contacted specialists in the field, manufacturers and authors of the included trials. SELECTION CRITERIA We considered randomised controlled trials (RCTs) examining antiplatelet agents compared to BMP following initial standard anticoagulation treatment for DVT. We included studies where antiplatelet agents were given in addition to current BMP compared to current BMP (with or without placebo) for the treatment of DVT (acute: treatment started within 21 days of symptom onset; chronic: treatment started after 21 days of symptom onset). We evaluated only RCTs where the antiplatelet agents were the unique difference between the groups (intervention and control). DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. Two review authors independently extracted data and assessed risk of bias of the trials. Any disagreements were resolved by discussion with a third review author. We calculated outcome effects using risk ratio (RR) or mean difference (MD) with a 95% confidence interval (CI) and the number needed to treat to benefit (NNTB). MAIN RESULTS We included six studies with 1625 eligible participants, with data up to 37.2 months of follow-up. For one preplanned comparison (i.e. antiplatelet agents plus BMP versus BMP plus placebo) for acute DVT we identified no eligible studies for inclusion. In acute DVT, antiplatelet agents plus BMP versus BMP alone was assessed by one study (500 participants), which reported on four outcomes until 6 months of follow-up. There were no deaths and no cases of major bleeding reported. The participants who received antiplatelet agents showed a lower risk of PTS (RR 0.74, 95% CI 0.61 to 0.91; 1 study, 500 participants; very low-certainty evidence). The control group presented a lower risk of adverse events compared to the intervention group (RR 2.88, 95% CI 1.06 to 7.80; 1 study, 500 participants; very low-certainty evidence). This study did not provide information for recurrent VTE or PE. In chronic DVT, antiplatelet agents plus BMP versus BMP alone was assessed by one study (224 participants). The study authors reported four relevant outcomes, three of which (major bleeding, mortality and adverse events) showed no events during the 3 years of follow-up. Therefore, an effect estimate could only be reported for recurrent VTE, favouring antiplatelet agents plus BMP versus BMP alone (RR 0.12, 95% CI 0.05 to 0.34; 1 study, 224 participants; very low-certainty evidence). For the outcomes PE and PTS, this study did not present information which could be used for analysis. In chronic DVT, antiplatelet agents plus BMP versus BMP plus placebo was assessed by four studies (901 participants). The meta-analysis of this pooled data showed a lower risk of recurrent VTE for the antiplatelet agents group (RR 0.65, 95%, CI 0.43 to 0.96; NNTB = 14; low-certainty evidence). For major bleeding, we found no clear difference between placebo and intervention groups until 37.2 months of follow-up (RR 0.98, 95% CI 0.29 to 3.34; 1 study, 583 participants; moderate-certainty evidence). In PE fatal/non-fatal outcome, we found no clear difference with the use of antiplatelet agents (RR 0.52, 95% CI 0.23 to 1.14; 1 study, 583 participants; moderate-certainty evidence). For all-cause mortality, the overall effect of antiplatelet agents did not differ from the placebo group (RR 0.48, 95% CI 0.21 to 1.06; 3 studies, 649 participants; moderate-certainty evidence). The adverse events outcome did not show a clear difference (RR 1.57, 95% CI 0.34 to 7.19; 2 studies, 621 participants; moderate-certainty evidence). There is no assessment of PTS in these studies. We downgraded the certainty of evidence for risk of bias, indirectness, imprecision and publication bias. AUTHORS' CONCLUSIONS In chronic DVT settings, following the initial standard treatment with anticoagulants, there is low-certainty evidence that antiplatelet agents in addition to BMP may reduce recurrent VTE, (NNTB = 14) when compared to BMP plus placebo. Moderate-certainty evidence shows no clear difference in adverse events, major bleeding and PE when antiplatelet agents are used in addition to BMP compared to BMP plus placebo. In acute and chronic DVT settings, following the initial standard treatment with anticoagulants, we can draw no conclusions for antiplatelet agents in addition to BMP compared to BMP alone due to very low-certainty evidence. Trials of high methodological quality, that are large and of sufficient duration to detect significant clinical outcomes are needed. Trials should ideally last more than 4 years in order to estimate the long-term effect of antiplatelet agents. Trials should include people with acute and chronic DVT and provide relevant individual data, such as the outcome for each index event (DVT or PE), the use of an inferior vena cava (IVC) filter, whether the DVT is provoked or unprovoked, and the age of participants.
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Affiliation(s)
- Carolina Dq Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis Cu Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Cc Baptista-Silva
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
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Bosevski M, Krstevski G, Di Micco P, Fidalgo A, Loring M, Porras JA, Mellado M, Sánchez Muñoz-Torrero JF, Vela JR, Tzoran I, Monreal M. Risk for post-thrombotic syndrome after lower-limb deep vein thrombosis: location of the thrombus or residual thrombi? ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:62-72. [PMID: 34166345 DOI: 10.33529/angio2021108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Many works aimed to determine factors that influence the onset of postthrombotic syndrome after an acute episode of deep venous thrombosis. We aimed to compare the prognostic value of the most proximal extent of thrombus (proximal and distal DVT) versus the residual thrombosis as identified by venous ultrasonography performed during follow-up. METHOD We conducted a retrospective study of prospectively collected 1183 consecutive cohort patients in the RIETE registry after a first episode of deep venous thrombosis and assessed for postthrombotic syndrome after 12 months. RESULTS Multivariate analysis revealed that: residual thrombosis (OR 1.40; 95% CI 0,88-2,21), the presence of cancer (OR 1.38; 95% CI: 0,64-2,97), immobility (OR 1.31; 95% CI 0,70-2,43) and estrogen-containing drugs use (OR 2.08, 95% CI 0,63-6,83), all had a predictive value for the occurrence of PTS. CONCLUSION Our study results revealed that ultrasound finding of residual thrombosis is more predictive than proximal location of thrombus for postthrombotic syndrome after episode of deep venous thrombosis. Real life data from a large group of patients from the RIETE registry substantiates that.
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Affiliation(s)
- M Bosevski
- University Cardiology Clinic, Vascular Centre, Faculty of Medicine, Skopje, R.N. Macedonia
| | - G Krstevski
- University Cardiology Clinic, Vascular Centre, Faculty of Medicine, Skopje, R.N. Macedonia
| | - P Di Micco
- Department of Internal Medicine and Emergency Room, Ospedale Buon Consiglio Fatebenefratelli, Naples, Italy
| | - A Fidalgo
- Department of Internal Medicine, Hospital Universitario de Salamanca, Salamanca, Spain
| | - M Loring
- Department of Internal Medicine, Hospital Comarcal de Axarquía, Málaga, Spain
| | - J A Porras
- Department of Internal Medicine, Hospital Universitario Joan XXIII de Tarragona, Tarragona, Spain
| | - M Mellado
- Department of Angiology and Vascular Surgery, Hospital del Mar, Barcelona, Spain
| | | | - J R Vela
- Department of Internal Medicine, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - I Tzoran
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - M Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol Badalona, Barcelona, Universidad Autónoma de Barcelona, Barcelona, Spain
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Engel ER, Nguyen ATH, Amankwah EK, Albisetti M, Brandão LR, Goldenberg NA, Betensky M. Predictors of postthrombotic syndrome in pediatric thrombosis: A systematic review and meta-analysis of the literature. J Thromb Haemost 2020; 18:2601-2612. [PMID: 32614496 DOI: 10.1111/jth.14984] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/28/2020] [Accepted: 06/22/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Postthrombotic syndrome (PTS) is a significant complication of pediatric deep venous thrombosis (DVT). There is a gap in the understanding of the risk factors associated with the development of pediatric PTS preventing the early identification of those patients at greatest risk, and the development of risk-stratified interventions. OBJECTIVES To conduct a systematic review and meta-analysis of the literature on prognostic factors for PTS development in pediatric patients. METHODS A systematic search of MEDLINE, EMBASE, and the Cochrane Library from 1960 to December 2018 was performed. Eligible studies reported at least one prognostic factor for PTS development in patients < 21 years of age with a radiographically confirmed DVT. To be included in the meta-analysis, prognostic factors had to be reported in at least three published studies. RESULTS AND CONCLUSIONS Twelve studies (n = 1160 patients) met criteria for inclusion. Ninety-three percent of patients with an extremity DVT (n = 1076) were assessed for PTS. PTS developed in 40% (n = 434) of these patients. Central venous catheter-associated DVT (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.08-2.98), complete veno-occlusion (OR, 1.89; 95% CI, 1.04-3.46), and incomplete DVT resolution (OR, 2.07; 95% CI, 1.4-3.07) were identified as candidate prognostic factors for pediatric PTS. These findings should be interpreted in the context of the heterogeneity of the included studies and the limitations of current pediatric PTS assessment tools. Further, the predictive value of these prognostic factors will need to be validated in future collaborative prospective multicenter studies that maximize the homogeneity of pediatric DVT patients.
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Affiliation(s)
- Elissa R Engel
- Department of Pediatrics, University of South Florida, Tampa, FL, USA
| | - Anh Thy H Nguyen
- Epidemiology and Biostatistics Unit, Johns Hopkins All Children's Health Informatics, St. Petersburg, FL, USA
| | - Ernest K Amankwah
- Epidemiology and Biostatistics Unit, Johns Hopkins All Children's Health Informatics, St. Petersburg, FL, USA
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, FL, USA
| | - Manuela Albisetti
- Hematology Department, University Children's Hospital, Zürich, Switzerland
| | - Leonardo R Brandão
- Division of Pediatric Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Neil A Goldenberg
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, FL, USA
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marisol Betensky
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins All Children's Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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Darwin E, Liu G, Kirsner RS, Lev-Tov H. Examining risk factors and preventive treatments for first venous leg ulceration: A cohort study. J Am Acad Dermatol 2019; 84:76-85. [PMID: 31884088 DOI: 10.1016/j.jaad.2019.12.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/25/2019] [Accepted: 12/14/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Large studies that examine risk factors for first occurrence of venous leg ulcerations are needed to guide management. OBJECTIVE To investigate factors associated with development of first occurrence of venous leg ulcerations. METHODS A retrospective cohort study using a validated national commercial claims database of patients with venous insufficiency. Subjects were followed to determine whether they developed first occurrence of venous leg ulcerations, and risk and protective factors were analyzed. RESULTS Adjusted hazard ratio (AHR) for comorbidities demonstrated an increased risk in men (AHR 1.838; 95% confidence interval [CI] 1.798-1.880), older age (45-54 years: AHR 1.316, 95% CI 1.276-1.358; 55-64 years, AHR 1.596, 95% CI 1.546-1.648), history of nonvenous leg ulceration (AHR 3.923; 95% CI 3.699-4.161), anticoagulant use (AHR 1.199; 95% CI 1.152-1.249), antihypertensive use (AHR 1.067; 95% CI 1.040-1.093), and preexisting venous insufficiency including chronic venous insufficiency (AHR 1.244; 95% CI 1.193-1.298), edema (AHR 1.224; 95% CI 1.193-1.256), and chronic venous hypertension (AHR 1.671; 95% CI 1.440-1.939). Possible protective factors were having venous surgery (AHR 0.454; 95% CI 0.442-0.467), using compression stockings (AHR 0.728; 95% CI 0.705-0.753), using prescribed statin medications (AHR 0.721; 95% CI 0.700-0.743), and using pain medications (AHR 0.779; 95% CI 0.757-0.777). LIMITATIONS Risk of misclassification, given the use of International Classification of Diseases, Ninth Revision codes. Possible confounding factors such as body mass index could not be adequately controlled with these codes. CONCLUSION The new evidence presented supports a paradigm shift toward venous leg ulceration prevention.
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Affiliation(s)
- Evan Darwin
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Guodong Liu
- Center for Applied Studies in Health Economics, Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Robert S Kirsner
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Hadar Lev-Tov
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida.
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Vosicka K, Qureshi MI, Shapiro SE, Lim CS, Davies AH. Post thrombotic syndrome following deep vein thrombosis in paediatric patients. Phlebology 2017; 33:185-194. [PMID: 28121229 DOI: 10.1177/0268355516686597] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Although well characterised in adults, less is known about post-thrombotic syndrome in children. In this review, current knowledge regarding paediatric post-thrombotic syndrome is summarised, with particular emphasis on pathophysiology, aetiology, diagnosis and management. Methods A Medline literature review was performed using search terms 'post thrombotic syndrome', 'post phlebitic syndrome', paediatric and children. Relevant articles were identified and included for summation analysis. Results The incident of paediatric venous thromboembolism is rising. Deep vein thrombosis can cause venous hypertension through a combination of venous reflux, venous obstruction and impairment of the calf muscle pump, leading to development of post-thrombotic syndrome. In children, this is more likely to occur if deep vein thrombosis diagnosis and treatment are delayed, if a higher number of vessels are involved, and if factors such as D-dimer are elevated at diagnosis and throughout treatment. Post-thrombotic syndrome occurs in about 26% of paediatric deep vein thrombosis, though the results of individual studies vary widely. A number of tools exist to diagnose paediatric post-thrombotic syndrome, including the modified Villalta scale and Manco-Johnson instrument. Once post-thrombotic syndrome develops, the mainstay of treatment remains supportive, with little evidence of benefit from pharmacological measures. Conclusion Surgical or interventional treatment is not advised except in exceptional cirumstances, due to variable prognosis of PTS in paediatric populations with rising incidence of paediatric venous thromboembolism, it follows that the prevalence of post-thrombotic syndrome in children may also increase. Evidence-based venous thromboembolism prevention strategies need to be implemented for prevention of deep vein thrombosis, but when it does occur, deep vein thrombosis requires prompt and effective treatment to prevent post-thrombotic syndrome. Optimum treatment strategies for post-thrombotic syndrome require further investigation.
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Affiliation(s)
- Klara Vosicka
- 1 Department of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, UK
| | - Mahim I Qureshi
- 1 Department of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, UK
| | - Susan E Shapiro
- 2 Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford Comprehensive Biomedical Resource Centre, Oxford, UK
| | - Chung S Lim
- 1 Department of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, UK
| | - Alun H Davies
- 1 Department of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, UK
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Flumignan CDQ, Flumignan RLG, Baptista-Silva JCC. Antiplatelet agents for the treatment of deep venous thrombosis. Hippokratia 2016. [DOI: 10.1002/14651858.cd012369] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Carolina DQ Flumignan
- Universidade Federal de São Paulo; Department of Surgery, Discipline of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo SP Brazil 04038-001
| | - Ronald LG Flumignan
- Universidade Federal de São Paulo; Department of Surgery, Discipline of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo SP Brazil 04038-001
| | - Jose CC Baptista-Silva
- Universidade Federal de São Paulo; Department of Surgery, Discipline of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo SP Brazil 04038-001
- Universidade Federal de São Paulo; Evidence Based Medicine, Cochrane Brazil; Rua Borges Lagoa, 564, cj 124 São Paulo São Paulo Brazil 04038-000
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Wang KL, Chu PH, Lee CH, Pai PY, Lin PY, Shyu KG, Chang WT, Chiu KM, Huang CL, Lee CY, Lin YH, Wang CC, Yen HW, Yin WH, Yeh HI, Chiang CE, Lin SJ, Yeh SJ. Management of Venous Thromboembolisms: Part I. The Consensus for Deep Vein Thrombosis. ACTA CARDIOLOGICA SINICA 2016; 32:1-22. [PMID: 27122927 DOI: 10.6515/acs20151228a] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
UNLABELLED Deep vein thrombosis (DVT) is a potentially catastrophic condition because thrombosis, left untreated, can result in detrimental pulmonary embolism. Yet in the absence of thrombosis, anticoagulation increases the risk of bleeding. In the existing literature, knowledge about the epidemiology of DVT is primarily based on investigations among Caucasian populations. There has been little information available about the epidemiology of DVT in Taiwan, and it is generally believed that DVT is less common in Asian patients than in Caucasian patients. However, DVT is a multifactorial disease that represents the interaction between genetic and environmental factors, and the majority of patients with incident DVT have either inherited thrombophilia or acquired risk factors. Furthermore, DVT is often overlooked. Although symptomatic DVT commonly presents with lower extremity pain, swelling and tenderness, diagnosing DVT is a clinical challenge for physicians. Such a diagnosis of DVT requires a timely systematic assessment, including the use of the Wells score and a D-dimer test to exclude low-risk patients, and imaging modalities to confirm DVT. Compression ultrasound with high sensitivity and specificity is the front-line imaging modality in the diagnostic process for patients with suspected DVT in addition to conventional invasive contrast venography. Most patients require anticoagulation therapy, which typically consists of parenteral heparin bridged to a vitamin K antagonist, with variable duration. The development of non-vitamin K oral anticoagulants has revolutionized the landscape of venous thromboembolism treatment, with 4 agents available,including rivaroxaban, dabigatran, apixaban, and edoxaban. Presently, all 4 drugs have finished their large phase III clinical trial programs and come to the clinical uses in North America and Europe. It is encouraging to note that the published data to date regarding Asian patients indicates that such new therapies are safe and efficacious. Ultimately, our efforts to improve outcomes in patients with DVT rely on the awareness in the scientific and medical community regarding the importance of DVT. KEY WORDS Combination therapy; Hypertension; α1-blocker.
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Affiliation(s)
- Kang-Ling Wang
- General Clinical Research Center, Taipei Veterans General Hospital; School of Medicine, National Yang-Ming University
| | - Pao-Hsien Chu
- Division of Cardiology, Department of Internal Medicine, Heart Failure Center, Healthcare Center, Chang Gung Memorial Hospital; College of Medicine, Chang Gung University
| | - Cheng-Han Lee
- Department of Internal Medicine, National Cheng Kung University Hospital; College of Medicine, National Cheng Kung University
| | - Pei-Ying Pai
- Division of Cardiology, Department of Internal Medicine, China Medical University Hospital; School of Medicine, China Medical University
| | - Pao-Yen Lin
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital
| | - Kou-Gi Shyu
- Division of Cardiology, Shin Kong Wu Ho-Su Memorial Hospital
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Hospital
| | - Kuan-Ming Chiu
- Division of Cardiovascular Surgery, Cardiovascular Center, Far Eastern Memorial Hospital
| | - Chien-Lung Huang
- Division of Cardiology, Department of Internal Medicine, Cheng Hsin General Hospital
| | - Chung-Yi Lee
- Department of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital
| | - Yen-Hung Lin
- Department of Internal Medicine, National Taiwan University Hospital
| | - Chun-Chieh Wang
- Department of Cardiology, Chang Gung Memorial Hospital; College of Medicine, Chang Gung University
| | - Hsueh-Wei Yen
- Division of Cardiology, Department of Internal Medicine; Kaohsiung Medical University Hospital
| | - Wei-Hsian Yin
- Division of Cardiology, Department of Internal Medicine, Cheng Hsin General Hospital
| | - Hung-I Yeh
- Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital; Mackay Medical College
| | - Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital; School of Medicine, National Yang-Ming University
| | - Shing-Jong Lin
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital
| | - San-Jou Yeh
- Division of Cardiology, Department of Internal Medicine, Heart Failure Center, Healthcare Center, Chang Gung Memorial Hospital; College of Medicine, Chang Gung University
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Catarinella FS, Nieman FHM, Wittens CHA. Reply. J Vasc Surg Venous Lymphat Disord 2016; 3:466. [PMID: 26992629 DOI: 10.1016/j.jvsv.2015.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 03/25/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Fabio S Catarinella
- Department of Venous Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Fred H M Nieman
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Cees H A Wittens
- Department of Venous Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Vascular Surgery, Universitäts Klinikum, Aachen, Germany
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Saghazadeh A, Rezaei N. Inflammation as a cause of venous thromboembolism. Crit Rev Oncol Hematol 2016; 99:272-85. [DOI: 10.1016/j.critrevonc.2016.01.007] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 11/27/2015] [Accepted: 01/12/2016] [Indexed: 12/12/2022] Open
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de Franciscis S, Gallelli L, Amato B, Butrico L, Rossi A, Buffone G, Caliò FG, De Caridi G, Grande R, Serra R. Plasma MMP and TIMP evaluation in patients with deep venous thrombosis: could they have a predictive role in the development of post-thrombotic syndrome? Int Wound J 2015; 13:1237-1245. [PMID: 26403997 DOI: 10.1111/iwj.12489] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 06/30/2015] [Accepted: 08/07/2015] [Indexed: 12/26/2022] Open
Abstract
Post-thrombotic syndrome (PTS) is a condition that can develop in about half of the patients with deep vein thrombosis (DVT) of lower limbs. In the present study, we evaluated the expression of inflammatory biomarkers in the early phases of DVT and their correlation with the onset of PTS. Patients were enrolled after the first episode of DVT and were followed up for 1, 4, 8, 12 and 18 months. At each visit, blood sample was collected to evaluate plasma levels of matrix metalloproteinase (MMP)-1,-2,-3,-7,-8 and -9 MMP inhibitors, TIMP-1,-2, neutrophil gelatinase-associated lipocalin (NGAL) and cytokines TNF-α and IL-6. Analysis included 201 patients [86 males (42·79%) and 115 females (57·21%); average age 56 ± 7 years]. Of the 201 patients, 47 (23·38%; 21 males, 26 females) developed PTS during the follow-up period. The control group was made up of 60 individuals without DVT (22 males and 38 females). High plasma levels of MMPs, NGAL and cytokines were recorded during the acute phase after DVT. Moreover, patients with PTS showed higher levels of MMP-1 and MMP-8 with respect to patients without PTS. There is a close relationship between DVT, the individual risk of PTS and specific biomarkers such as MMPs and other related molecules, which may help guide prevention and therapy based on the patient's individual risk profile, and has to be studied in future.
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Affiliation(s)
- Stefano de Franciscis
- Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology, Headquarters: University Magna Graecia of Catanzaro, Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Luca Gallelli
- Department of Health Sciences, University of Catanzaro, Catanzaro, Italy
| | - Bruno Amato
- Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology, Headquarters: University Magna Graecia of Catanzaro, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, University Federico II of Naples, Naples, Italy
| | - Lucia Butrico
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Alessio Rossi
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Gianluca Buffone
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy.,Division of Vascular Surgery, S. Anna Hospital, Catanzaro, Italy
| | | | - Giovanni De Caridi
- Department of Dentistry and Medical and Surgical Experimental Sciences, University of Messina, Messina, Italy
| | - Raffaele Grande
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology, Headquarters: University Magna Graecia of Catanzaro, Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
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Rates of elastic compression stockings prescription following the diagnosis of deep venous thrombosis among Canadian emergency physicians and trainees. CAN J EMERG MED 2015; 17:248-52. [PMID: 26034910 DOI: 10.1017/cem.2014.37] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
UNLABELLED Introduction Postthrombotic syndrome (PTS) is a complication of deep vein thrombosis (DVT) characterized by chronic pain, swelling, and heaviness, and may result in ulceration. Elastic compression stockings (ECS) worn daily after DVT have been shown to reduce the incidence and severity of PTS. The aim of our study was to investigate practices and perceptions of physicians regarding adjunct therapies to anticoagulation in patients diagnosed with lower extremity DVT. METHODS A national online survey was conducted of Canadian emergency medicine staff physicians and residents (n=471) to investigate their attitudes toward the prescription of ECS post-diagnosis of DVT. A paper survey of patients in a thrombosis clinic (n=58) was also administered to better understand the patient experiences with ECS. RESULTS The majority of staff physician (62%) and resident (69%) respondents were unsure of whether ECS were effective in preventing PTS and managing venous symptoms. Only 6% of staff physicians and 7% of residents routinely prescribed ECS for above-knee DVTs. More than 78% of respondents were unsure about the optimal timing of initiation of ECS and duration of therapy. Although all patients noted symptomatic relief with ECS, only 50% were prescribed stockings by an emergency or family doctor, and 69% of those patients wore the stockings on a daily basis. Staff physicians most frequently identified poor fit as the reason for lack of patient compliance, whereas patients most frequently cited cost. CONCLUSIONS Our findings suggest that there is variability in practice among Canadian emergency medicine physicians and trainees and a need for widespread education regarding the latest evidence of the benefit of ECS after DVT.
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Lang KJ, Saha P, Roberts LN, Arya R. Changing paradigms in the management of deep vein thrombosis. Br J Haematol 2015; 170:162-74. [DOI: 10.1111/bjh.13431] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Kathryn J. Lang
- King's Thrombosis Centre; King's College Hospital NHS Foundation Trust; London UK
| | - Prakash Saha
- Guy's Hospital; Guy's and St. Thomas’ NHS Foundation Trust; London UK
| | - Lara N. Roberts
- King's Thrombosis Centre; King's College Hospital NHS Foundation Trust; London UK
| | - Roopen Arya
- King's Thrombosis Centre; King's College Hospital NHS Foundation Trust; London UK
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Abstract
Introduction Acute thrombus removal therapies may reduce post-thrombotic syndrome in certain deep venous thrombosis patients. The LET classification is designed to identify patients at high risk for developing post-thrombotic syndrome in the acute phase using thrombus location and extent. This study evaluates the use of the LET classification to predict post-thrombotic syndrome in a cohort of patients after deep venous thrombosis. Methods A cohort of 660 deep venous thrombosis patients was invited to participate and fill out a questionnaire with Quality of life questionnaires, basic information, a modified self-assessment version of the Villalta scale for post-thrombotic syndrome and potential confounders. Original data on thrombus extension was available, and the LET classes were determined. Obtained information was analysed using ANOVA and in a multiple logistic regression model to correct for confounders. All different LET classes were compared to post-thrombotic syndrome occurrence, post-thrombotic syndrome prediction and disease specific quality of life scores (VEINES-Sym/Qol). Results Three hundred and fifteen patients responded, and in 309 a post-thrombotic syndrome score was distilled. LET I,II,III ( n = 63) had an odds ratio of 3.4(1.2–9.2) for predicting severe post-thrombotic syndrome, and LET II ( n = 17) had an odds ratio of 5.1(1.3–20.8) compared to LET class I ( n = 97). Both the VEINES-Sym and VEINES-Qol score were significantly lower for LET I,II,III compared to LET I, and LET II compared to LET I. Conclusion The LET classification can be used to classify patients according to acute thrombus location and extent. Extensive and centrally located (LET I,II,III) deep venous thrombosis showed the highest probability in developing severe post-thrombotic syndrome and lower disease specific quality of life.
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Affiliation(s)
- RHW Strijkers
- Department of Vascular Surgery and Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - CWKP Arnoldussen
- Department of Diagnostic and Interventional Radiology, Viecuri Medical Centre, Venlo, The Netherlands
- Department of Vascular Surgery, Maastricht University Medical Centre, The Netherlands
| | - CHA Wittens
- Department of Vascular Surgery and Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Vascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
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Affiliation(s)
- Ronald LG Flumignan
- Universidade Federal de São Paulo; Department of Surgery, Discipline of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo SP Brazil 04038-001
| | - Carolina DQ Flumignan
- Universidade Federal de São Paulo; Department of Surgery, Discipline of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo SP Brazil 04038-001
| | - Jose CC Baptista-Silva
- Universidade Federal de São Paulo; Surgery and Evidence Based Medicine, Brazilian Cochrane Centre; Rua Borges Lagoa, 564, cj 124 São Paulo São Paulo Brazil 04038-000
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16
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Catarinella FS, Nieman FHM, de Wolf MAF, Wittens CHA. Short-term follow-up of Quality-of-Life in interventionally treated patients with post-thrombotic syndrome after deep venous occlusion. Phlebology 2014; 29:104-111. [DOI: 10.1177/0268355514529505] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Treatment of deep venous occlusive disease is gaining popularity, although the results and outcomes of various techniques are yet to be fully studied. Quality-of-Life (QoL) improvement is a valid and important outcome in medicine, but no specific QoL instruments for deep venous pathology exist up until now. We assessed the short term QoL effects of treated patients with post thrombotic syndrome after deep venous occlusion. Materials and methods Patients with proven venous occlusive disease referred to the outpatient clinic of our department of Venous Surgery in the Maastricht University Medical Centre were included. After inclusion, patients were treated by PTA and stenting and when indicated an endophlebectomy was performed and an AV fistula was made. QoL was assessed with the disease specific VEINES-QOL/Sym and the generic SF-36 questionnaires preoperatively at baseline and postoperatively at 3 and 12 months. Results 61 patients completed the 3 month follow-up period and 28 patients the 12 month follow-up period. VEINES-QOL and Sym scores improved after 3 months: 17.5 points for QOL (p = < 0.001) and 21.4 points for Sym (p = < 0.001)) and after 12 months 18.8 points for QOL (p = 0.004) and 21.3 points for Sym (p = 0.003)). The SF-36 scores improved significantly in the domains “physical functioning”, “role physical” and “bodily pain”. Conclusions Treating deep venous occlusive disease leads to short-term improvement of both disease specific QoL as well as generic QoL scores. Larger long-term follow-up studies are needed to corroborate these results.
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Affiliation(s)
- FS Catarinella
- Department of Venous Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - FHM Nieman
- Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - MAF de Wolf
- Department of Venous Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - CHA Wittens
- Department of Venous Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
- Department of vascular surgery, Universitäts Klinikum, Aachen, Germany
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Grommes J, von Trotha K, Wolf MD, Jalaie H, Wittens C. Catheter-directed thrombolysis in deep vein thrombosis: Which procedural measurement predicts outcome? Phlebology 2014; 29:135-139. [PMID: 24843099 DOI: 10.1177/0268355514529394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The post-thrombotic syndrome (PTS) as a long-term consequence of deep vein thrombosis (DVT) is caused by a venous obstruction and/or chronic insufficiency of the deep venous system. New endovascular therapies enable early recanalization of the deep veins aiming reduced incidence and severity of PTS. Extended CDT is associated with an increased risk of bleeding and stenting of residual venous obstruction is indispensable to avoid early rethrombosis. Therefore, this article focuses on measurements during or after thrombolysis indicating post procedural outcome.
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Affiliation(s)
- J Grommes
- European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Germany
| | - Kt von Trotha
- European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Germany
| | - Ma de Wolf
- European Vascular Center Aachen-Maastricht, Maastricht University Medical Centre, the Netherlands
| | - H Jalaie
- European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Germany
| | - Cha Wittens
- European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Germany European Vascular Center Aachen-Maastricht, Maastricht University Medical Centre, the Netherlands
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Abstract
The results of the CaVent-study and the expected results of the ATTRACT and CAVA trials will form the base of evidence to support that rapid cloth removal is beneficial for patients with iliofemoral DVT. Although beneficial, there are still significant risks associated with this therapy. Therefore alternative methods for rapid cloth removal without lysis are a potential valid alternative. In this article we describe the techniques currently available for thrombolysis and discuss the potential improvements to be made to clot removal techniques in the future.
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Affiliation(s)
- Rob HW Strijkers
- Department of Vascular Surgery and Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Carsten WKP Arnoldussen
- Department of Diagnostic and Interventional Radiology, Viecuri Medical Centre, Venlo, The Netherlands
- Department of Vascular Surgery, Maastricht University Medical Centre, The Netherlands
| | - Cees HA Wittens
- Department of Vascular Surgery and Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
- Department of Vascular Surgery, University Hospital RWTH Aachen, Nordrhein-Westfalen, Pauwelsstraße 30, 52074 Aachen, Germany
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de Wolf MAF, Arnoldussen CWKP, Wittens CHA. Indications for endophlebectomy and/or arteriovenous fistula after stenting. Phlebology 2013; 28 Suppl 1:123-8. [PMID: 23482547 DOI: 10.1177/0268355513477063] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovenous recanalization with percutaneous transluminal angioplasty and stenting in post-thrombotic syndrome patients with iliocaval obstruction is a treatment modality quickly gaining popularity. Studies show good patency and clinical success rates. If the obstruction extends distally, below the inguinal ligament, stenting remains controversial. Without adequate inflow, the patency of stented iliocaval segments drops dramatically. This suggests that treatment of diseased common femoral, femoral and profunda femoral veins is required to ensure adequate inflow. Endophlebectomy, the removal of synechiae and septae from the common femoral vein, is a viable option in these cases. Another option, which can be done concurrently with the endophlebectomy, is the creation of an arteriovenous fistula. Selecting patients for these interventions however remains difficult, as precise preoperative prediction of inflow into the stented segments is difficult. In this paper we describe our experience in using duplex ultrasonography, magnetic resonance venography and conventional venography to assess the patency of the inflow trajectory. We believe this approach is essential in dealing with cases of complex post-thrombotic disease extending below the inguinal ligament. There is a great need to establish criteria to accurately assess pre- and postinterventional flow through treated vein segments.
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Affiliation(s)
- M A F de Wolf
- Department of General Surgery, Maastricht University Medical Center (MUMC), Maastricht, the Netherlands
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Minimally invasive treatment of chronic iliofemoral venous occlusive disease. J Vasc Surg Venous Lymphat Disord 2013; 1:146-53. [DOI: 10.1016/j.jvsv.2012.07.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 05/22/2012] [Accepted: 07/15/2012] [Indexed: 11/19/2022]
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Jackson BP, McCloskey LJ, Stickle DF. Investigation of a slope discontinuity in a patients’ results distribution for D-dimer. Clin Chem Lab Med 2012; 50:2243-5. [PMID: 23095197 DOI: 10.1515/cclm-2012-0491] [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: 06/28/2012] [Accepted: 08/01/2012] [Indexed: 11/15/2022]
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