In the Clinic. Deep venous thrombosis

Resistance exercise promotes the resolution and recanalization of deep venous thrombosis in a mouse model via SIRT1 upregulation

BACKGROUND

Early exercise for acute deep venous thrombosis (DVT) improves the patient's symptoms and does not increase the risk of pulmonary embolism. However, information about its effect on thrombus resolution is limited. The aim of this study was to investigate the role of resistance exercise (RE) in thrombus resolution and recanalization and determine its underlying mechanisms.  METHODS: Ninety-six C57BL/6 J mice were randomly divided into four groups: Control group (C, n = 24); DVT group (D, n = 24); RE + DVT group (ED, n = 24); and inhibitor + RE + DVT group (IED, n = 24). A DVT model was induced by stenosis of the inferior vena cava (IVC). After undergoing IVC ultrasound within 24 h post-operation to confirm DVT formation, mice without thrombosis were excluded. Other mice were sacrificed and specimens were obtained 14 or 28 days after operation. Thrombus-containing IVC was weighed, and the thrombus area and recanalization rate were calculated using HE staining. Masson's trichrome staining was used to analyze the collagen content. RT-PCR and ELISA were performed to examine IL-6, TNF-α, IL-10, and VEGF expression levels. SIRT1 expression was assessed using immunohistochemistry staining and RT-PCR. VEGF-A protein expression and CD-31-positive microvascular density (MVD) in the thrombus were observed using immunohistochemistry.  RESULTS: RE did not increase the incidence of pulmonary embolism. It reduced the weight and size of the thrombus and the collagen content. Conversely, it increased the recanalization rate. It also decreased the levels of the pro-inflammatory factors IL-6 and TNF-α and increased the expression levels of the anti-inflammatory factor IL-10. RE enhanced VEGF and SIRT1 expression levels and increased the MVD in the thrombosis area. After EX527 (SIRT1 inhibitor) was applied, the positive effects of exercise were suppressed.

CONCLUSIONS

RE can inhibit inflammatory responses, reduce collagen deposition, and increase angiogenesis in DVT mice, thereby promoting thrombus resolution and recanalization. Its underlying mechanism may be associated with the upregulation of SIRT1 expression.

Construction and Verification of Risk Predicting Models to Evaluate the Possibility of Venous Thromboembolism After Robot-Assisted Radical Prostatectomy

Background

Venous thromboembolism (VTE) is the second leading cause for death of radical prostatectomy. We aimed to establish new nomogram to predict the VTE risk after robot-assisted radical prostatectomy (RARP).

Methods

Patients receiving RARP in our center from November 2015 to June 2021, were enrolled in study. They were randomly divided into training and testing cohorts by 8:2. Univariate and multivariate logistic regression (model A) and stepwise logistic regression (model B) were used to fit two models. The net reclassification improvement (NRI), integrated discrimination improvement (IDI), and receiver operating characteristic (ROC) curve were used to compare predictive abilities of two new models with widely used Caprini risk assessment (CRA) model. Then, two nomograms were constructed and received internal validation.

Results

Totally, 351 patients were included. The area under ROC of model A and model B were 0.967 (95% confidence interval: 0.945–0.990) and 0.978 (95% confidence interval: 0.960–0.996), which also were assayed in the testing cohorts. Both the prediction and classification abilities of the two new models were superior to CRA model (NRI > 0, IDI > 0, p < 0.05). The C-index of Model A and Model B were 0.968 and 0.978, respectively. For clinical usefulness, the two new models offered a net benefit with threshold probability between 0.08 and 1 in decision curve analysis, suggesting the two new models predict VTE events more accurately.

Conclusions

Both two new models have good prediction accuracy and are superior to CRA model. Model A has an advantage of less variable. This easy-to-use model enables rapid clinical decision-making and early intervention in high-risk groups, which ultimately benefit patients.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-022-11574-5.

Curcumin promotes venous thrombi resolve process in a mouse deep venous thrombosis model via regulating miR-499

BACKGROUND/AIMS

The morbidity of deep venous thrombosis (DVT) is increasing rapidly and the current therapeutic strategies for DVT are unsatisfactory. Accumulating evidence suggest that venous thrombi resolve (VTR) may provide new insights into DVT therapeutic strategies. The aim of this study was to investigate the role of curcumin in VTR process and try to reveal the potential mechanism.

METHODS

Immunofluorescence and HE staining were performed to investigate the therapeutic angiogenesis effect of curcumin in VTR process. Microarray analysis and RT-PCR were performed to examine the expression level of miR-499 in thrombosis after curcumin administration. Cell proliferation, migration and angiogenesis capacity were tested by CCK8 assay, Transwell assay and Tube formation assay, respectively. Dual-luciferase reporter assay (DLR) was used to confirm the connection between miR-499 and paired phosphate and tension homology deleted on chromosome ten (PTEN).

RESULTS

We found that curcumin could effectively promote VTR process by activating angiogenesis in thrombus in vivo. The expression of miR-499 exhibited notably downregulated after curcumin administration. The proangiogenic effect of curcumin in HUVECs could be blocked by miR-499 overexpression. In addition, we confirmed that miR-499 directly target to the 3'UTR region of PTEN.

CONCLUSION

Curcumin promotes VTR process in DVT through activating therapeutic angiogenesis. Mechanically, curcumin promotes therapeutic angiogenesis by regulating miR-499 mediated PTEN/VEGF/Ang-1 signaling pathway.

Xueshuantong Injection in Treating Deep Venous Thrombosis: A Systematic Review and Trial Sequential Analysis

AIMS

In recent years, the incidence of deep venous thrombosis (DVT) presents an increasing trend year by year. The current evidence regarding the efficacy and safety of Xueshuantong injection for DVT is controversial. This systematic review (SR) aimed to assess the efficacy and safety of Xueshuantong injection in the treatment of DVT systematically and provide an evidence-based reference for clinical treatment.

METHODS

Nine electronic databases were used to identify the literature consisting of randomized controlled trials (RCTs) with a date of search of 1 November 2020. Clinical effective rate and incidence rate of adverse events were investigated as primary outcomes. Patency rate of femoral vein, patency rate of popliteal vein, patency rate of posterior tibial vein, circumference difference, activated partial thromboplastin time (APTT), and D-dimer (D-D) were investigated as secondary outcomes. Revman 5.4.1 was used to analyze the results. Analysis of the power of evidence was performed with Trial Sequential Analysis (TSA).

RESULTS

A total of 12 articles including 1018 patients were included. The results of the meta-analysis showed that the clinical effective rate in the experimental group was higher than that in the control group, the incidence rate of adverse events in the experimental group was higher than that in the control group; after the operation, the patency rate of femoral vein, patency rate of popliteal vein, patency rate of posterior tibial vein, circumference difference, APTT, and D-D in the experimental group were significantly improved compared with those in the control group, and the difference between the groups was statistically significant. TSA suggested that the meta-analysis concerning the clinical effectiveness of Xueshuantong injection in the treatment of DVT was of adequate power to reach firm conclusions.

CONCLUSION

Based on the current analysis, Xueshuantong injection as an add-on treatment provided better treatment effect for DVT with adequate power but this benefit should be considered with caution because of the small number of studies included in the meta-analysis and the high or unclear risk of bias of the included trials, suggesting that further studies are needed.

Prognostic nomogram for 30-day mortality of deep vein thrombosis patients in intensive care unit

Background

We aimed to use the Medical Information Mart for Intensive Care III database to build a nomogram to identify 30-day mortality risk of deep vein thrombosis (DVT) patients in intensive care unit (ICU).

Methods

Stepwise logistic regression and logistic regression with least absolute shrinkage and selection operator (LASSO) were used to fit two prediction models. Bootstrap method was used to perform internal validation.

Results

We obtained baseline data of 535 DVT patients, 91 (17%) of whom died within 30 days. The discriminations of two new models were better than traditional scores. Compared with simplified acute physiology score II (SAPSII), the predictive abilities of two new models were improved (Net reclassification improvement [NRI] > 0; Integrated discrimination improvement [IDI] > 0; P < 0.05). The Brier scores of two new models in training set were 0.091 and 0.108. After internal validation, corrected area under the curves for two models were 0.850 and 0.830, while corrected Brier scores were 0.108 and 0.114. The more concise model was chosen to make the nomogram.

Conclusions

The nomogram developed by logistic regression with LASSO model can provide an accurate prognosis for DVT patients in ICU.

Delayed surgery versus nonoperative treatment for hip fractures in post-COVID-19 arena: a retrospective study of 145 patients

Background and purpose - Following the outbreak of COVID-19 in December 2019, in China, many hip fracture patients were unable to gain timely admission and surgery. We assessed whether delayed surgery improves hip joint function and reduces major complications better than nonoperative therapy. Patients and methods - In this retrospective observational study, we collected data from 24 different hospitals from January 1, 2020, to July 20, 2020. 145 patients with hip fractures aged 65 years or older were eligible. Clinical data was extracted from electronic medical records. The primary outcomes were visual analogue scale (VAS) score and Harris Hip Score. Major complications, including deep venous thrombosis (DVT) and pneumonia within 1 month and 3 months, were collected for further analysis. Results - Of the 145 hip fracture patients 108 (median age 72; 70 females) received delayed surgery and 37 (median age 74; 20 females) received nonoperative therapy. The median time from hip fracture injury to surgery was 33 days (IQR 24-48) in the delayed surgery group. Hypertension, in about half of the patients in both groups, and cerebral infarction, in around a quarter of patients in both groups, were the most common comorbidities. Both VAS score and Harris Hip Score were superior in the delayed surgery group. At the 3-month follow-up, the median VAS score was 1 in the delayed surgery group and 2.5 in the nonoperative group (p < 0.001). Also, the percentage of complications was higher in the nonoperative group (p = 0.004 for DVT, p < 0.001 for pulmonary infection). Interpretation - In hip fracture patients, delayed surgery compared with nonoperative therapy significantly improved hip function and reduced various major complications.

Sequential Release Platform of Heparin and Urokinase with Dual Physical (NIR-II and Bubbles) Assistance for Deep Venous Thrombosis

Disability and even death from acute thrombosis remain a grave menace to public health. At present, the traditional drugs represented by urokinase (UK) in clinical thrombolysis can cause side effects of bleeding when the dosage is excess. Therefore, a more effective and safer method of thrombolysis is urgently needed. In this paper, a multifunctional dual-drug sequential release thrombolysis platform (UK-UH@PDA@HMSNs) consisting of polydopamine (PDA)-modified hollow mesoporous silicon (HMSNs) loading with UK and unfractionated heparin (UH) was constructed with a double physical assistance (NIR-II and bubbles). With the aid of near infrared-II (NIR-II, 1064 nm, 1.0 W cm^-2) laser, the photothermal effect of PDA could be motivated to facilitate the UH release, thereby accelerating the dissolution of thrombus. Afterward, the local hyperthermia effect could expedite the phase transition of l-menthol in HMSNs to generate bubbles to promote the release of UK, thereby realizing the sequential release of two thrombolytic drugs. Importantly, this method deftly conquered the inherent obstacle that UK and UH cannot be combined directly. In vivo and in vitro experiments proved that the thrombolytic efficiency of UK-UH@PDA@HMSNs stimulated by NIR-II was nearly 3 times than that of UK alone. Collectively, the proposed dual physical assistance and sequential dual-drug delivery system significantly improved the efficiency of thrombolysis under the premise of limiting drug doses; the risk of death from intracranial hemorrhage thus could be decreased radically.

Risk factors associated with deep venous thrombosis in patients with different bed-rest durations: A multi-institutional case-control study

BACKGROUND

Deep vein thrombosis represents a threat to public health and a heavy economic burden to society, and often occurs as a complication or cause of death in bedridden patients. How to prevent deep vein thrombosis is a general concern in clinical practice. However, it remains uncertain whether the risk factors for deep vein thrombosis would be affected by different bed-rest durations. Solving this issue will be invaluable for the provision of more rational medical care to prevent deep vein thrombosis.

OBJECTIVE

To explore whether risk factors for deep vein thrombosis are affected by bed-rest durations and to identify different risk factors in groups with different bed-rest durations.

DESIGN

A retrospective multicenter case-control study.

SETTINGS AND PARTICIPANTS

This multicenter study was conducted in wards with high rates of bed rest in 25 general hospitals in China. Participants were bedridden patients from these wards.

METHODS

Bedridden patients were identified from the research database of bedridden patients' major immobility complications. These data were collected from prospective descriptive studies by a standardized web-based online case report form. Cases were defined as bedridden patients who suffered deep vein thrombosis during hospitalization (n=186). Each case was matched with three controls, bedridden patients who did not suffer deep vein thrombosis in the same center with the same bed-rest duration (n=558). Descriptive statistics, univariate analysis, and multivariate conditional logistic regression models were employed.

RESULTS

Among 23,985 patients, the overall incidence of deep vein thrombosis during hospitalization was 1.0%. Multivariate analysis showed that for patients with bed-rest duration of 4 weeks or less, older age (odds ratio [OR] =1.027, 95% confidence interval [CI] 1.013-1.041) and being in a surgical department (OR=2.527, 95% CI 1.541-4.144) were significantly associated with increased risk of deep vein thrombosis. Female sex (OR=4.270, 95% CI 1.227-14.862), smoking (OR=10.860, 95% CI 2.130-55.370), and special treatment (OR=3.455, 95% CI 1.006-11.869) were independent factors predicting deep vein thrombosis for patients with bed-rest durations from 5 to 8 weeks. For those with bed-rest durations from 9 to 13 weeks, Charlson Comorbidity Index (OR=1.612, 95% CI 1.090-2.385) was the only independent risk factor for deep vein thrombosis.

CONCLUSIONS

Risk factors for deep vein thrombosis varied among patients with different bed-rest durations. This finding is helpful for nurses to increase their awareness of prevention of deep vein thrombosis in patients with different bed-rest durations, and lays a more solid foundation for clinical decision making.

Initial experience with a new pharmacomechanical thrombectomy device for deep venous thrombosis: Report of 91 cases

Background

To evaluate the efficacy and safety of pharmacomechanical thrombectomy using a new rotational thrombectomy device with additional thrombus-removal methods for deep venous thrombosis.

Methods

A total of 91 patients admitted to our tertiary center with symptomatic iliac, ilio-femoral, femoro-popliteal deep venous thrombosis and who underwent hybrid pharmacomechanical thrombectomy constituted the study group. Postinterventional color Doppler ultrasonography was repeated at 1st, 6th, and 12th months. Villalta scoring system was used to evaluate the patients for the development of post-thrombotic syndrome after deep venous thrombosis. The patient-reported severity of pain in the index leg was measured on a Likert scale.

Results

Of the 91 patients whose charts were reviewed, the location of thrombus was iliofemoral in 60 (65.9%) and femoropopliteal in 31 (34.1%) patients, respectively. Duration of symptoms was 5.62 ± 3.43 (range, 2–15) days. Technical success was observed in 82 patients (90.1%) at 3 months, in 77 patients (84.6%) at 6 months, and in 74 patients (81.3%) at 12 months. Villalta score was over 10 points in 15 of 17 patients whose Doppler US revealed venous occlusions, at 12 months, and in 8 patients with recurrent deep venous thrombosis. Post-thrombotic syndrome was detected in 18 patients in our study. Twelve (13.2%) of these 18 patients had mild, 5 (5.5%) moderate, and 1 (1.1%) severe PTS. In predicting predisposing factors in 18 patients with PTS, 13 patients (72.2%) had a Villalta score ≥10, 10 patients (55.6%) had experienced a delayed endovascular procedure (≥10 days), and 8 patients (44.4%) had recurrent deep venous thrombosis.

Conclusion

The endovenous pharmacomechanical thrombectomy with the Mantis thrombectomy device in the treatment of acute and subacute iliofemoral deep venous thrombosis is a promising approach in terms of efficacy and safety in the early period regarding reasonable and long-term prevention of post-thrombotic syndrome, development of pulmonary thromboembolism, and adequate venous system patency.