Thrombotic Risk of Women with Hereditary Antithrombin III-, Protein C- and Protein S-Deficiency Taking Oral Contraceptive Medication

The thrombotic risk of women with a heterozygous natural clotting inhibitor deficiency taking oral contraceptives (OC) has not been evaluated. Therefore, a retrospective collaborative controlled cohort-study was carried out in 8 coagulation laboratories and thrombosis units in Austria, Germany and Switzerland.

The incidence of thromboembolism in 48 females heterozygous for hereditary type I deficiency of antithrombin ITT (n = 1.5), protein C. (n = 16) or protein S (n = 17), who had taken OC at least once in their life were compared with that of 48 deficient women, who had never taken OC (controls). Diagnosis of the deficiency state was made in the participating centers. Data on the onset and duration of OC intake and the date and site of thrombotic events were obtained from a questionnaire filled in by the patient or a physician during a visit at a participating center. The observation period in the OC patients was started with onset of OC intake and was terminated when a thromboembolic event had occurred or when OC medication were discontinued. In the patients without OC, the observation period began at an age matched to that of the OC patient and ended when a thromboembolic event had occurred or was continued as long as the corresponding OC patient was on treatment.

In AT Ill-deficient females the probability for thrombosis was significantly higher for patients taking OC compared to the non-OC-patients (Wilcoxon test p = 0.004, Log Rank test p = 0.005). In patients with protein C- ((3-error 0.8) and protein S-deficiency ((3-error 0.05) there was no significant difference between the OC- and non-OC-group. The incidence of thrombosis/patient year in AT III-, PC- and PS-deficient females on OC was 27.5%, 12% and 6.5%, respectively and 3.4%, 6.9% and 8.6%, respectively, in the control patients.

We conclude that females with hereditary antithrombin Ill-deficiency are at high risk for venous thromboembolism when taking OC. Therefore, OC should be strictly avoided in these females and AT III measurement is mandatory in female relatives of AT Ill-deficient patients at young age before starting OC. There is no evidence for an excess thrombotic risk by OC intake in PS-deficient females. In protein C-deficient women OC medication was not associated with a significant increase of thrombosis, but an increased risk cannot be excluded.

Congenital Deficiency of Plasminogen and Its Relationship to Venous Thrombosis

In a patient with deep venous thrombosis, plasma concentrations of coagulant and inhibitor proteins were normal except for moderate deficiency of plasminogen. Family studies revealed a similar deficiency in the mother and sister of the propositus. Evaluation of purified plasminogen demonstrated that it functioned normally. The patient represents our only example of plasminogen deficiency in 435 German individuals evaluated with a history of thromboembolism.

Abschätzung des Thromboserisikos bei internistischen Patienten

Bei einem thromboembolischen Ereignis handelt es sich möglicherweise um eine vermeidbare Komplikation, wenn das Risiko prospektiv erkennbar ist. Die richtige Einschätzung des individuellen Risikos ist deshalb von herausragender klinischer Bedeutung, bei internistischen Patienten wegen der Komplexität und Multimorbidität älterer Patienten jedoch schwierig. Bei nicht chirurgischen Patienten ist das individuelle Thromboserisiko definiert als Summe aus expositionellen und dispositionellen Risikofaktoren, die nach evidenzbasierter Studienlage gewichtet und in ein Risikoschema umgesetzt werden. In ein praxisnahes und alltagstaugliches Risikoschema können nicht alle klinischen Situationen aufgenommen werden, jedoch erlauben die Schemata in dieser Arbeit die flexible Anwendung und Anpassung an die individuelle Patientensituation in Klinik und ambulanter Versorgung. Damit soll ermöglicht werden, dass der Arzt eine begründete Ja/Nein-Entscheidung zur Thromboseprophylaxe treffen kann.

Therapie mit Dabigatran

Summary Dabigatran, an oral, reversible direct factor IIa inhibitor, is approved in Europe for stroke prevention in atrial fibrillation and for the prevention of venous thromboembolism after elective hip and knee replacement. In contrast to vitamin K antagonists, a routine coagulation monitoring during the treatment with dabigatran etexilate is not necessary. However, in specific clinical situations such as invasive emergency procedures or serious haemorrhage, the actual anticoagulant status of dabigatran may be of importance for the treating clinician and can be assessed by clotting tests (aPTT, TT, ECT). The diluted thrombin time test (Hemoclot®), which is specifically calibrated for dabigatran, is useful for quantitative determination of the dabigatran serum concentration. In general, discontinuation of dabigatran etexilate 24 hours before standard elective surgery is sufficient to normalise the bleeding risk in patients with normal renal function. In patients with renal impairment and/or in the case of a high bleeding risk procedure the recommended duration of discontinuation is prolonged. If a bleeding episode occurs in a patient on dabigatran, further treatment should be based on the severity and localisation of the bleeding. A distinct feature of dabigatran is the possibility of effectively removing dabigatran from the circulation by haemodialysis. Recommendation: In the case of clinically minor bleedings, a delay in the administration of the next dabigatran etexilate dose is recommended. The length of the delay is based on the patient’s individual thromboembolic risk. In minor bleedings the use of prothrombin complex concentrates is not indicated. In the case of moderate or major bleedings the main focus should be on stabilising the circulation by using fluids and blood products and, if a lesion can be identified, the local treatment thereof. If time and infrastructure is available, dialysis offers an effective and fast option to remove dabigatran out of the circulation. In the incidence of severe and life threatening bleedings, an additional, more complex haemostasis management is required. Besides haemodynamic stabilisation of the circulation, administration of prothrombin complex concentrates should not be delayed. It has to be kept in mind that standard laboratory coagulation parameters may not accurately reflect the effect of prothrombin complex concentrates in patients on dabigatran. Hence the effect of the prothrombin complex concentrate should be monitored clinically and adjusted by means of onset of coagulation in vivo.

Leg Ulcer Patients: No Decreased Fibrinolytic Response but White Cell Trapping after Venous Occlusion of the Upper Limb

Objective:

To study changes in indicators of fibrinolytic activity and white cell trapping in response to raised venous pressure in the upper limbs of patients with chronic venous insufficiency.

Design:

Comparison of disease group versus control group study.

Setting:

Departments of Dermatology and Medicine, University of Freiburg.

Patient:

Thirty patients with chronic venous insufficiency and thirty control subjects of similar age with unrelated conditions.

Interventions:

The venous pressure was raised in one upper limb by application of a sphygmomanometer cuff around the upper arm for a period of 10 minutes.

Main outcome measures:

Red cell count, white cell count, plasminogen activator inhibitor, tissue plasminogen activator were measured in blood drawn from the arm subjected to raised venous pressure.

Results:

No significant changes were observed in the parameters of fibrinolytic activity. After 10 minutes of venous hypertension the white cell trapping in the disease group was 17.7% (interquartile range, 10.7–22), compared with 12.8% (interquartile range 4.9–16.1%) in the control group.

Conclusion:

The differences in white cell trapping parameters between healthy control subjects and patients with chronic venous insufficiency is probably attributable to systemic activation of white cells associated with their venous disease.

[On the ancient and magical lesions in the sixteenth to eighteenth centuries]

At the beginning of the Renaissance magical, witchcraft and demonological medicine still played a large role in the poor healing ability of chronic leg ulcers. This included the general administration of magical potions and topical application. An example of the manipulation of the whole body by the devil was the Abracadabra text from Johann Christoph Bitterkraut in the year 1677. The use of bewitched ointments was particularly propagated by Paracelsus in 1622; however, even as early as the beginning of the seventeenth century, the invocation of supernatural powers was slowly diminishing until at the beginning of the nineteenth century the medical schools on chronic leg ulcers could be cultivated at the universities and by specialized wound healers.

[New oral anticoagulants. Significance for dermatology and phlebology]

Venous thromboembolism and atrial fibrillation are common and are treated with vitamin K antagonists in 1.7% of the total population in the western world. The limitations of the vitamin K antagonists and of heparin have led to the development of new oral drugs. These drugs inhibit thrombin or factor Xa and can be given in a fixed dosage; they have a broad therapeutic margin and relatively few drug interactions. Specific risks and problems also are associated with the new drugs such as interference with common coagulation tests without being able to draw any conclusion as to the actual bleeding risk and the lack of specific antidotes. No established coagulation monitoring is available. The article gives reviews the current knowledge and provides practical advice on how to use the new drugs for the approved indications such as knee and hip replacement, therapy of deep venous thrombosis and of atrial fibrillation. Beyond that, recommendations are given for perioperative management and for change of treatment.

Die Behandlung der Varikose zu Billroths Zeiten

Theodor Billroth was one of the founders of our modern surgery. He was trained at the Berliner Charité hospital and at the age of 30, was appointed Professor at Zürich University. In 1867 he moved to Vienna University as Director of the Second Surgical Hospital where he was a member of the famous Neuen Wiener Schule (New Vienna School). Among his scientific achievements were papers on wound infection, the introduction of medical statistics, the discovery of new methods of surgery and reform of the study of medicine.

Many new editions of Billroth’s textbook „Die allgemeine chirurgische Pathologie und Therapie“ (General Surgical Pathology and Treatment) have appeared since 1863 and it has been translated into several languages. One of the 50 lectures dealt in great detail with varicose veins. Prior to the introduction of antisepsis, virtually all operations were at risk from the danger of wound fever and hence a fatal outcome. Although Billroth knew the suturing methods of the French School and also taught them in lectures, he nonetheless thought, “It’s a shame they are futile and not entirely without danger“. The possibilities of conservative treatment were exhaustively described.

Bloodletting and the saphenous veins

Bloodletting is one of the oldest forms of treatment in our culture complex. It was already in use as a ritual in biblical-talmudic medicine. In Germany it is still in use today in complementary medicine as “Hildegard's bloodletting”. The theoretical principle is based on the four humour philosophy of antiquity which was introduced to medicine as humoral pathology by Galen (129–199 AD). The four humours are blood, phlegm, yellow and black bile. In healthy people these were in equilibrium with each other. Imbalance caused diseases.

Bloodletting was performed prophylactically to keep people healthy and to treat almost all serious conditions and injuries. In the Middle Ages many conditions had to be satisfied during the performance. The positions of the stars and the zodiac were vital. A rising moon the in respective sign of the zodiac was considered dangerous. However, age, sex, climate, season of the year, wind direction and the stage of the disease all played a role. Each organ had its own special vein. Even the person performing the bleeding also had to satisfy certain conditions. Surgeons were expected to see well, not to have podgy hands or tremor, and not to be drunk. He had to have sharp instruments and be skilled in their use. Walther Ryff (1500–1562) was a strong advocate of the method at the beginning of modern times in Germany.

Bloodletting also included inspection of the blood. To this end, blood was collected in bloodletting vessels, many of which were attractively ornamented. The surgeon also had to assess the taste of the blood. Bloodletting was associated with a wide range of complications before the advent of antiseptic techniques, deaths were not uncommon. It was not until modern times that warning voices started to advise against the procedure; the most vociferous being Christian Friedrich Samuel Hahnemann (1755–1843), the founder of homoeopathy.

[Diagnosis and treatment of venous thrombosis]

In the diagnosis of deep vein thrombosis in ambulatory patients, the recommended initial steps are assessment of clinical probability (CP) and a sensitive D-dimer test. With a low CP and negative D-dimer, thrombosis can be ruled out. All other constellations require further investigation with imaging techniques. Compression ultrasonography is the first-line investigation. Low-molecular weight heparin or fondaparinux is the treatment of choice for uncomplicated venous thrombosis. Secondary prophylaxis with a vitamin K antagonist is introduced in parallel as quickly as possible. The duration of treatment depends on the exposure and predisposing factors, weighing carefully the risk of recurrence on the one hand against the risk of bleeding on the other. The danger of a post thrombotic syndrome is reduced by the immediate begin of a long lasting compression therapy.

Hundert Jahre Babcock-Operation

William Wayne Babcock (1872–1963) gehörte zu den herausragenden Persönlichkeiten einer Gründergeneration der amerikanischen Chirurgie. Schon als 31-jähiger Wissenschaftler war er so renommiert, dass ihm die Leitung der Frauenklinik und der Chirurgischen Klinik an der Temple University in Philadelphia übertragen wurde. Er behielt diese Stellungen während seines ganzen Berufslebens inne und erhielt alle Ehrungen seiner Zeit. Zu den wichtigsten Arbeiten zählten die neuen Operationsverfahren der kolorektalen Chirurgie.

Die Babcock-Venenexhairese mit einem intravasalen Stripper ergab sich gewissermaßen als logische Konsequenz der theoretischen Ansichten zur Phlebologie anfangs des 20. Jahrhunderts. Vorausgegangen waren ungünstige Erfahrung mit der Keller- und der Mayo-Methode. In der ersten Veröffentlichung beschrieb Babcock elf typische Krankheitsverläufe mit erfolgreichem Ausgang. Aber das Verfahren konnte sich sowohl in Europa als auch in Amerika nur zögerlich durchsetzen. Erst in den 1930er Jahren wurde es nach und nach in die deutschen Lehrbüchern der Chirurgie aufgenommen.

Die Krossektomie gehörte nicht zur originalen Babcock-Operation. Auch dieser Operationsschritt fand nur langsam seine Anerkennung. Trotz der 100 Jahre überdauernden weltweiten Erfahrung sind die wissenschaftlichen Diskussionen über das Stripping nach Babcock neu entbrannt.

De Phlegmasia alba

Heinrich Hoffmann, der Vater des Struwwelpeter, gilt in seiner Heimatstadt Frankfurt am Main als Reformator der Sozialmedizin. Vor allem die Psychiatrie hat unter seiner ärztlichen Leitung den Weg in eine moderne Zukunft angetreten. Aus seiner Klinik für Irre und Epileptische ging die Frankfurter Universitätsklinik für Psychiatrie hervor. Problemstellung: Die Doktorarbeit von Heinrich Hoffmann befasst sich mit der Phlegmasia alba. Sie ist in lateinischer Sprache abgefasst. Bezüglich der Pathogenese gab es zu Beginn des 19. Jahrhunderts noch drei verschiedene Vorstellungen, Metastasen von Milch oder Lochien, die Verletzung oder Erkrankung von Lymphgefäßen und den Verschluss von Venenstämmen im Beckenbereich. Hoffmann griff aus der Literatur eine vierte Variante auf, die Entzündung der Tunica cellulosa, der bindegewebigen Umhüllungen von Muskeln und Sehnen sowie des Neurolemm der Vaginalnerven. Gegen die Theorie der Venenkrankheit hatte er wichtige scheinbare Argumente anzuführen. Die Doktorarbeit endet mit einer ausführlichen Beschreibung des Krankheitsverlaufes einer jungen Soldatenfrau. Konsequenzen: Die Arbeit bringt zwar in medizinhistorischer Hinsicht keine originellen neuen Aspekte. Ihr Studium erinnert an diagnostische Einzelheiten, die unter dem Eindruck der modernen technischen Möglichkeiten verloren zu gehen drohen. Dazu gehören die Charakteristik des Schmerzes vor dem Stadium der Schwellung, eine strenge Seitenbegrenzung auch der Beckenvenenthrombose, die treffende Bezeichnung des Ödems als porzellanartig und nicht zuletzt die Vorausschau des Begriffes des Klinischen Wahrscheinlichkeit in der Art von kritischen Tagen.

Diagnostik und Therapie der venösen Thrombose

Für die diagnostische Abklärung einer tiefen Beinvenenthrombose bei ambulanten Patienten empfiehlt es sich, mit der Einstufung in die klinische Wahrscheinlichkeit (KW) sowie mit einem sensitiven D-Dimer-Test zu beginnen. Bei geringer KW und negativem D-Dimer-Test gilt die Thrombose als ausgeschlossen. Alle anderen Konstellationen bedürfen der weiteren Abklärung mittels bildgebender Verfahren. Die Kompressionssonographie steht dabei an erster Stelle. Die Therapie der unkomplizierten Venenthrombose erfolgt vorzugsweise mit niedermolekularem Heparin oder Fondaparinux. So rasch wie möglich wird parallel dazu die Sekundärprophylaxe mit einem Vitamin-K-Antagonisten eingeleitet. Die Behandlungsdauer richtet sich nach den Expositions- und Dispositionsfaktoren unter sorgfältiger Abwägung des Rezidivrisikos einerseits und des Blutungsrisikos andererseits. Die Gefahr eines postthrombotischen Syndroms lässt sich durch eine sofortige und langfristige Kompressionstherapie reduzieren.

De Phlegmasia alba

Heinrich Hoffmann, der Vater des Struwwelpeter, gilt in seiner Heimatstadt Frankfurt am Main als Reformator der Sozialmedizin. Vor allem die Psychiatrie hat unter seiner ärztlichen Leitung den Weg in eine moderne Zukunft angetreten. Aus seiner Klinik für Irre und Epileptische ging die Frankfurter Universitätsklinik für Psychiatrie hervor. Problemstellung: Die Doktorarbeit von Heinrich Hoffmann befasst sich mit der Phlegmasia alba. Sie ist in lateinischer Sprache abgefasst. Bezüglich der Pathogenese gab es zu Beginn des 19. Jahrhunderts noch drei verschiedene Vorstellungen, Metastasen von Milch oder Lochien, die Verletzung oder Erkrankung von Lymphgefäßen und den Verschluss von Venenstämmen im Beckenbereich. Hoffmann griff aus der Literatur eine vierte Variante auf, die Entzündung der Tunica cellulosa, der bindegewebigen Umhüllungen von Muskeln und Sehnen sowie des Neurolemm der Vaginalnerven. Gegen die Theorie der Venenkrankheit hatte er wichtige scheinbare Argumente anzuführen. Die Doktorarbeit endet mit einer ausführlichen Beschreibung des Krankheitsverlaufes einer jungen Soldatenfrau. Konsequenzen: Die Arbeit bringt zwar in medizinhistorischer Hinsicht keine originellen neuen Aspekte. Ihr Studium erinnert an diagnostische Einzelheiten, die unter dem Eindruck der modernen technischen Möglichkeiten verloren zu gehen drohen. Dazu gehören die Charakteristik des Schmerzes vor dem Stadium der Schwellung, eine strenge Seitenbegrenzung auch der Beckenvenenthrombose, die treffende Bezeichnung des Ödems als porzellanartig und nicht zuletzt die Vorausschau des Begriffes des Klinischen Wahrscheinlichkeit in der Art von kritischen Tagen.

Invasive therapeutic options in truncal varicosity of the great saphenous vein

It is known from current pathophysiology that disease stages I and II of truncal varicosity of the great saphenous vein do not cause changes in venous pressure on dynamic phlebodynamometry. This is possibly also the case for mild cases of the disease in stage III. In pronounced cases of stage III and all cases of stage IV, however, venous hypertension occurs which triggers the symptoms of secondary deep venous insufficiency and all the complications of chronic venous insufficiency. From these facts the therapeutic consequence is inferred that in stages I and II and perhaps also in very mild cases of stage III disease, it is enough "merely" to remove varicose veins without expecting there to be any other serious complications in the patient’s further life caused by the varicosity. Recurrence rates are not included in this analysis. In marked cases of disease stages III and IV of the great saphenous vein, however, secondary deep venous insufficiency is to be expected sooner or later. The classical operation with saphenofemoral high ligation ("crossectomy") and stripping strictly adheres to the recognized pathophysiologic principles. It also takes into account in the greatest detail aspects of minimally invasive surgery and esthetics. In the past few years, developments have been advanced to further minimize surgical trauma and to replace the stripping maneuver using occlusion of the trunk vein which is left in place. Obliteration of the vessel is subsequently performed via transmission of energy through an inserted catheter. This includes the techniques of radiofrequency ablation and endovenous laser treatment. High ligation is not performed as a matter of principle. In a similar way, sclerotherapy using microfoam is minimally invasive in character. All these procedures may be indicated for disease stages I and II, and with reservations also in mild forms of stage III disease. Perhaps high ligation previously constituted overtreatment in some cases. Targeted studies are still needed to prove whether secondary deep venous insufficiency can be avoided in advanced stages of varicose vein disease without high ligation and thus without exclusion of the whole recirculation circuit.

Venous thromboembolic risk and thromboprophylaxis in acutely ill medical outpatients

215 German family physicians participated in a prospective registry to assess the venous thromboembolic risk in acutely ill medical outpatients. In 1247 patients who were visited at home due to an acute medical illness, the risk factors were documented using a standardised questionnaire. The doctors subjectively rated the patient’s risk on a scale ranging from 1 to 10 and the result was compared with an objective risk-score which had been previously developed for hospitalized patients and has been successfully used in these patients. The results showed a wide agreement of the subjective risk assessment and the objective score. The resulting consequence of an adequate thromboprophylaxis reflects a high awareness of venous thromboembolic risk among the physicians treating acutely ill medical outpatients.

[Diagnosis and treatment of venous thrombosis]

In the diagnosis of deep vein thrombosis in ambulatory patients, the recommended initial steps are assessment of clinical probability (CP) and a sensitive D-dimer test. With a low CP and negative D-dimer, thrombosis can be ruled out. All other constellations require further investigation with imaging techniques. Compression ultrasonography is the first-line investigation. Low-molecular weight heparin is the treatment of choice for uncomplicated venous thrombosis. Secondary prophylaxis with a vitamin K antagonist is introduced in parallel as quickly as possible. The duration of treatment depends on the exposure and predisposing factors, weighing carefully the risk of recurrence on the one hand against the risk of bleeding on the other. If there are contraindications to anticoagulation with heparins or coumarins, various other anticoagulant drugs are available.

Diagnostik und Therapie der venösen Thrombose

Für die diagnostische Abklärung einer tiefen Beinvenenthrombose bei ambulanten Patienten empfiehlt es sich, mit der Einstufung in die klinische Wahrscheinlichkeit (KW) sowie mit einem sensitiven D-Dimer-Test zu beginnen. Bei geringer KW und negativem D-Dimer-Test gilt die Thrombose als ausgeschlossen. Alle anderen Konstellationen bedürfen der weiteren Abklärung mittels bildgebender Verfahren. Die Kompressionssonographie steht dabei an erster Stelle.

Die Therapie der unkomplizierten Venenthrombose erfolgt vorzugsweise mit niedermolekularem Heparin. So rasch wie möglich wird parallel dazu die Sekundärprophylaxe mit einem Vitamin-K-Antagonisten eingeleitet. Die Behandlungsdauer richtet sich nach den Expositions- und Dispositionsfaktoren unter sorgfältiger Abwägung des Rezidivrisikos einerseits und des Blutungsrisikos andererseits. Bei Kontraindikationen gegen eine Antikoagulation mit Heparinen bzw. mit Cumarinen stehen verschiedene gerinnungshemmende Substanzen alternativ zur Verfügung.

Duplexsonographische Beurteilung des belassenen Segments der Vena saphena magna nach partieller Resektion wegen Stammvarikose

Fragestellung: Die stadiengerechte Operation einer Stammvarikose der V. saphena magna gilt als Standardtherapie. Über das Schicksal des verbliebenen distalen Venensegments ist wenig bekannt. Die V. saphena magna hat eine wichtige Bedeutung als Transplantat in der Chirurgie der koronaren Herzkrankheit und der peripheren arteriellen Verschlusskrankheit. Patienten und Methode: Wir erfassten 66 Patienten (89 Beine), bei denen vor 10,2 ± 5,4 Jahren eine partielle Resektion der V. saphena magna durchgeführt worden war. Das verbliebene Venensegment wurde auf seine potenzielle Verwendbarkeit als Bypass mit der farbkodierten Duplexsonographie untersucht. Dazu wurden 3 Kollektive gebildet (Kollektiv A: transplantationsfähige Gefäßsegmente; Kollektiv B: Venen mit leichter Dilatation; Kollektiv C: ungeeignete Gefäße mit folgenden Merkmalen: Venensegment <2 mm, Venenabschnitte <10 cm oder destruktive Veränderung). Ergebnisse: Dem Kollektiv A wurden 57 (65%), dem Kollektiv B 5 (5,6%) und dem Kollektiv C 27 (29,4%) Venensegmente zugeordnet. Die Gründe für eine Unbrauchbarkeit der Venen im Kollektiv C waren: Venensegment zu schmal 9 (28,1%), postphlebitisch 2 (6,2%) oder phlebosklerotisch verändert 4 (12,5%), verschlossen 4 (12,5%), unterbrochen 5 (15,6 %), zu kurz 8 (25%), mit multiplen Seitenästen 2 (6,2%) und fehlend 1 (3,1%). Schlussfolgerung: Die Ergebnisse rechtfertigen die stadiengerechte Operation einer Stammvarikose der V. saphena magna, weil 70,6% der belassenen Venensegmente potenziell als Bypass tauglich sind. Bei 29,4% besteht eine Unbrauchbarkeit des belassenen Segments. Die präoperative sonographische Untersuchung der V. saphena magna vor Transplantation erscheint daher sinnvoll.

[Venous thrombosis in pregnancy]

Lung embolism is one of the most common causes of death during pregnancy and the puerperium. It is usually due to thrombosis of the deep leg and pelvic veins. As a result of modern imaging methods, it can be reliably diagnosed at an early stage. In some cases, special haemostaseological tests can identify congenital or acquired defects. This allows an initial assessment of the individual risk of thrombosis to be made. Body weight-dependent anticoagulation therapy with heparin is the major medication-based treatment. Compression treatment can be administered if accepted by the patient.

[Vascular manifestation of von Recklinghausen neurofibromatosis: case report of venous dysplasia]

We present the case report of a patient with neurofibromatosis and regional dysmorphism in the superficial femoral vein. Colour coded duplex sonography revealed an incidental finding: thickening of a short portion of the vein wall with calcification. This unusual finding strongly suggests a causal relationship. Pathological processes in the arteries have often been described in patients with von Recklinghausen's disease (neurofibromatosis). Dysplastic and hyperplastic reactions of the intramural nerve tissues and the smooth muscle elements in the vascular wall have been observed. This leads to the formation of aneurysms and arteriovenous fistulas and to stenosing processes in the peripheral, visceral and cerebral arteries. However, involvement of the veins in type 1 von Recklinghausen's neurofibromatosis has only been reported in old histopathological studies of medium-sized and small vessels.

Combined occurrence of a heterozygous missense mutation in the protein C gene and allelic exclusion of one protein S allele leading to severe venous thrombosis

Individuals with more than one defect in the natural anticoagulant system exhibit an increased risk for thrombosis. We report on a family with two cases of combined protein C (PROC) and protein S (PROS) deficiency, five cases of isolated PROC deficiency Type I, and two cases of isolated PROS deficiency Type I. PROC and PROS deficiency were documented by functional and immunologic tests. The sequencing of all exons and splice junctions of the PROC gene led to the identification of a new, unpublished G-->A transition at nt 8490, leading to an exchange of alanine 259 by threonine. The mutation was present in all family members with PROC deficiency. The carriers of the isolated PROC mutation were asymptomatic at ages of 4, 7, 10, 11, and 80 years. The combination of the PROC mutation with a PROS deficiency in two family members triggered venous thromboembolism at age 31 and 6 years, respectively. The PROS deficiency was associated with complete exclusion of one PROS allele. Two family members with isolated PROS deficiency are still asymptomatic at age 21 and 9 years, respectively. Our findings in this family suggest that the heterozygous mutation at codon 259 of the PROC gene represents a mild thrombotic risk factor and only confers a high thrombotic risk in combination with a second defect, such as the complete exclusion of one PROS allele.

Effects of a low-molecular-weight heparin on thrombus regression and recurrent thromboembolism in patients with deep-vein thrombosis

BACKGROUND

Low-molecular-weight heparins are frequently used to treat venous thromboembolism, but optimal dosing regimens and clinical outcomes need further definition.

METHODS

In this multicenter, open-label study with blinded adjudication of end points, we randomly assigned patients with acute deep-vein thrombosis to one of three treatment regimens: intravenous administration of unfractionated heparin; subcutaneous administration of a low-molecular-weight heparin, reviparin, twice a day for one week; or subcutaneous administration of reviparin once a day for four weeks. The primary end point was evidence of regression of the thrombus on venography on day 21; secondary end points were recurrent venous thromboembolism, major bleeding within 90 days after enrollment, and death.

RESULTS

Of the patients receiving unfractionated heparin, 40.2 percent (129 of 321) had thrombus regression, as compared with 53.4 percent (175 of 328) of patients receiving reviparin twice daily and 53.5 percent (167 of 312) of the patients receiving reviparin once daily. With regard to thrombus regression, reviparin administered twice daily was significantly more effective than unfractionated heparin (relative likelihood of thrombus regression, 1.28; 97.5 percent confidence interval, 1.08 to 1.52), as was reviparin administered once daily (relative likelihood, 1.29; 97.5 percent confidence interval, 1.08 to 1.53). Mortality and the frequency of episodes of major bleeding were similar in the three groups.

CONCLUSIONS

In acute deep-vein thrombosis, reviparin regimens are more effective than unfractionated heparin in reducing the size of the thrombus. Reviparin is also more effective than unfractionated heparin for the prevention of recurrent thromboembolism and equally safe.

Postmenopausal hormone replacement therapy and the vascular wall: epidemiology and clinical studies

The clinical relevance of estrogen's multiple acute and more delayed effects on vascular wall structure and function is incompletely understood. This review attempts to reevaluate epidemiological findings and clinical studies concerning the vascular actions of estrogens and gives implications for strategies in postmenopausal hormone replacement therapy (HRT). There is large evidence from observational studies that HRT reduces the risk of cardiovascular mortality and morbidity in postmenopausal women. However, according to the only large randomized, placebo-controlled, secondary prevention Heart and Estrogen/progestin Replacement Study (HERS), women with prevalent cardiovascular disease (CVD) have increased CVD events within the first year after onset of HRT. The net effects of HRT on atherosclerosis, coagulation, fibrinolysis or the inflammatory response are unproven. Randomized trials of intermediate outcomes reveal that HRT has favorable effects on isolated cardiovascular risk factors, e.g. lipoproteins, carbohydrate metabolism and vasodilatation, but the impact of this effects on clinical endpoints is still not clear. The basis of "evidenced based medicine" is currently not sufficient to provide exact recommendation who will benefit from HRT and who might not. Therefore, the decision about hormone use should consider individual benefit-risk profiles.

Hämodynamische Auswirkungen der Trikuspidalinsuffizienz auf die sekundäre Leitveneninsuffizienz bei Stammvarikose der V. saphena parva

Eine schwere Herzinsuffizienz muß sich auch auf die Hämodynamik der peripheren venösen Zirkulation auswirken. Wir hatten Gelegenheit, den Einfluß der Trikuspidalinsuffizienz auf die Entwicklung einer Stammvarikose zu studieren. Es handelt sich um den ungewöhnlichen Krankheitsverlauf eines 73-jährigen Patienten, der wegen eines Ulcus cruris venosum zur Untersuchung kam. Als Ursache wurde eine klinisch nicht sehr ausgeprägte Stammvarikose der Vena saphena parva festgestellt, die aber in diesem Ausmaß erfahrungsgemäß noch keine sekundäre Leitveneninsuffizienz induzieren würde. Gleichzeitig bestand jedoch eine hämodynamisch relevante Trikuspidalinsuffizienz als Folge der Operation eines Myxoms im rechten Vorhof. Mit der Duplexsonographie gelang der Nachweis eines »positiven Venenpulses« im gesamten tiefen Leitvenensystem. Durch die Trikuspidalinsuffizienz wurden sowohl eine antegrade als auch eine erhebliche retrograde Strömungsinsuffizienz verursacht, die eine dynamische venöse Hypertonie mit konsekutiver Störung der Mikrozirkulation an beiden Beinen zur Folge hatte. Durch die Herzkrankheit ist die nur mäßig ausgeprägte Stammvarikose der Vena saphena parva im Sinne der sekundären Leitveneninsuffizienz richtunggebend verschlimmert worden. Damit ließ sich die ungewöhnliche Entstehung des Ulcus cruris erklären.

The chronic venous compartment syndrome

BACKGROUND

A chronic exertional compartment syndrome has only been observed in athletes and soldiers. In the vast majority, the disease affects the anterior compartment and the fibular muscle group, and only rarely the lateral and dorsal muscle compartments. Muscle tissue necrosis does not occur. In the course of venous diseases with a severe chronic venous stasis syndrome, a chronic venous compartment syndrome develops that differs considerably from the familiar functional syndrome. The predominant symptom is an uncurable cuff ulceration on the lower leg.

PATIENTS AND METHODS

From 1993 to 1996 a total of 16 patients with a chronic fascial compression syndrome underwent surgery on 18 extremities. The crural fascia was resected and a mesh graft was applied.

RESULTS

In the group of ten controls with healthy veins the average pressure in the deep compartment was 13.6 mmHg (range 9-17 mmHg) lying down and 29.9 mmHg (range 15-42 mmHg) standing up. In 14 patients with chronic fascial compression syndrome, the average pressure was higher, measuring 21.1 mmHg (range 8-47 mmHg) lying down and 62.5 mmHg (range 33-87) standing up. After surgery, the pressure dropped to 15.5 mmHg (range 5-24 mmHg) lying down and 34.5 mmHg (range 10-58 mmHg) standing up, but did not fall as low as the average values recorded in the control group or in the patient's healthy leg. The results from the standing up position were statistically significant (p = 0.003). Computed tomography showed major changes in the muscles indicating muscle atrophy and fatty degeneration. The crural fascia seemed to be incorporated in the scars of the subcutaneous tissue in large areas. After crural fasciectomy and healing of the ulceration, the tissue structure of the muscles recovered.

CONCLUSIONS

In chronic fascial compression syndrome, the trellis arrangement of the collagen fibres becomes disordered. This results in a loss of flexibility during muscle contraction. Every step causes an increase of intracompartmental pressure and microstructural injury. The consequence is resection of the crural fascia.

Postmenopausal hormone replacement therapy and the vascular wall: mechanisms of 17 beta-estradiol's effects on vascular biology

17 beta-estradiol (E2) protects against atherosclerosis independent of changes in plasma lipoproteins in a variety of animal models, which is explained by direct effects of E2 on the vascular wall. E2 improves vasomotion by modulation of vasoconstrictor and vasodilator systems through endothelium-dependent and endothelium-independent mechanisms. E2 affects the remodeling of the vascular wall by inhibiting smooth muscle cell proliferation and accelerating reendothelialization of injured blood vessels. E2 modulates the vascular inflammatory response by inhibiting cytokine production, cytokine-induced expression of cell adhesion molecules and platelet aggregation/adhesion. This review focuses on the cellular and molecular mechanisms underlying these vasculoprotective actions of E2. E2 can act through nongenomic stimulation of membrane/intracellular mediators and/or the classical genomic pathway of steroid actions, which is dependent on transcription and protein synthesis. The existence of at least two nuclear estrogen receptor (ER) subtypes alpha and beta and a putative membrane ER present the potential of tissue-specific as well as biologically different E2 actions. Nuclear ERs act as ligand-activated transcription factors and can affect gene regulation by interaction with the classical estrogen response element or other nonreceptor transcription factors. The molecular basis of genomic E2 actions by identifying transcription factors and regulatory elements involved in the induction and inhibition of E2 regulated gene expression is only at the beginning of being understood. The impact of E2-mediated increased NO availability on the hemodynamic and antiatherosclerotic actions of E2 is still a debate of controversy.

[Predisposition and initiation of venous thrombosis]

The causes of thromboembolic disease are complex. In addition to acquired risks, thrombophilic diatheses in particular now play an important role. The combination of predisposing factors increases the risk of thrombosis. However, a precise prognosis cannot yet be made for an individual patient.

Recombinant hirudin (lepirudin) provides safe and effective anticoagulation in patients with heparin-induced thrombocytopenia: a prospective study

BACKGROUND

The immunological type of heparin-induced thrombocytopenia (HIT) is the most frequent drug-induced thrombocytopenia. This study evaluated the efficacy of recombinant hirudin (r-hirudin or lepirudin), a potent thrombin inhibitor, for anticoagulation in patients with confirmed HIT.

METHODS AND RESULTS

Eighty-two patients in this prospective, multicenter study received 1 of 4 intravenous r-hirudin regimens: A1, HIT patients with thrombosis (n=51), 0.4-mg/kg bolus and then 0.15 mg. kg-1. h-1; A2, HIT patients with thrombosis receiving thrombolysis (n=5), 0. 2-mg/kg bolus and then 0.1 mg. kg-1. h-1; B, HIT patients without thrombosis (n=18), 0.1 mg. kg-1. h-1; and C, during cardiopulmonary bypass surgery (n=8), 0.25-mg/kg bolus and then 5-mg boluses as needed. Response criteria were increase in platelet count by >/=30% to >10(9)/L and activated partial thromboplastin time (aPTT) values 1.5 to 3.0 times baseline values achieved with a maximum of 2 dose increases. No placebo control was used for ethical reasons. Outcomes of a subset of r-hirudin-treated patients who met predefined inclusion criteria (n=71) were compared with those of a historical control group (n=120) for combined and individual incidences of death, amputations, new thromboembolic complications, and incidences of bleeding. Platelet counts increased rapidly in 88.7% of r-hirudin-treated patients with acute HIT. In regimens A1 and A2, the 25% and 75% quartiles of the aPTT were within the target range at all but 1 time point. The incidence of the combined end point (death, amputation, new thromboembolic complications) was significantly reduced in r-hirudin patients compared with historical control patients (P=0.014). During first selected treatment, the adjusted hazard ratio for r-hirudin patients versus historical control was 0.279 (95% CI, 0.112 to 0.699; P=0.003). Bleeding rates were similar in both groups.

CONCLUSIONS

r-Hirudin treatment is associated with a rapid and sustained recovery of platelet counts, sufficient aPTT prolongations, and true clinical benefits for patients with HIT.