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PubMed1999

[Incidence of pulmonary embolism in venous thrombosis].

The frequency of pulmonary embolism in patients with deep vein thrombosis can be assessed by pathological-anatomical and by nuclear medical studies. The frequency of deep vein thrombosis in autopsies ranges from 23.7% to 62%, by inclusion of microscopic thrombi the frequency increases to 72%. In most cases the localisation of the venous thrombosis is bilateral. In cases of venous thrombosis the frequency of pulmonary embolism is 52 to 79.4%, if microscopic thrombi are included, the number is 87.8%. 7.8% to 78.9% of all pulmonary emboli are considered as cause of death or severely contributing to death. The fatal embolisms originate preferentially from iliofemoral thrombosis. About 1/10 of all emboli originate from V. cava sup. and the right heart. In a small number of pulmonary emboli the origin could not be detected. The rate of correct intra vitam diagnosis is low, not more than 11 to 25% of all pathological-anatomical proven emboli had a correct diagnosis during life. In fatal pulmonary embolism the correct clinical diagnosis was made in 1/3. In nuclear medicine studies pulmonary embolisms are searched for from the clinical suspicion or the diagnosis of deep vein thrombosis with the perfusion-/ventilation- or inhalation scintigraphy. Patients with deep vein thromboses showed in 38 to 57.9% pulmonary embolism. In 80% of all pulmonary embolism multiple perfusion defects (2 to 9 perfusion defects) were detected, the lesions were evenly distributed in both lungs. The frequency of pulmonary embolism in calf vein thrombosis was 46%, in leg vein thrombosis 67% and reached 77% if the pelvic veins were involved. It is remarkable that the majority of all pulmonary emboli (46.3% to 100%) showed no clinical symptoms. The knowledge about the high frequency of pulmonary embolism in patients with deep vein thrombosis can improve the diagnosis of pulmonary embolism. For the diagnostic process of pulmonary embolism the presence of acute deep vein thrombosis increases the pre-test probability (prevalence of more than 50%). Every positive test for pulmonary embolism will gain a very high post-test probability according to Bayes' theorem.

Adult↗
PubMed1992

Venous thrombosis during pregnancy: leg and trimester of presentation.

In order to determine the relative frequencies of left and right leg venous thrombosis during pregnancy and the frequencies of venous thrombosis during the three trimesters, a cohort study of 60 consecutive patients with a first episode of venous thrombosis during pregnancy was performed. Fifty-eight women had isolated left leg thrombosis, two patients had bilateral venous thrombosis and no patient had isolated right leg venous thrombosis. Thirteen patients had venous thrombosis during the first trimester (21.7%), 28 during the second trimester (46.7%) and 19 during the third trimester (31.7%). These findings indicate that patients with symptoms in the right leg rarely have venous thrombosis. Because leg pain and swelling occur most frequently during the third trimester but venous thrombosis is relatively equally distributed during all three trimesters, patients presenting earlier during pregnancy are more likely to have venous thrombosis than patients presenting later during pregnancy.

Female↗
PubMed1993

Clinical significance of routine imaging of iliac and calf veins by color flow duplex scanning in patients suspected of having acute lower extremity deep venous thrombosis.

BACKGROUND: Because duplex ultrasonography is used increasingly to evaluate patients suspected of having acute deep venous thrombosis of the lower extremity, the clinical significance of limiting venous duplex scanning to the common femoral, superficial femoral, and popliteal veins becomes an important question. METHODS: We prospectively studied by venous color flow duplex ultrasonography 181 patients referred for evaluation to rule out acute deep venous thrombosis to determine (1) the frequency with which the iliac and calf veins could be imaged adequately to determine the presence or absence of acute deep venous thrombosis, (2) the frequency of acute venous thrombosis in these venous segments, and (3) the time required to scan these additional segments. RESULTS: In 79% of the patients studied, one segment of the iliac venous system was imaged adequately to determine the presence or absence of venous thrombosis. In the lower extremity, the common femoral vein, the superficial femoral vein, and the popliteal vein were imaged adequately in 94% of the patients. In 76% of the patients all three calf veins were imaged adequately to determine whether acute deep venous thrombosis was present or absent. The anterior tibial vein was the most difficult vein to image consistently and was imaged adequately in 76% of the patients referred. The mean time to scan the affected limb was 8 minutes 37 seconds. Forty-seven patients (26%) of the 180 patients studied had positive venous scans. Twenty-three percent of the patients who had positive scans were found to have iliac vein involvement. Thirty-two percent who had positive venous scans were found to have thrombosis of the calf veins. Fifteen percent of the 47 patients who had positive scans had either an isolated iliac or calf vein thrombosis. CONCLUSIONS: We believe this frequency of isolated iliac or calf vein thrombosis coupled with the frequency of successful imaging of these venous segments and the short additional time required to image these segments justifies the inclusion of routine imaging of the iliac and calf veins in patients undergoing venous duplex scanning to rule out acute deep venous thrombosis.

Acute Disease↗
PubMed1997

Deep vein thrombosis after uncemented total hip replacement.

One-hundred-fourteen consecutive cases of venography after primary uncemented total hip replacement were performed in a randomized trial to identify the natural incidence of deep vein thrombosis, the effectiveness of prophylactic regimens such as 1.2 grams of aspirin daily and low-molecular-weight dextran for 3 days, and other relative factors for the development of venous thrombosis. In addition, intraoperative venography was conducted in 10 patients to study the speed of the flow of contrast media in the femoral vein and the development of deep vein thrombosis and the extent of the twisting of the femoral vein during hip joint manipulation. The incidence of venous thrombosis in the control, aspirin, and dextran prophylaxis groups were 20%, 11.5%, and 5.2% respectively. The incidence in the aspirin group was reduced, but this was statistically insignificant. The dextran group showed a marked decrease in incidence, and the difference with the control group was statistically significant. With regard to the development site of venous thrombosis, it was prevalent in iliofemoral, lower femoral, and major calf vein in the control group, while the popliteal and major calf vein were the major site of thrombosis development in the aspirin and dextran groups. The risk factors affecting the incidence of the venous thrombosis are confirmed to be obesity and long-term administration of steroids. Hematologic analysis was meaningless in investigating the development of venous thrombosis. The reliable clinical sign and symptom suggestive of the development of venous thrombosis was the severe swelling on the entire portion of affected lower extremity. In the intraoperative venogram, no correlation was found between the venous blood flow speed and the development of venous thrombi. A remarkable change in the blood flow of the femoral vein was noticed when the hip joint was flexed an average of 40.4 degrees, adducted at 11.5 degrees, and internally rotated at 81.5 degrees. Especially, when the joint was internally rotated, severe kinking of the vein could be observed. Thus it seems desirable to reduce the duration of internal rotation of the hip joint as much as possible to prevent venous thrombosis.

Adult↗
PubMed1997

[Case control studies of the risk factors for deep-vein thrombosis in an adult population hospitalized in internal medicine].

BACKGROUND: The ain of this study was to demonstrate risk factors for deep-vein thrombosis in adults in a hospital setting. MATERIALS AND METHODS: From May 1993 to Februrary 1995, 233 patients hospitalized in the internal medicine unit at the Montpellier University Hospital for deep-vein thrombosis were included. Each case was matched to a control case for age, hospitalization unit, and use or not of anti-thrombosis prophylaxy. Venous thrombosis was diagnosed in patients and confirmed to be absent in controls using duplex Doppler when phlebography findings were unconvincing. To eliminate possible false negatives (poor sensitivity of duplex Doppler in asymptomatic patients), all controls were contacted by telephone 3 to 6 months after discharge to ascertain whether or not they had been rehospitalized and if so for what reason. The patients and controls responded to questions designed to identify risk factors for deep-vein thrombosis described in the literature (patient characteristics, personal and family history, surgical history, associated diseases, abnormal blood tests, medical treatment, life style). RESULTS: The three main risk factors for deep-vein thrombosis for all ages and both sexes identified by multivariate analysis were: personal history of venous thrombosis (OR = 4.7, 95% CI = [2.4; 8.9]), family history of venous thrombosis (OR = 3.3, 95% CI [1.8; 5.9]) and surgical during the preceding 45 days (OR = 3.7, 95% CI = [1.2; 10.9]). In non-menopaused women, the main risk factor was minidose oral contraception (OR = 6.9, 95% CI = [1.9; 25.4]). CONCLUSION: In our population of hospitalized patients in an internal medicine unit, the main risk factor for thrombosis appeared to be, in general, a past history of venous thrombosis and in non-menopaused women, minidose oral contraception.

Adult↗
PubMed2004

High prevalence of anti-prothrombin antibody in patients with deep vein thrombosis.

The present study was designed to determine the prevalence of lupus anticoagulant (LA) antibody and several antibodies for antiphospholipid syndrome (APS) in patients with deep vein thrombosis (DVT)/pulmonary embolism (PE) (n = 48), cerebral thrombosis (CT, n = 30), systemic lupus erythematosus (SLE, n = 22), and idiopathic thrombocytopenic purpura (ITP, n = 30). The presence of antibodies was examined by using the respective ELISA kits. LA was positive in 38.6% of patients with DVT/PE, suggesting that LA is one of the most important risk factors in DVT/PE. The highest prevalence of anti-beta(2) glycoprotein I (beta(2)GPI) IgG was in CT and SLE, followed by DVT, and none in ITP and healthy volunteers (control, n = 40), suggesting that it is related to thrombosis, particularly arterial thrombosis. The highest prevalence of anti-prothrombin (aPT) IgG antibody was in DVT, followed by CT and SLE, and none in ITP and the control, suggesting that it is related to thrombosis, especially venous thrombosis. The highest prevalence of antiphospholipid (aPL) IgG was in DVT, CT, and SLE, but 0% in ITP and control. On the other hand, aPL IgM, anti-annexin V IgG, and anti-annexin V IgM were positive in patients both with and without thrombosis, suggesting that they are not related to thrombosis. Our results indicated that among the anti-phospholipid antibodies, LA is the most sensitive marker for APS while anti-beta(2)GPI IgG, aPT IgG, and aPL IgG are risk factors for thrombosis. In particular, aPT IgG is a significant marker for DVT/PE.

Adult↗
PubMed2001

Combined risk factors contributing to cerebral venous thrombosis in a young woman.

Cerebral venous thrombosis is a rare condition affecting predominantly adolescents or young adults. The presentation is often non-specific, and delay in diagnosis is common. The otolaryngologist may be consulted about the radiological findings of lateral sinus thrombosis and mastoid changes. The association of congenital thrombophilia with unusual presentations of venous thrombosis, especially in young individuals is now well documented. We present a case of lateral and sagittal sinus thrombosis complicated by cerebral venous infarction in a girl with protein C deficiency and masked mastoiditis. Unusual forms of venous thrombosis, including cerebral venous thrombosis may develop in association with a single risk factor for thrombosis, but additional risk factors should be sought especially when thrombosis presents in very young individuals. This case draws attention to the multi-causal nature of cerebral venous thrombosis in young adults, and highlights the issue of masked mastoiditis. A coordinated approach by otolaryngological and haematological teams is recommended in such cases.

Adolescent↗
PubMed2006

[Factor V Leiden and prothrombin G20210A among Chilean patients with venous and arterial thrombosis].

BACKGROUND: Factor V Leiden and G20210A mutation of prothrombin gene are two important genetic polymorphisms associated with an increased risk for thrombosis. AIM: To establish the prevalence of factor V Leiden and prothrombin G20210A mutation in the Chilean population and their association to venous and arterial thromboembolism. MATERIAL AND METHODS: A case-control study was conducted where 149 patients with thrombosis (87 with arterial and 62 with venous thrombosis) confirmed by CAT-scan, electrocardiogram and cardiac enzymes or Doppler depending on the case, and 160 healthy blood donors were genetically analyzed for the presence of both polymorphisms. RESULTS: Factor V Leiden mutation was found in 5.4% of patients and in 1.3% of healthy controls (p=0.04). Heterozygosity for G20210A prothrombin mutation was found in 5.4% of patients and in 2.5% of the control group (p=NS). When arterial and venous thrombosis were considered as separate entities, 4.6% of patients with arterial thrombosis and 6.5% with venous thrombosis presented factor V Leiden (p=NS). Likewise, 8.1% of patients with venous thrombosis and 3.5% of patients with arterial thrombosis had G20210A prothrombin mutation (p=NS). CONCLUSIONS: In non selected consecutive Chilean patients with arterial and venous thrombosis the frequency of factor V Leiden and prothrombin G20210A is less than we could expect from their prevalence in the general population.

Case-Control Studies↗
PubMed1995

Thrombosis of the deep venous drainage of the brain in adults. Analysis of seven cases with review of the literature.

OBJECTIVES: To characterize the clinical, radiographic, and pathologic findings in thrombosis of the deep venous drainage of the brain. To highlight clinical and radiographic findings that may lead to the diagnosis of disease and distinguish it from dural sinus thrombosis. To review the published literature on this disorder. DESIGN: Retrospective review of the medical and radiographic records of seven patients from three institutions over the past 10 years. Review of the English language literature from 1971 to the present. RESULTS: All seven patients had risk factors for cerebral venous thrombosis. Five patients presented with a short, rapidly progressing course characterized by headache, nausea and vomiting, and decline in level of consciousness. All five patients died or were rendered severely disabled. Computed tomographic scans, magnetic resonance imaging, and magnetic resonance angiography showed findings associated with deep cerebral vein thrombosis in three of four, in five of five, and in three of three patients, respectively. Transfemoral catheter angiography was diagnostic in two of two patients. Twenty-one reported cases of deep cerebral venous thrombosis were identified in the literature. CONCLUSIONS: When the two populations are combined and compared with large series of patients with dural sinus thrombosis, patients with deep venous system thrombosis are more commonly women, tend to present with a more rapidly declining time course, altered consciousness, and long tract signs. Death or long-term sequelae are far more likely to occur in internal cerebral vein thrombosis than with dural sinus thrombosis. Unenhanced computed tomography can demonstrate findings that are strongly suggestive of the diagnosis. Magnetic resonance imaging and magnetic resonance angiography are confirmatory. Angiography may still be necessary when the diagnosis is not clear.

Adolescent↗
PubMed2005

Malignancies, prothrombotic mutations, and the risk of venous thrombosis.

CONTEXT: Venous thrombosis is a common complication in patients with cancer, leading to additional morbidity and compromising quality of life. OBJECTIVE: To identify individuals with cancer with an increased thrombotic risk, evaluating different tumor sites, the presence of distant metastases, and carrier status of prothrombotic mutations. DESIGN, SETTING, AND PATIENTS: A large population-based, case-control (Multiple Environmental and Genetic Assessment [MEGA] of risk factors for venous thrombosis) study of 3220 consecutive patients aged 18 to 70 years, with a first deep venous thrombosis of the leg or pulmonary embolism, between March 1, 1999, and May 31, 2002, at 6 anticoagulation clinics in the Netherlands, and separate 2131 control participants (partners of the patients) reported via a questionnaire on acquired risk factors for venous thrombosis. Three months after discontinuation of the anticoagulant therapy, all patients and controls were interviewed, a blood sample was taken, and DNA was isolated to ascertain the factor V Leiden and prothrombin 20210A mutations. MAIN OUTCOME MEASURE: Risk of venous thrombosis. RESULTS: The overall risk of venous thrombosis was increased 7-fold in patients with a malignancy (odds ratio [OR], 6.7; 95% confidence interval [CI], 5.2-8.6) vs persons without malignancy. Patients with hematological malignancies had the highest risk of venous thrombosis, adjusted for age and sex (adjusted OR, 28.0; 95% CI, 4.0-199.7), followed by lung cancer and gastrointestinal cancer. The risk of venous thrombosis was highest in the first few months after the diagnosis of malignancy (adjusted OR, 53.5; 95% CI, 8.6-334.3). Patients with cancer with distant metastases had a higher risk vs patients without distant metastases (adjusted OR, 19.8; 95% CI, 2.6-149.1). Carriers of the factor V Leiden mutation who also had cancer had a 12-fold increased risk vs individuals without cancer and factor V Leiden (adjusted OR, 12.1; 95% CI, 1.6-88.1). Similar results were indirectly calculated for the prothrombin 20210A mutation in patients with cancer. CONCLUSIONS: Patients with cancer have a highly increased risk of venous thrombosis especially in the first few months after diagnosis and in the presence of distant metastases. Carriers of the factor V Leiden and prothrombin 20210A mutations appear to have an even higher risk.

Adult↗
PubMed2003

Increased incidence of symptomatic venous thrombosis in patients with cervical carcinoma treated with concurrent chemotherapy, radiation, and erythropoietin.

BACKGROUND: Because studies have suggested that anemia has an adverse effect on outcome for patients with cervical carcinoma who are treated with radiation, recombinant human erythropoietin (rHuEpo) has been used increasingly to maintain hemoglobin levels in these patients. Erythropoietin may increase the risk of thrombosis. The authors performed a retrospective analysis to determine whether there was an increased rate of symptomatic venous thrombosis associated with the use of rHuEpo in patients with carcinoma of the uterine cervix and vagina. METHODS: A retrospective, case-control study was performed on consecutive patients with localized carcinoma of the uterine cervix or vagina who were treated with chemotherapy and radiation (chemoradiotherapy). The primary outcome was symptomatic venous thrombosis. RESULTS: One hundred forty-seven patients were reviewed. When they were divided into women who received rHuEpo (n = 75 patients) and women who did not receive rHuEpo (n = 72 patients), there were no significant differences in age, height, weight, disease stage, or body mass index. Fewer patients in the rHuEpo group required transfusions. In the rHuEpo group, 17 of 75 patients had either an upper extremity thrombosis (n = 12 patients) or a lower extremity thrombosis (n = 7 patients): 2 patients had both, and 2 patients had more than 1 event. Two of 72 patients who did not receive rHuEpo had symptomatic thrombosis. Patients who received rHuEpo had an odds ratio (OR) of developing thrombosis of 10.3 (95% confidence interval [95% CI], 2.3-46.2). Multiple logistic regression revealed that only the use of rHuEpo was associated with an increased risk of thrombosis (OR, 15.3; 95% CI, 3.1-76.7). CONCLUSIONS: Patients with cervical carcinoma who received chemoradiotherapy and rHuEpo had an increased risk of symptomatic venous thrombosis.

Adult↗
PubMed1999

Clinical relevance of genetic risk factors for thrombosis in paediatric oncology patients with central venous catheters.

UNLABELLED: We prospectively evaluated the clinical relevance of genetic risk factors of thrombosis in 137 paediatric patients with solid tumours or leukaemia/lymphoma. The factor V G1691A (FV-L), the prothrombin G20210A (FII-L) and the homozygous MTHFR variant were examined. In addition, protein C, protein S and antithrombin (AT) deficiency were evaluated in patients with ALL or thrombosis. The inter-group incidence of risk factors and thrombotic events was compared. 73 of the 137 patients had ALL and 64 another form of leukaemia, lymphoma or a solid tumour. They were treated according to the established paediatric tumour protocols ALL-BFM, NHL-BFM, COSS, CWS and others. All patients had central venous lines. No patient received heparin or any other anticoagulant. Endpoints of the study were thrombosis, regular completion of chemotherapy or death. Incidence of mutations in the whole group: FV-L (7.3% heterozygous, 0.7% homozygous); FII-L (2.9% heterozygous, no homozygotes); MTHFR (51.8% heterozygous, 10.9% homozygous). Ten patients (7.3%), 6 with ALL and 4 with solid tumours, developed thrombosis. 4 of the 6 patients with ALL and thrombosis (67%) but only 21% of ALL patients without thrombosis had a genetic risk factor (P < 0.013, chi2). No genetic defect was found in the 4 patients with other malignancies and thrombosis. However, besides a tumour, these patients had additional exogenous risk factors including diabetes insipidus and hemiparesis. CONCLUSION: Genetic mutations appear to be additional risk factors for the development of thrombosis in patients with ALL. In contrast, these mutations do not appear to be relevant risk factors for thrombosis in the small number of children with other malignant diseases reported here. This difference may be due to asparaginase and corticosteroids being used in ALL but not in solid tumour protocols.

Adolescent↗
PubMed2001

[Prevention of thrombosis in hip prosthesis implantation].

Deep venous thrombosis is one of the most common perioperative complications after total hip arthroplasty. Systemic anticoagulation has been the gold standard for prophylaxis of postoperative deep venous thrombosis. There is no doubt that early mobilization and the use of pneumatic compression devices decrease the overall deep venous thrombosis rate. Single postoperative prophylaxis may decrease the overall deep venous thrombosis rate to 15-20% and the proximal deep venous thrombosis rate to approximately 7%. However,the activation of thrombogenesis is mainly an intraoperative event. The position of the extremity during the implantation of the femoral component leads to obstruction of the venous outflow. At the same time, the coagulation cascade is activated and markers of thrombogenesis in the blood are increased. By combining intraoperative (hypotensive epidural anesthesia and intraoperative heparin) and postoperative (pneumatic compression devices and aspirin) prophylaxis of deep venous thrombosis, the total deep venous thrombosis rate is reduced to less than 10% and the proximal deep venous thrombosis rate is reduced to 2%. Patients with increased risk for deep venous thrombosis should receive Coumadin or low-molecular weight heparin. In addition, hypotensive epidural anesthesia reduces the intraoperative blood loss and the need for postoperative blood transfusion.

Anesthesia, Epidural↗
PubMed2003

Symptomatic thrombotic events among Egyptian patients with systemic lupus erythematosus: special consideration for renal vein thrombosis.

OBJECTIVE: To evaluate the prevalence of symptomatic thrombotic events among Egyptian patients with systemic lupus erythematosus (SLE), and to evaluate the frequency and the risk factors associated with renal vein thrombosis in those patients. METHODS: Fifty-four patients with SLE, 51 (94.4%) females, were involved in this study. All of them were submitted for abdominal sonography, chest X-ray, echocardiography, and Doppler of renal, abdominal and lower limb veins, with examination of data on clinical and laboratory profile. Abdominal CT, brain MRI, MRI both hips, CT chest and pulmonary scintigraphy were used when needed. RESULTS: Sixteen patients (29.6%) were diagnosed with symptomatic thrombotic events. Eight patients had more than one type of thrombosis. Two patients (3.7%) were diagnosed by Doppler as having renal vein thrombosis (RVT). This was confirmed by abdominal CT. One of them presented with nephrotic syndrome, graded by renal biopsy as World Health Organization (WHO) class V, and had positive anticardiolipin antibodies (ACL). The other patient had RVT and inferior vena cava (IVC) thrombosis, nephrotic syndrome, positive ACL, and died before renal biopsy was performed. Both of them were without history of peripheral thrombotic events. One patient was diagnosed with IVC thrombosis, lupus nephritis grade II, positive ACL, and diagnosed by abdominal CT. One patient was diagnosed with portal vein thrombosis and had positive ACL. One patient with retinal vessel thrombosis and positive ACL. Four patients had deep vein thrombosis (DVT). Recurrent miscarriages were reported in 4 patients (7.4%), skin ulcerations in 3 (5.6%), avascular necrosis of the hips in 4 (7.4%), stroke in 1 (1.9%), and pulmonary hypertension in 2 patients (3.7%). CONCLUSION: Sixteen SLE patients (29.6%) were diagnosed with symptomatic thrombotic events. RVT was detected in 2 patients representing 3.7% of all patients, and 12.5% of patients with thrombosis. Both patients with RVT presented with nephrotic syndrome.

Adult↗
PubMed2006

Non-catheter associated venous thrombosis in hemophilia A and B. A critical review of all reported cases.

All reported cases of non-catheter induced venous thrombosis in patients with hemophilia A or B have been carefully evaluated. A total of 27 cases were reported,12 patients with hemophilia A and 15 patients with hemophilia B. The age of patients varied between 9 and 67 years. There were 10 cases of deep vein thrombosis, 8 patients with pulmonary embolism accompanied or not by deep vein thrombosis, 5 cases of superficial vein thrombosis. In addition, there were 3 cases of thrombosis in unusual sites (1 retinal central vein thrombosis and 2 portal vein thrombosis). Finally, in one case, venous thrombosis was multiple. There was a fatality in a hemophilia B patient with pulmonary embolism. The most frequent risk or triggering factor in hemophilia A was the administration of Feiba or rFVIIa concentrates in patients with inhibitors. Surgery together with Prothrombin Complex concentrates was the most frequent cause in hemophilia B patients. Congenital associated prothrombotic risk factors were present in two patients. No or very few therapeutic procedures were initiated in these patients but for a suspension or reduction of concentrates infusion. In a few instances low molecular weight heparin was given for a few days. The frequent association of venous thrombosis with infusion of concentrates indicates the need for a careful evaluation of patients about to receive such therapy.

Hemophilia A↗
PubMed1996

Coronary angioplasty and intracoronary thrombolysis are of limited efficacy in resolving early intracoronary stent thrombosis.

OBJECTIVES: This study sought to evaluate treatment of early intracoronary stent thrombosis. BACKGROUND: Although refinements in intracoronary stent implantation technique and pharmacologic treatment have reduced the frequency of early stent thrombosis, stent thrombosis remains a feared complication of this procedure. Optimal treatment for stent thrombosis is still undefined. METHODS: Twenty-nine patients (44 stents) with early (< or = 30 days) coronary stent thrombosis over a 5-year period at our institution were identified. Treatment and outcome of stent thrombosis were analyzed. RESULTS: Mean (+/- SD) time from implantation to stent thrombosis was 6.1 +/- 5 days. Twenty-three patients were treated with catheter-based therapies (angioplasty alone in 14, angioplasty and intracoronary urokinase in 7, intracoronary urokinase alone in 2). Flow was restored without residual thrombus in 11 (48%) of the catheter-treated patients (6 of 14 with angioplasty alone, 4 of 7 with angioplasty and urokinase, 1 with urokinase alone). Of the 23 patients, 2 died despite restoration of anterograde flow, and 9 were referred for emergent or urgent bypass surgery because of residual thrombus and refractory angina despite restoration of blood flow. Of the remaining six patients, five were treated medically and one with coronary bypass surgery; three died. Acute myocardial infarction evolved in 26 patients (90%), including 20 (87%) of the 23 catheter-treated patients. CONCLUSIONS: Stent thrombosis is associated with severe adverse outcomes. Although catheter-based therapies are effective in restoring patency in a majority of patients, patients are referred frequently for coronary bypass surgery because of residual thrombus and refractory angina. These findings suggest that alternative or adjunctive therapies for stent thrombosis are needed.

Angioplasty, Balloon, Coronary↗
PubMed2006

Late thrombosis of drug-eluting stents: a meta-analysis of randomized clinical trials.

PURPOSE: Drug-eluting stents are commonly used for percutaneous coronary intervention. Despite excellent clinical efficacy, the association between drug-eluting stents and the risk for late thrombosis remains imprecisely defined. METHODS: We performed a meta-analysis on 14 contemporary clinical trials that randomized 6675 patients to drug-eluting stents (paclitaxel or sirolimus) compared with bare metal stents. Eight of these trials have reported more than a year of clinical follow-up. RESULTS: The incidence of very late thrombosis (>1 year after the index procedure) was 5.0 events per 1000 drug-eluting stent patients, with no events in bare metal stent patients (risk ratio [RR]=5.02, 95% confidence interval [CI], 1.29 to 19.52, P=.02). Among sirolimus trials, the incidence of very late thrombosis was 3.6 events per 1000 sirolimus stent patients, with no events in bare metal stent patients (RR=3.99, 95% CI, .45 to 35.62, P=.22). The median time of late sirolimus stent thrombosis was 15.5 months, whereas with bare metal stents it was 4 months. Among paclitaxel trials, the incidence of very late thrombosis was 5.9 events per 1000 paclitaxel stent patients, with no events in bare metal stent patients (RR=5.72, 95% CI, 1.08 to 32.45, P=.049). The median time of late paclitaxel stent thrombosis was 18 months, whereas it was 3.5 months in bare metal stent patients. CONCLUSIONS: Although the incidence of very late stent thrombosis more than 1 year after coronary revascularization is low, drug-eluting stents appear to increase the risk for late thrombosis. Although more of this risk was seen with paclitaxel stents, it remains possible that sirolimus stents similarly increase the risk for late thrombosis compared with bare metal stents.

Coronary Disease↗
PubMed2004

Acute arterial thrombosis associated with cocaine abuse.

PURPOSE: Cocaine-induced arterial thrombosis is uncommon, and most reported cases involved small-diameter vessels such as the cerebral and coronary arteries. This study was undertaken to review our experience with peripheral arterial thrombosis presumed caused by cocaine abuse. METHODS: Hospital records were reviewed for all patients admitted over 10 years with acute arterial occlusion involving the peripheral arterial system. Patients with confirmation of cocaine use or of its derivative, crack cocaine, within 24 hours of hospital admission formed the basis of this study. Symptoms at presentation, management, and outcome in these patients were reviewed. RESULTS: Three hundred eighty-two patients with acute peripheral arterial occlusion were identified during the study period. The presumptive diagnosis of cocaine-induced arterial occlusion was made in 5 patients (4 men, mean age 38 years). Cocaine use was achieved via intranasal inhalation in 2 patients (40%), whereas the 3 remaining patients smoked crack cocaine (60%). The mean time between cocaine use and onset of arterial thrombosis was 9.2 hours (range, 2-20 hours). Symptoms at presentation included acute limb ischemia without pedal Doppler signals (3 patients, 60%) and abdominal pain without femoral pulses (2 patients, 40%). Arterial occlusion was confirmed on angiograms in all patients, which revealed aortic thrombosis in 1 patient (20%), iliac thrombosis in 2 patients (40%), superficial femoral artery thrombosis in 1 patient (20%), and popliteal artery occlusion in 1 patient (20%). Surgical thrombectomy was successfully performed in 4 patients (80%), and 1 patient (20%) underwent successful thrombolytic therapy for femoropopliteal artery occlusion. There was no perioperative mortality. All 5 patients who were discharged were available for follow-up (mean, 36 months; range, 6-75 months). There was 1 late death from myocardial infarction. In 1 patient recurrent lower extremity arterial thrombosis developed after 28 months, which was successfully treated with thrombolytic therapy. CONCLUSIONS: Our study underscores cocaine abuse as a potential cause of acute arterial thrombosis. Cocaine-induced arterial thrombosis should be suspected in patients with recent history of cocaine abuse with acute limb ischemia without an identifiable source or overt cardiovascular risk factors. Prompt angiography with operative or endovascular intervention should be performed to avert arterial ischemic sequelae.

Adult↗