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PubMed1991

Venous thromboembolic disease.

During the past year, the findings of several clinical trials have been published that have important implications for the care of patients with venous thromboembolism. These clinical trials have produced advances in the diagnosis and treatment of venous thrombosis and pulmonary embolism and in the prevention of venous thromboembolism in high-risk patients. In patients with clinically suspected pulmonary embolism, the value and limitations of ventilation-perfusion lung scanning have been established, and it is now accepted that objective tests for deep vein thrombosis have an important role. There have been important advances also in the diagnosis of deep vein thrombosis; these advances include the finding that impedance plethysmography is effective in pregnant symptomatic patients and the development of an objective technique for Doppler ultrasound. The optimal duration of initial intravenous heparin treatment of established thrombosis has been determined. In the prevention of venous thromboembolism, the effectiveness of sequential intermittent compression in patients having hip replacement has been established, and further data on the effectiveness of low-molecular-weight heparin in high-risk patients have become available.

Heparin↗

PubMed1990

Use of subsequent anticoagulants to increase the predictive value of Medicaid deep venous thromboembolism diagnoses.

Linked data bases that derive their information from health care administrative sources are increasingly being used to conduct pharmacoepidemiologic research. Computerized case ascertainment using these data would be highly advantageous in terms of time and cost considerations. For a study of oral-contraceptive-associated deep venous thromboembolism, we evaluated the utility of using anticoagulant treatment codes to validate diagnostic codes suggestive of deep venous thrombosis and pulmonary embolism. By requiring evidence of outpatient anticoagulant use within six months of hospitalization, the predictive value of case ascertainment increased from 42% to 65% for "probable" deep venous thromboembolism and from 70% to 97% for "possible" deep venous thromboembolism. In addition, use of anticoagulant treatment codes as a second marker of disease resulted in nondifferential outcome misclassification when the study base was restricted to current oral-contraceptive users. Use of confirmatory treatment claims may provide a rapid, cost-effective alternative to medical-record-based case ascertainment for pharmacoepidemiologic studies of selected outcomes conducted in Medicaid and other linked universal health care coverage populations.

Adolescent↗

PubMed2002

Role of homocysteine for thromboembolic complication in patients with non-valvular atrial fibrilation.

Thromboembolism is the most important complication in patients with atrial fibrilation (AF). Homocysteine is a toxic amino acid that has been recently accepted as a risk factor for atherosclerosis and stroke. The aim of the present study is to show whether there is a relation between hyperhomocysteinemia and thromboembolic complications in patients with non-valvular AF. We admitted 38 patients with non-valvular AF. The patients were divided into two groups: group A (n = 20; mean age, 75.7 +/- 10.4 years; three males/17 females), and group B (n = 18; mean age, 68.0 +/- 10.6 years; 11 males/seven females). While group A consisted of the patients with AF and stroke, group B was composed of the patients with AF but without stroke. The patients having sinus rhythm (15 subjects) were used as the reference group to obtain the cut-off value. Homocysteine was measured by the immunoassay method. The means of the homocysteine levels were 12.4 +/- 3.3 micromol/l in group A, 8.3 +/- 2.3 micromol/l in group B and 9.3 +/- 1.8 micromol/l in the reference group. The cut-off value was 10.6 micromol/l. Group A had a statistically higher homocysteine level than not only group B, but also the reference group (P < 0.05). While 60% of group A (n = 12) had the elevated homocysteine level, the rate was only 22% for group B (n = 4). In conclusion, hyperhomocysteinemia may be one of the explanations for the increased rate of thromboembolic complications in older patients with AF.

Aged↗

PubMedDate not supplied

Enoxaparin for thromboembolism prophylaxis in spinal injury: preliminary report on experience with 105 patients.

Venous thromboembolism continues to be a major cause of morbidity and mortality in patients with spinal injury (SI). Recently, we reported on the effectiveness and safety of a low molecular weight heparin (LMWH), tinzaparin, in preventing deep vein thrombosis in motor-complete SI patients. Recently, another LMWH, enoxaparin, was approved by the United States Food and Drug Administration for prevention of thromboembolism in hip and knee replacement surgery. Since its approval, we have used 30 mg of enoxaparin subcutaneously every 12 h as routine prophylaxis in all hospitalized SI patients. In this retrospective study, we present an analysis of safety and efficacy of the first six months experience, during which 105 patients received the drug. No patient developed clinical evidence of thromboembolism, and none of the 60 venous ultrasound examinations showed a deep vein thrombus. Eleven patients had evidence of hemorrhage, but the LMWH was considered to have contributed to the bleeding in only three. This additional experience with enoxaparin reinforces our previous conclusion that LMWHs are safe and effective thromboprophylactic agents in SI patients.

Adolescent↗

PubMedDate not supplied

In vitro model for studying the effects of hemodynamics on device induced thromboembolism in human blood.

Biomateria related thromboembolism is a complex phenomenon, affected by such variables as biomaterial surface chemistry, hemodynamics, and individual donor variations. Thus, isolation of the individual variables would greatly facilitate the understanding and inhibition of this phenomenon. A low volume in vitro model with this potential has been developed, with the initial focus on studying the influence of hemodynamics on thromboembolism (TE) in human blood. Patterned after a larger in vitro model for bovine blood used successfully in our laboratory, the smaller model directed fresh human blood in a single pass through 1/32 inch ID PVC tubing and a flow cell at 3 ml/min. The flow cell consisted of alternating abrupt expansions and contractions of cylindrical tubing that could be modified to study the effects of hemodynamic parameters on TE. Thrombus growth in the flow cell was monitored visually by transillumination microscopy. Emboli from the flow cell were detected continuously by a light-scattering microemboli detector (LSMD), and their strength was assessed by using the constant-pressure filtration (CPF) method. Preliminary studies confirmed the potential of this model. Thrombi were observed visually in the flow cell at sites of high vorticity and at flow separation and reattachment points and were also observed to embolize. Emboli were detected by the LSMD downstream of the flow cell in significantly greater numbers than upstream and were coincident with the embolization of thrombi observed visually. Emboli collected downstream of the flow cell occluded the CPF filters at 50 mm Hg, suggesting that they possessed sufficient strength to occlude microvessels. This model may be used to aid in developing a computer model of thromboembolism, which could subsequently be refined with clinical data.

Hemodynamics↗

PubMed1975

Thromboembolic complications of cast immobilization for injuries of the lower extremities.

Six cases of thromboembolic complications in patients being treated with plaster cast immobilization for a variety of injuries to the lower extremity were encountered over a four month period on an Air Force orthopaedic service. These injuries, consisting of three ruptures of the tendo achillis, two fractures of the tibia, and a sub-talar dislocation of the foot, resulted in one death from pulmonary emboli and three other serious complications of pulmonary emboli. The literature on thromboembolic complications following lower extremity injuries (including information of pathogenesis, clinical characteristics and epidemiology of venous thromboembolism and the hazards of lowere extremity cast immobilization in an individual susceptible to his complication) suggests that prophylaxis against thrombosis should be instituted in high risk individuals who must undergo case immobilization for injuries to the lower extremity.

Achilles Tendon↗

PubMed1996

Prevention of venous thromboembolism in orthopaedics in the United States.

The use of different types of antithrombotic prophylactics in various clinical settings was examined. A standardized questionnaire was mailed to 5000 randomly selected practicing orthopaedic surgeons that detailed practice profile, surgical case type and frequency, method of thromboembolism prophylaxis used, incidence of morbidity, and type of screening used. Twenty-one percent (n = 1046) of surgeons surveyed returned the questionnaire. Four of 5 surgeons performing elective hip arthroplasty used some form of thromboembolic prophylaxis for all of their patients, 13% used prophylaxis only for patients considered to be at high risk, and 3% of respondents never used prophylaxis. The rates of prophylactic use for patients undergoing elective knee arthroplasty were similar. A considerably lower rate of routine prophylactic use was seen among surgeons performing surgery for pelvic and lower extremity trauma. Except for cases involving neurologic compromise, most patients undergoing either elective or traumatic spinal surgery were not given prophylaxis. Low dose warfarin alone was the most commonly used prophylaxis modality. A comparison of the results of the current survey with those of past surveys showed that the use of aspirin has fallen. The use of routine pharmacologic prophylaxis against thromboembolism in hip and knee arthroplasty has become the standard of care in the United States. Among patients undergoing surgery for hip fracture and other lower extremity trauma, however, prophylaxis remains underused.

Adult↗

PubMed2001

Surveillance for venous thromboembolic disease after total knee arthroplasty.

The value of deep venous thrombosis screening after total knee arthroplasty is controversial. The purpose of the current study was to examine the value of routine surveillance for venous thrombosis after total knee arthroplasty done with modern operative and perioperative treatment. Computerized search engines were used to identify papers published between 1985 and July 2000 relevant to the purpose of the study. Papers that met the inclusion criteria for review were categorized as follows: the frequency of deep venous thrombosis; the natural history of deep venous thrombosis; the accuracy of screening methods for venous thrombosis; and efficacy of screening in reducing morbidity attributable to venous thromboembolism after total knee arthroplasty. Several studies have shown a low complication rate related to venous thromboembolic disease when compression ultrasound is used for screening as part of a clinical algorithm after knee arthroplasty. However, the only large prospective randomized trial evaluating ultrasound screening failed to show a reduction in morbidity with a surveillance protocol. The benefits of surveillance depend on factors specific to each surgeon's practice including the type and duration of venous prophylaxis, the rate of symptomatic and asymptomatic thromboembolic disease associated with that protocol, and the accuracy of screening tests used for surveillance.

Arthroplasty, Replacement, Knee↗

PubMedDate not supplied

Thromboembolic disease: prophylaxis and treatment.

Thromboembolic disease ranks among the most dangerous and common complication in the postoperative or post-traumatic patient. As previously mentioned, the incidence is increasing and fatalities from this complication have also risen substantially. The pathogenesis of thromboembolic disease and the predictability of its occurrence remain elusive. Based upon evidence suggesting that the thrombotic process may begin during surgery, greater attention should be given to the use of prophylactic agents before as well as during the operative procedure. The search continues for a safe, oral agent uniformly effective in preventing thromboembolism.

Dextrans↗

PubMed1992

Thromboembolism following multiple trauma.

The true incidence of thromboembolic complications following multiple trauma is unknown, and no method of prophylaxis has been shown to be both safe and effective in managing seriously injured patients. In this prospective study, 113 trauma patients were assigned on admission to receive either low-dose heparin (LDH), (5,000 U subcutaneously every 12 hours) or to wear sequential compression devices (SCDs) as prophylaxis against the development of deep venous thrombosis (DVT). Both groups of patients were serially studied with duplex venous ultrasound imaging to detect thrombus in the veins of the thigh. Ventilation-perfusion lung scans and pulmonary angiograms were performed when pulmonary embolism (PE) was suspected clinically. There were 12 patients who had thromboembolic complications, including 9 of 76 in the SCD group (12%) and 3 of 37 in the LDH group (8%). Five patients had DVT only, four had PE without detectable DVT, and three had both DVT and PE. None of the patients with PE died, and there were no major complications associated with either method of prophylaxis. Compared with the patients who did not develop DVT/PE, those with thromboembolic complications were older (49 +/- 23 vs. 36 +/- 17 years, p less than 0.02), spent more hospital days immobilized (24 +/- 15 vs. 10 +/- 13 days, p less than 0.001), received more transfusions (11 +/- 12 vs. 3 +/- 5 U, p less than 0.001) and had clotting abnormalities on admission, as demonstrated by prolonged PTT values (39 +/- 28 vs. 26 +/- 5 seconds, p less than 0.001). It appears that there is an identifiable subgroup of injured patients at highest risk for PE who warrant both prophylaxis and close surveillance for DVT.

Adolescent↗

PubMed1999

Venous thromboembolic disease in the pediatric intensive care unit.

Long recognized to be a major source of morbidity in the adult population, venous thromboembolism is being increasingly recognized in the pediatric age group. Pediatric intensive care unit patients are exposed to multiple risk factors for venous thromboembolism. Prothrombotic tendencies may be inherited or acquired, secondary to either the underlying disease or selected therapeutic interventions. In children in whom venous thromboembolism is diagnosed, the most commonly identified risk factor is the presence of a central venous catheter. Many cases are not diagnosed until autopsy. Because current treatment recommendations are extrapolated from adult studies, further investigation is needed to define the optimal treatment and prophylaxis regimens in critically ill children.

Canada↗

PubMed2002

Thromboembolism in children.

Acquired and inherited prothrombotic risk factors increase the risk of thrombosis in children. This review is based on "milestone" pediatric reports and new literature data (January 2001-February 2002) on the presence of acquired and inherited prothrombotic risk factors, imaging methods, and treatment modalities in pediatric thromboembolism. After confirming clinically suspected thromboembolism with suitable imaging methods, pediatric patients should be screened for common gene mutations (factor V G1691A, prothrombin G20210A and MTHFR C677T genotypes), rare genetic deficiencies (protein C, protein S, antithrombin, and plasminogen), and new candidates for genetic thrombophilia causing elevated levels of lipoprotein(a), and homocysteine, and probable genetic risk factors (elevations in fibrinogen, factor IX, and factor VIIIC, and decreases in factor XII). Data interpretation is based on age-dependent reference ranges or the identification of causative gene mutations/polymorphisms with respect to individual ethnic backgrounds. Pediatric treatment protocols for acute thromboembolism, including thrombolytic and anticoagulant therapy, are mainly adapted from adult patient protocols.

Child↗

PubMed2001

Prevention of venous thromboembolism in trauma and long bone fractures.

Patients sustaining traumatic injuries are at high risk for the development of venous thromboembolism. The reported incidence of deep venous thrombosis in trauma patients ranges from 20 to 90%. The reported incidence of pulmonary embolism in trauma patients varies between 2.3 and 22%. The aging population and the survival of more severely injured patients may suggest an increasing risk of thromboembolism in the trauma patient population. There have been few randomized prospective studies assessing methods of thromboembolism prophylaxis in trauma patients. Controversy exists as to the optimal method of prophylaxis in this high-risk population. Contraindications arising from associated injuries often limit the potential options for prophylaxis in patients with trauma. Large prospective randomized studies are needed to determine the most effective means of prophylaxis in trauma patients, who have a wide range of both isolated and combined injuries. Future studies should also address the duration of prophylaxis because many trauma patients remain immobile for an extended time.

Aged↗

PubMedDate not supplied

Association of transesophageal echocardiographic findings with the site of arterial occlusion in patients with thromboembolic stroke.

The authors investigated the association of transesophageal echocardiographic findings with the site of arterial occlusion in patients who underwent transesophageal echocardiography because of thromboembolic stroke and in whom the site of arterial occlusion was diagnosed by computerized axial tomography. The study population included 101 patients (mean age 59 +/- 15 years) with thromboembolic stroke and 101 randomly selected age-matched and sex-matched control without stroke. Transesophageal echocardiographic findings that were significantly higher in the patients with thromboembolic stroke than in the control group were vegetations on the aortic or mitral valve (9% versus 1%, P < 0.01), left atrial or left atrial thrombus or spontaneous echocardiographic contrast (20% versus 6%, P < 0.005), thrombus on a prosthetic valve or in the left ventricle (4% versus 0%, P < 0.05), and atherosclerosis in the thoracic aorta (37% versus 21%, P < 0.02). A higher prevalence of atherosclerosis in the thoracic aorta was found in patients with lacunar infarction compared with patients with middle cerebral artery occlusion (67% versus 25%, P < 0.02), as well as a higher prevalence of vegetations on the aortic or mitral valve in patients with occlusion of 2 arteries compared with patients with vertebrobasilar artery occlusion (28% versus 0%, P < 0.05).

Adult↗

PubMed1983

Thromboembolic complications in Cushing's syndrome.

Thromboembolic events are thought to occur with increased frequency in Cushing's syndrome due to the predisposing factors, obesity, hypertension, a raised haematocrit and major surgery plus a 'hypercoagulable state'. To examine this postulate further we have studied 43 patients with Cushing's syndrome retrospectively and 10 patients prospectively to determine the incidence of arterial and venous thrombosis, both spontaneous and post-operative. Arterial events were noted in four cases (9%) and deep vein thrombosis or pulmonary thromboembolism (PTE) occurred in six cases (11%). Post-operative PTE occurred in 2.7% of all operations. These vascular complications tended to occur in the older patients with Cushing's syndrome. In our series, clinically significant thromboembolic episodes appear no more common than expected and the indications for prophylactic anticoagulation (the older and more obese patients) may not be different from other patients undergoing major surgery. An incidental finding was of a greater frequency of hypertension in Cushing's patients due to an adrenal adenoma.

Adrenalectomy↗

PubMed2006

Venous thromboembolic disease: a single-centre case series study.

AIM: The epidemiology of venous thromboembolism in children has likely changed since first being described a decade ago because of evolving management strategies and a greater awareness of predisposing factors for thrombosis in children. The Royal Children's Hospital commenced a 4-year prospective registry of venous thrombosis in 1999 to determine the current Australian epidemiology of venous thrombosis in infants and children. METHODS: A prospective, single-centre registry was established to determine the prevalence, aetiology, diagnostic criteria, management and outcome of venous thromboembolism in an Australian tertiary paediatric centre. RESULTS: The incidence of venous thrombosis was 8.0/10 000 hospital admissions. Fifty-eight per cent of infants and 49% of children were male. Seventy-seven per cent of venous thromboses in infants were associated with central venous cannulation compared with 47% in children. Doppler ultrasonography was the most frequently used diagnostic tool. Treatment strategies varied between age groups. The all-cause mortality rate for infants and children in this study was 8.4% (direct thrombus-related mortality 0%). Fifteen per cent of all patients demonstrated complete resolution of their venous thrombosis at discharge, with 48% demonstrating complete resolution at follow-up assessment. Fifteen per cent of patients experienced significant thrombosis-related morbidity at follow-up assessment. CONCLUSION: In this single-centre registry, venous thrombosis in infants and children occurred with greater frequency than has previously been reported and its epidemiology varied. Central venous catheterisation continues to be a common precipitant to venous thrombosis. Optimal diagnostic and treatment interventions for venous thromboembolism have not yet been determined for infants and children, despite the significant incidence of long-term sequelae.

Adolescent↗

PubMed1985

Prophylaxis of thromboembolism in pregnancy: an alternative.

Twenty-six pregnancies in women who had one or more episodes of thromboembolism in the past were managed by a regimen in which routine antenatal prophylactic anticoagulation was not given, apart from during delivery which was covered with intravenous infusion of dextran 70. After delivery, these patients received either subcutaneous heparin for 6 weeks or subcutaneous heparin for 1 week, followed by 5 weeks of warfarin. One patient (4%) possibly developed an episode of thromboembolism in the antenatal period. There were no episodes of postnatal thromboembolism. There were two spontaneous mid-trimester abortions and no perinatal losses. There were no significant complications or reactions related to the use of dextran, heparin or warfarin.

Adult↗

PubMed1999

The role of inherited thrombophilia in venous thromboembolism associated with pregnancy.

Venous thromboembolism is an important cause of maternal morbidity and mortality. The puerperium should be regarded as the period of greatest risk. However, fatalities in early pregnancy emphasise the need to assess thrombotic risk at all stages of pregnancy. In many cases those at increased risk are potentially identifiable on clinical grounds alone such as those with a personal or family history of venous thromboembolism, obesity, or surgery. Identification of women with multiple clinical risks for thrombosis during pregnancy remains the key to reducing the incidence of this condition. In women who present with a personal or family history of proven venous thromboembolism, thrombophilia screening should be performed in early pregnancy, since the results may influence subsequent management during pregnancy. The investigation and management of patients considered at increased risk of venous thrombosis during pregnancy requires close liaison between obstetricians and haematologists familiar with this rapidly expanding and complex field of thrombophilia.

Activated Protein C Resistance↗