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PubMed1999

Pulmonary thromboembolism after spinal instrumentation surgery.

A 57-year-old woman was hospitalized because of gait disturbance and dysuria. Close examination revealed a cauda equina tumor at the level of L2 and L3. Tumor resection was performed, with posterolateral fusion and spinal instrumentation. On the eleventh day after the surgery, she experienced dyspnea and chest pain during standing and walking exercise. Pulmonary thromboembolism was diagnosed, based on: (1) blood gas analysis findings of hypoxemia and (2) defective images in both of the upper lobes on urgent pulmonary blood flow scintigram. Her clinical status improved with urgent thrombolytic therapy (with tisokinase and urokinase) and anticoagulation therapy (with heparin and warfarin), and her life was saved. When pulmonary thromboembolism occurs, early diagnosis by pulmonary blood flow scintigram and early thrombolytic and anticoagulative therapies are necessary. Special attention should be paid to symptoms of pulmonary thromboembolism in patients after spinal surgery.

Anticoagulants↗
PubMed2005

Risk factors for thromboembolic complications in inflammatory bowel disease: the role of hyperhomocysteinaemia.

Inflammatory bowel disease (IBD) is associated with an increased risk for thromboembolic events. Aim of this study was to examine the relationship of hyperhomocysteinemia and thrombosis in IBD patients and to assess the role of this factor in addition to other known prothrombotic abnormalities. IBD patients with a history of thrombosis (n = 22) and sex-, age-, and diagnosis-matched IBD controls (n = 23) were studied. Homocysteine (tHcy) was assessed before and after methionine loading. Plasma levels of protein C, protein S, antithrombin III, and fibrinogen and the presence of anticardiolipin and antiphospholipid antibodies were determined and genetic testing for factor V Leiden and the prothrombin gene mutation was performed. Results showed that fasting homocysteine levels in IBD patients with a history of arterial or venous thrombosis tended to be higher than in IBD controls, although not significantly. The increase in homocysteine levels after methionine loading was significantly higher in IBD patients in the arterial thrombosis group than in IBD controls (40.9 +/- 17.7 vs. 27.2 +/- 9.9 microM; P < 0.05). Among the other prothrombotic factors, only factor V Leiden was significantly associated with a history of venous thrombosis (20 vs. 0%). At least one risk factor was found in 64% of the IBD patients with previous thromboembolic complications. We conclude that there is an association between hyperhomocysteinemia and a history of arterial thrombosis in IBD patients. We confirm the high prevalence of factor V Leiden in IBD patients with a history of venous thrombosis. In the majority of IBD patients with previous thromboembolic complications, at least one prothrombotic risk factor is detected.

Adult↗
PubMed2004

Treatment of Venous Thromboembolism in Pregnancy.

Venous thromboembolism is a major preventable cause of maternal mortality in developed countries. Following objective diagnosis of deep vein thrombosis or pulmonary embolism, appropriate treatment with anticoagulation should be initiated. The therapeutic options in pregnancy are limited to the use of either unfractionated heparin or low molecular weight heparin. Oral anticoagulants, like warfarin, are relatively contraindicated for use during pregnancy for the treatment of venous thromboembolism because they freely cross the placenta and can be associated with adverse fetal effects. The appropriate length of treatment for acute venous thromboembolic disease diagnosed during pregnancy should be at least 3 months and possibly up till 6 weeks after delivery.

Journal Article↗
PubMed1987

Prevention of venous thromboembolism after general surgery. Cost-effectiveness analysis of alternative approaches to prophylaxis.

A number of methods of prophylaxis can reduce the risk of postoperative venous thromboembolism in patients undergoing general surgery. The cost-effectiveness of several of these--low-dose subcutaneous heparin, intermittent pneumatic compression, graduated compression stockings, heparin plus dihydroergotamine, heparin plus stockings, and intermittent pneumatic compression plus stockings--was assessed by pooling data from published reports of randomized controlled trials. Using clinical protocols, costs for prophylaxis, diagnosis, and treatment of venous thromboembolism were determined. The expected outcomes and costs of each strategy were then calculated using techniques of decision analysis. The results indicate that stockings are the only prophylactic method that is actually cost-saving. Costs of care average $34 less per admission for patients using stockings than for those receiving no prophylaxis. Most other methods of prophylaxis further reduce thromboembolic risk, but increase costs by $50 to $88 per patient relative to costs for the use of stockings. Differences in the cost-effectiveness of these prophylaxis are more marked, ranging from about $50,000 to almost $500,000 per additional life saved.

Clothing↗
PubMed1994

Thromboembolic prophylaxis with low molecular weight heparin during pregnancy.

OBJECTIVE: The objective of this study was to show that low molecular weight heparin (LMWH) can be used in preventing veno-pulmonary thromboembolic diseases in pregnancy. METHODS: Twenty-four women carrying 27 pregnancies with known risk of veno-pulmonary thromboembolic diseases in pregnancy were prophylactically treated with LMWH (dalteparin) during part of their pregnancy. Our therapeutic target was a plasma concentration of 0.20-0.50 anti-Xa U/ml measured 2-6 h after subcutaneous administration of LMWH into the abdominal wall. To obtain this anti-Xa activity the patients were given total doses of 2500-10,000 anti-Xa U daily. Monitoring of anti-Xa activity in patients receiving < or = 5000 U/day was not necessary. RESULTS: Twelve out of the 24 women received LMWH at the time of delivery. Our biochemical assay could not show the presence of anti-Xa activity in the blood samples from the babies although it was possible to show anti-Xa activity in their mothers. In three out of 24 women, blood samples showed activation of coagulation. These patients were changed to the vitamin K antagonist phenindione. CONCLUSIONS: None of the treated women showed any clinical or paraclinical signs of thromboembolic diseases during pregnancy or 6 weeks postpartum. All the babies were born healthy. None of the women had any side effects due to the treatment.

Factor Xa Inhibitors↗
PubMed1989

Role of free radicals in pulmonary thromboembolism in mice.

Involvement of free radicals and their scavenging enzymes in mice pulmonary thromboembolism, induced by intravenous infusion of collagen and adrenaline, has been studied. Malonaldehyde (MDA) and activities of xanthine oxidase (XO), catalase (CAT) and superoxide dismutase (SOD) were estimated in platelets, heart and lung homogenates. MDA increased in all the tissues sharply, while animals showed 70-80% thrombocytopenia. Xanthine oxidase activity in these animals increase significantly in heart. However, increased SOD activity and decreased catalase activity was observed in platelets. Intravenous administration of superoxide dismutase (5 mg/kg), catalase (5 mg/kg) and mannitol (200 mg/kg) protected the mice against pulmonary thromboembolism. The importance of free radicals in mice pulmonary thromboembolism has been demonstrated.

Animals↗
PubMed1996

Patients at risk of venous thromboembolism--clinical results with reviparin.

Perioperative thromboembolism can be effectively prevented by low-dose heparin. However, its clinical benefit is limited, due to the risk of bleeding, the need for multiple daily doses, infrequent disorders of platelet function and other potential side effects. Low molecular weight heparin (LMWH) was developed with the aim that the antithrombotic efficacy of heparin could be maintained, while the risk of bleeding and other side effects would be reduced. Prior to recent studies, the anticipated clinical benefit of LMWH remained a controversial issue. We have reviewed the clinical pharmacology and the results of several prospective trials using reviparin a LMWH which has been compared with unfractionated heparin (UFH) and another LMWH. The efficacy and safety of reviparin was examined in the prevention of venous thromboembolism in high risk patients undergoing elective major abdominal and hip surgery. The results of these clinical trials show that reviparin is as effective as UFH in preventing venous thromboembolism whilst having a lower incidence of bleeding complications. Of major significance was the finding that a very low dose of reviparin, namely 1750 anti-Xa IU once daily, was found to be as effective as UFH in preventing deep vein thrombosis whilst having a significantly lower incidence of bleeding complications in patients undergoing major abdominal surgery. Reviparin has also been shown to be effective and safe as enoxaprin in patients undergoing elective hip surgery. Further clinical trials are required to test different dosage regimens as a thromboprophylactic agent in high risk patients. It is possible that reviparin and other LMWHs with similar pharmacological properties may have an important clinical benefit over earlier compounds. However, this needs to be assessed in large scale, double-blind, randomised clinical trials.

Abdomen↗
PubMed1988

The prevalence and pattern of pulmonary thromboembolism in the Chinese in Hong Kong.

The prevalence and clinical pattern of pulmonary thromboembolism was studied by a multifaceted approach. This documented the occurrence of pulmonary thromboembolism among the Chinese and confirmed an increasing incidence in Hong Kong, although comparatively it was still much lower (about one-tenth) than that found in western communities. Their clinical pattern, regarding presentation, risk factors, clinical features and response to thrombolytic therapy, conformed well with those reported in the west, but perhaps appeared in a milder form. The strong association of pulmonary thromboembolism with varicose veins and immobilisation would appeal for recommending routine heparinisation in Chinese patients having these combinations. Our findings will stimulate more interest in the comparative study of the haematological profile and the ethnic particulars of the Chinese.

Adult↗
PubMed2005

Oral anticoagulation strategies after a first idiopathic venous thromboembolic event.

PURPOSE: The optimal duration and intensity of warfarin therapy after a first idiopathic venous thromboembolic event are uncertain. We used decision analysis to evaluate clinical and economic outcomes of different anticoagulation strategies with warfarin. METHODS: We built a Markov model to assess 6 strategies to treat 40- to 80-year-old men and women after their first idiopathic venous thromboembolic event: 3-month, 6-month, 12-month, 24-month, and unlimited-duration conventional-intensity anticoagulation (International Normalized Ratio, 2-3) and unlimited-duration low-intensity anticoagulation (International Normalized Ratio, 1.5-2). The model incorporated age- and sex-specific clinical parameters, utilities, and costs. Using a societal perspective, we compared strategies based on quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios. RESULTS: In our baseline analysis, incremental cost-effectiveness ratios were lower in younger patients and in men, reflecting the higher bleeding risk at older ages, and the lower risk of recurrence among women. Based on a willingness-to-pay of <$50000/QALY, the 24-month strategy was most cost-effective in 40-year-old men ($48805/QALY), while the 6-month strategy was preferred in 40-year-old women ($35977/QALY) and 60-year-old men ($29878/QALY). In patients aged >/=80 years, 3-month anticoagulation was less costly and more effective than other strategies. Cost-effectiveness results were influenced by the risks associated with recurrent venous thromboembolism, the major bleeding risk of conventional-intensity anticoagulation and the disutility of taking warfarin. CONCLUSION: Longer initial conventional-intensity anticoagulation is cost-effective in younger patients while 3 months of anticoagulation is preferred in elderly patients. Patient age, sex, clinical factors, and patient preferences should be incorporated into medical decision making when selecting an appropriate anticoagulation strategy.

Adult↗
PubMed2003

Thromboembolic complication after arthroscopic shoulder surgery.

Thromboembolic complications after arthroscopic shoulder surgery are very unusual and need thorough investigation of the possible origin. In this case of venous pulmonary thromboembolism after arthroscopy of the shoulder, neither a hint of coagulopathy nor an anatomic abnormality could be found that explains this complication. Therefore, irritation of the subclavian vein caused by compression by the motor-driven shaver is probably one cause for our thromboembolic complication. Careful attention to positioning, fluid management, and use of traction, as well as an appreciation of shoulder anatomy to select portal placement will help decrease the common complications associated with shoulder arthroscopy. A further option to prevent thrombembolic complications in shoulder arthroscopy patients might be prophylaxis with a low-weight heparin in patients with risk factors. In conclusion, awareness of uncommon complications such as deep venous thrombosis and pulmonary embolism will help the orthpaedic surgeon promptly diagnose and treat these problems.

Anticoagulants↗
PubMed2005

Complement factor H Y402H gene polymorphism, C-reactive protein, and risk of incident myocardial infarction, ischaemic stroke, and venous thromboembolism: a nested case-control study.

OBJECTIVES: An exonic polymorphism (Y402H) in the complement factor H (CFH) gene, which locates within the binding sites for heparin and C-reactive protein, has recently been described and hypothesized to play an important role in atherothrombosis. METHODS: We, therefore, evaluated the CFH genetic variant Y402H amongst 685 Caucasian individuals who subsequently developed arterial or venous thrombotic event (incident myocardial infarction (MI), ischaemic stroke, or venous thromboembolism) and amongst 685 age- and smoking-matched Caucasian individuals who remained free of reported vascular disease during follow-up (controls) within the Physicians' Health Study cohort. RESULTS: Genotype distribution for the polymorphism tested was in Hardy-Weinberg equilibrium in the control group. In contrast to expected results, we found no association of Y402H polymorphism with risk of atherothrombosis (adjusted: myocardial infarction, OR=1.09, 95%CI 0.88-1.36, p=0.43; ischaemic stroke, OR=1.11, 95%CI 0.81-1.54, p=0.52; venous thromboembolism, OR=1.41, 95%CI 0.88-2.24, p=0.15), nor with baseline plasma C-reactive protein levels [median (interquartile range) mg/L: YY, 1.39 (0.70-2.60); YH, 1.10 (0.57-2.16); HH, 1.00 (0.48-1.79); p=0.14]. CONCLUSIONS: In this large, prospective cohort of apparently healthy Caucasian men, we found no association of the complement factor H Y402H gene polymorphism with risk of incident thromboembolic events, nor with baseline levels of C-reactive protein.

Adult↗
PubMedDate not supplied

Lung scintigraphy in the diagnosis and follow-up of pulmonary thromboembolism in children with nephrotic syndrome.

Thromboembolic phenomenon and pulmonary embolism is quite frequent in children with nephrotic syndrome (NS). The incidence of pulmonary thromboembolism in children with NS is as common as in adults, and severity is also reported to be relatively high. The mortality rate in NS with thromboembolic complications may be significantly increased if not diagnosed and treated well in time. For establishing the diagnosis of pulmonary embolism, although the combined use of magnetic resonance venography and CT angiography has been proposed, V/Q scan is still the best modality. We performed serial lung perfusion scans in two young patients with NS who developed sudden onset tachypnea during their stay in the hospital. Initial lung perfusion scans showing marked perfusion defects and normal chest X-rays indicated a high probability for pulmonary embolism. The patients were treated with streptokinase, and the study was repeated. Marked improvement was seen in lung perfusion, thereby highlighting the importance of lung perfusion scan in the follow-up of such patients.

Child, Preschool↗
PubMed2005

Left atrial appendage flow velocity as a quantitative surrogate parameter for thromboembolic risk: determinants and relationship to spontaneous echocontrast and thrombus formation--a transesophageal echocardiographic study in 500 patients with cerebral ischemia.

BACKGROUND: Hemostasis in the left atrial (LA) appendage (LAA) is an important cause in the formation of thrombi. Determination of the LAA flow velocity (LAAV) could be a quantitative parameter for estimating thromboembolic risk. The objective of this study was to: (1) determine the relationship between LAAV and qualitative parameters with elevated thromboembolic risk (thrombus/spontaneous echocontrast [SEC]); and (2) define factors that influence LAAV. METHODS: In all, 500 patients with stroke were examined consecutively by transesophageal echocardiography. In addition to measurement of the LAAV, the atrial appendage was examined for the presence of thrombi or SEC. RESULTS: LAAV differed significantly among patients with sinus rhythm (71 +/- 16 cm/s), paroxysmal atrial fibrillation (AF) and in sinus rhythm during transesophageal echocardiography (46 +/- 13 cm/s), paroxysmal AF and AF during transesophageal echocardiography (32 +/- 12 cm/s), and chronic AF (27 +/- 9 cm/s, P < .001). Independent of the rhythm, the risk of thrombus/SEC increased significantly at an LAAV less than 55 cm/s. At an LAAV 55 cm/s or more there is only a minimal risk of thrombus/SEC (negative predictive value 100% and 99%, respectively). Multivariate analysis showed that LAAV is the strongest predictor for the occurrence of thrombus/SEC (P < .0001). Further multivariate analysis showed that left ventricular ejection fraction, LA size, (paroxysmal) AF, age, and sex are independent parameters influencing LAAV. CONCLUSION: Independent of the basic rhythm, there is a close relationship between LAAV and qualitative parameters of elevated thromboembolic risk. LAAV could, therefore, be a quantitative surrogate parameter for risk stratification. It is influenced by both cardiac and extracardiac factors.

Adult↗
PubMed2006

Outcomes of pulmonary endarterectomy for treatment of extreme thromboembolic pulmonary hypertension.

OBJECTIVE: Pulmonary endarterectomy is the operation of choice for thromboembolic pulmonary hypertension. As the largest referral center for thromboembolic pulmonary hypertension in the world, we are frequently asked whether patients with extreme pulmonary hypertension (pulmonary artery systolic pressure >100 mm Hg) can safely undergo this operation with therapeutic benefit. METHODS: To determine whether patients with pulmonary artery systolic pressures of greater than 100 mm Hg have favorable outcomes after pulmonary endarterectomy, we reviewed the outcomes of 743 patients who underwent this operation between 1999 and 2004. We compared hemodynamic and outcome parameters of 65 patients (group 1: 26 male and 39 female patients; mean age, 49.5 years) who had preoperative pulmonary artery systolic pressures of greater than 100 mm Hg with 678 patients (group 2: 314 male and 364 female patients; mean age, 50.3 years) with preoperative pulmonary artery systolic pressures of less than 100 mm Hg. RESULTS: Group 1 patients had a greater overall diminution in pulmonary vascular resistance (mean decrease: 926.7 +/- 511.1 vs 546.4 +/- 365.1 dynes x sec x cm(-5), P < .01) and reduction in pulmonary artery systolic pressure (mean decrease: 50.5 +/- 18.7 vs 27.2 +/- 18.6 mm Hg, P < .05), with similar improvement in cardiac output (mean increase: 1.53 +/- 1.47 vs 1.55 +/- 1.58 L/min) compared with values seen in group 2 patients. Although length of hospital stay was similar for the 2 groups, overall perioperative survival was slightly lower in group 1 patients (89.2% [58/65] for group 1 vs 96.5% [654/678] for group 2). Patients with extreme pulmonary hypertension manifest a higher rate of postoperative reperfusion edema, leading to longer days of intubation compared with group 2 patients. CONCLUSIONS: Pulmonary endarterectomy can be performed safely in patients with severe thromboembolic pulmonary hypertension. The magnitude of preoperative pulmonary artery systolic pressure or pulmonary vascular resistance is not a contraindication for surgical intervention. Indeed, patients with extreme pulmonary hypertension might benefit the most from this operation.

Adolescent↗
PubMed2004

Decompressive craniectomy in acute cerebral ischemia in rats. Is there any benefit in smaller thromboembolic infarcts?

Early craniectomy has shown to reduce infarction size in experimental large MCA infarction probably due to improved leptomeningeal perfusion. Based on the hypothesis that craniectomy may also be beneficial in smaller MCA infarction we evaluated the effects of craniectomy on infarction size in small thromboembolic cerebral infarction in rats. Therefore, thromboembolic cerebral ischemia was induced in 40 rats by endovascular injection of autologous, fibrin-rich emboli. Twenty-one animals with a diffusion-weighted MR imaging (DWI)-derived infarction size of 50-100 mm3 (involving one- to two-third of the MCA territory) at 1 h after injection were randomly assigned to two groups. Eleven animals of group 1 immediately underwent craniectomy, ten animals of group 2 (controls) were not treated. Serial DWI was performed at 4 and 24 h. Infarction size was assessed by TTC-staining at 48 h after emboli injection. As result, prior to treatment, at 1 h after emboli injection, infarction size in groups 1 and 2 was 65.9 +/- 16.0 mm3 and 67.9 +/- 17.8 mm3, respectively. At 4 and 24 h, infarction size in group 1 was 73.5 +/- 22.1 mm3 and 85.2 +/- 24.7 mm3, and 76.3 +/- 21.0 mm3 and 83.4 +/- 22.9 mm3 in group 2, respectively. TTC-derived infarction size was 84.0 +/- 23.3 mm3 and 82.7 +/- 21.5 mm3, respectively. There was no significant difference between the two groups (P > 0.79). In conclusion, our results demonstrate that for small thromboembolic MCA infarction early craniectomy is not beneficial.

Animals↗
PubMed2006

[Chronic pulmonary thromboembolism revealing beta-thalassemia intermedia after splenectomy].

INTRODUCTION: The clinical expression of beta-thalassemia intermedia is variable and complications are more frequent than in the minor form. Thromboembolism risk increase after splenectomy. Few cases of the type of complications are reported. CASE RECORD: A man was admitted for beta-thalassemia intermedia with moderate chronic hemolysis anemia, complicated by chronic pulmonary thromboembolism and liver iron overload. Post-traumatic splenectomy probably increase the risk of this two complications. The patient's respiratory status improved following bosentan therapy without worsening his hepatopathy. CONCLUSION: The present study also notes that thromboembolism complications can be an indicator of beta thalassemia and interrogate about the risk and the benefit of splenectomy in the treatment of beta-thalassemia intermedia.

Antihypertensive Agents↗
PubMed1998

Operation for chronic pulmonary thromboembolism accompanied by thrombophilia in 8 patients.

BACKGROUND: Medical therapy for chronic pulmonary thromboembolism is limited, and surgical treatment has become more frequent recently. We have performed pulmonary thromboendarterectomy on 8 patients with chronic pulmonary thromboembolism accompanied by thrombophilia. METHODS: The patients were 6 men and 2 women aged 21 to 56 years (mean, 35 years). Five patients had antiphospholipid syndrome, 2 had protein C deficiency, and 1 had congenital antithrombin III deficiency. The preoperative condition was New York Heart Association functional class III in 5 and class IV in 3. Hypoxemia, marked pulmonary hypertension (mean pulmonary artery pressure, 47+/-6.7 mm Hg), and low cardiac output were observed in all patients. After a median sternotomy, deep hypothermia was induced using a cardiopulmonary bypass, and pulmonary thromboendarterectomy in the bilateral pulmonary arteries was performed under intermittent circulatory arrest. RESULTS: There were no operative deaths. Long-term respiratory management was needed postoperatively by 3 patients. In the remaining 5 patients, no reperfusion injury was observed. The arterial blood oxygen concentration improved, and the mean pulmonary pressure decreased to 16+/-5.5 mm Hg. The cardiac output also increased, and New York Heart Association functional class improved to I in 4 and II in 4 patients. CONCLUSION: Pulmonary thromboendarterectomy under deep hypothermic intermittent circulatory arrest was effective for chronic pulmonary thromboembolism accompanied by thrombophilia for which medical treatment is of limited value.

Adult↗
PubMed1999

A case of fatal pulmonary thromboembolism associated with the use of intravenous estrogen therapy.

OBJECTIVE: To report a case of fatal pulmonary embolism associated with the use of i.v. estrogen therapy for menometrorrhagia. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 52-year-old woman with fibroid uterus treated with GnRH analogues with add-back therapy who presented with excessive vaginal bleeding. INTERVENTION(S): Intravenous conjugated estrogens were administered for a total of six doses. MAIN OUTCOME MEASURE(S): Fatal thromboembolic event. RESULT(S): The day after i.v. conjugated estrogens were administered, the patient had only scant vaginal bleeding, but she experienced the sudden onset of respiratory distress, became comatose, and subsequently had ventricular fibrillation leading to asystole. All resuscitative efforts failed. Postmortem examination revealed bilateral pulmonary artery thromboembolism (saddle embolus). CONCLUSION(S): Intravenous conjugated estrogen therapy may be complicated by fatal thromboembolic events. This potential adverse effect must be considered in the use of such therapy for severe menometrorrhagia, especially when treating a patient at increased risk.

Drug Therapy, Combination↗