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PubMed2000

The role of the D-dimer in the diagnosis of venous thromboembolism.

Classic enzyme-linked immunosorbent assay (ELISA) D-dimer assays are sensitive in screening for thromboembolic disease; however, they are cumbersome and time consuming to perform, which limits their routine use. Latex agglutination assays are easier to perform, but they are not as sensitive as the ELISA assays. New D-dimer assays incorporating novel technologies can be performed rapidly with a sensitivity approaching that of classic ELISA assays. D-dimer assays are uniformly sensitive in detecting thromboembolic disease in different patient populations; however, low specificity limits the clinical utility of D-dimer measurements in medical inpatients and postoperative patients. Increasingly, these measurements are being incorporated into diagnostic algorithms for venous thromboembolism and are reducing the need for invasive diagnostic studies.

Journal Article↗
PubMed2001

[Treatment of peripheral arterial thromboembolic occlusions using a new percutaneous mechanical thrombectomy system].

PURPOSE: We report our experience with a new percutaneous thrombectomy device for the treatment of thromboembolic occlusions of peripheral arteries. MATERIAL AND METHODS: Between November 1999 and May 2000 12 patients (10 male) with thromboembolic occlusions of peripheral arteries were treated. 8 occlusions were located in the femoral and popliteal arteries, 3 in the infrapopliteal vessels and 1 in the brachial artery. In all cases a new 6 F-catheter with a rotational screw and a suction vacuum unit was used. RESULTS: The intervention was successful in 11 patients. 1 patient with a failed procedure had a duration of occlusion > 90 days. There were no complications. All patients were discharged on the same or the following day. CONCLUSION: Percutaneous treatment with the thrombectomy device is a feasible option in a small group of patients with thromboembolic occlusions of the peripheral arteries. Often additional treatment is necessary. The major indication seems to be acute thrombosis. The procedure is easy and safe to apply.

Aged↗
PubMed2003

Pulmonary balloon angioplasty of chronic thromboembolic pulmonary hypertension (CTEPH) in surgically inaccessible cases.

The clinical course of patients suffering from chronic thromboembolic pulmonary hypertension (CTEPH) depends on the distribution pattern of the thromboembolic material. In patients with thromboembolic findings in the central pulmonary segments pulmonary thrombendarterectomy (PTE) has excellent results and acceptable operative risk. This paper presents two surgically inaccessible cases that were successfully treated with balloon pulmonary angioplasty. Balloon angioplasty improved parenchymal perfusion, increased cardiac index (Delta CI +19.2 % [Case 1], and +15.4 % [2]), reduced pulmonary vascular resistance during follow-up (Delta PVRI -25.0 % [1] and -15.9 % [2]), and is discussed as an alternative treatment option for cases not suited for surgery.

Adult↗
PubMedDate not supplied

[Can the number of thromboembolisms incidents in total hips replacement be further reduced?].

QUESTION: Is it possible to reduce the rate of thrombembolic events during total hip arthroplasty (THA) by the intraoperative use of a mechanical device for thrombembolic prophylaxis (A-V Impulse System). METHOD: The efficacy of additional mechanical thrombembolic prophylaxis was investigated in a prospective randomised trial on 104 patients who underwent cementless THA. All patients received low dose heparin. In 52 patients the additional application of the A-V Impulse System was introduced intraoperatively for the next 24 h. A perfusion scintigram of the lung was performed before and 7 days after the operation in both groups to detect embolic patterns. RESULTS: Perfusion deficits typical for thromboembolic events were detected postoperatively in 8 patients (15.4 %) of the controls and 5 patients (9.6 %) of the A-V Impulse System group. CONCLUSIONS: With the perfusion lung scan we saw postoperatively a total of 13 patients (12.5 %, n=104) with an asymptomatic microthromboembolism of the lungs. Hence it is necessary to increase the protection against thromboembolism. Although statistically not significant (p=0.374), there is a tendency that the additional use of the mechanical thrombotic prophylaxis can reduce thromboembolic events in THA. The impact of the intraoperative introduction of the A-V Impulse System is not really clear. However, for a higher velocity of blood flow during the operation it makes sense to start the procedure intraoperatively.

Aged↗
PubMed1998

[Effect of oxygen inhalation on hemodynamics in chronic thromboembolic pulmonary hypertension].

PURPOSE: This study evaluates the haemodynamic effects of oxygen inhalation on pulmonary artery pressure and pulmonary vascular resistance in patients with chronic thromboembolic pulmonary hypertension. METHOD: In 47 patients with chronic thromboembolic pulmonary hypertension haemodynamic parameters were measured before and after oxygen inhalation. RESULTS: In moderately severe and severe pulmonary hypertension oxygen inhalation significantly reduced mean pulmonary artery pressure by about 11.1% and 4.6%, respectively. However, pulmonary vascular resistance was not significantly affected. Oxygen saturation improved and heart rate was reduced. Cardiac index decreased in severe pulmonary hypertension. Systemic vascular resistance increased. CONCLUSION: We conclude that oxygen inhalation reduces pulmonary artery pressure and improves oxygen supply in patients with moderately severe and severe chronic thromboembolic pulmonary hypertension.

Blood Pressure↗
PubMed1997

Recombinant hirudin in the prevention of venous thromboembolism in patients undergoing elective hip surgery.

Venous thromboembolism is a major cause of mortality and morbidity in patients undergoing orthopedic surgery. In these patients systemic prophylaxis with anticoagulants appears to be the most effective approach to reduce venous thromboembolic events. Low-molecular-weight heparins (LMWHs) are the prophylactic agents of choice in patients undergoing elective hip replacement. However, their use is still associated with a 15% incidence of deep vein thrombosis (DVT); hence, there is a need for potentially more effective agents. Among these, hirudin and other selective thrombin inhibitors have recently been evaluated. The main pharmacologic properties of recombinant hirudin and the clinical trials carried out with this agent in the prevention of DVT in patients undergoing elective hip replacement are reviewed in this article. Overall, the results of these clinical trials are quite promising; they actually indicate that a b.i.d. subcutaneous injection of 15 or 20 mg of recombinant hirudin is an effective and safe prophylactic approach. Hirudin was more effective than unfractionated heparin, given at a low fixed dose, in two clinical trials and of a LMWH in one clinical trial. However, further studies are required to define the role of recombinant hirudin in the prevention of venous thromboembolism in orthopedic surgery patients.

Elective Surgical Procedures↗
PubMed2002

Usefulness and limits of transthoracic echocardiography in the evaluation of patients with primary and chronic thromboembolic pulmonary hypertension.

The aim of the study was to evaluate the potential usefulness of transthoracic echocardiography in differentiating patients with primary or chronic thromboembolic pulmonary hypertension and to define the capability of echocardiography to assess right-heart performance in such patients. Right-heart catheterization and ultrasound examination were performed in 111 patients with chronic thromboembolic pulmonary hypertension and in 31 patients with primary pulmonary hypertension. All echocardiographic and Doppler parameters were similar in primary and chronic thromboembolic pulmonary hypertension. A significant correlation was found between the tricuspid annular plane systolic excursion and the right ventricular fractional area change and thermodilution-derived right ventricular ejection fraction (P <.001 for both). Furthermore, different patterns of the pulsed Doppler flow velocity curve into the superior vena cava were associated with different right-heart hemodynamic profiles. In conclusion, in patients with chronic pulmonary hypertension transthoracic echocardiography portends meaningful information on the capability of the right heart to confront the increased afterload but it does not permit etiologic differentiation.

Adult↗
PubMed1980

Pulmonary thromboembolism. 2. New trends in prophylaxis and therapy.

Although low-dose heparin therapy is the technique most commonly used for prophylaxis of pulmonary thromboembolism, its usefulness is being questioned. Platelet deaggregation prophylaxis with either aspirin or dipyridamole, or both, apparently is a reasonable alternative, but further studies are needed. For treatment of pulmonary thromboembolism, continuous conventional-dose heparin therapy is the approach of choice. It has the highest therapeutic/toxic ratio and is the most effective technique for prevention of clot propagation. The patient's fibrinolytic network must be intact, however, if clot degradation is to occur. Fibrinolytic therapy with urokinase or streptokinase should be restricted to use in patients with massive pulmonary embolism in whom hemodynamics are unstable. Caval interruption and pulmonary embolectomy have lower benefit/risk ratios than do the medical alternatives and are rarely used for pulmonary thromboembolism.

Aspirin↗
PubMed1996

Combination tissue plasminogen activator and ticlopidine therapy in a rabbit model of acute thromboembolic stroke.

The successful application of thrombolytic therapy to acute myocardial infarction has prompted a reinvestigation of thrombolytic therapy for acute stroke. However, an examination of safety and efficacy of thrombolytic therapy in acute thromboembolic stroke has precluded the entry of patients taking either antiplatelet or anticoagulant therapy. It was therefore of interest, in an established rabbit model of thromboembolic stroke, to examine the use of tissue plasminogen activator therapy in combination with ticlopidine treatment. Following ticlopidine administration (10 mg kg-1, i.v., daily for 5 days), rabbits (n = 7) were embolized by injecting a tin-laden clot into the internal carotid artery with clot placement confirmed by x-ray. Three hours later, t-PA was initiated as a square-wave pulse (6.3 mg kg-1 total dose, given as a 20% bolus, with the remainder administered over 2 h as a continuous infusion). The protocol was continued for a total of 7 h following embolization. Complete clot lysis was demonstrated in 6 of 7 animals. Brain infarct size (triphenyltetrazolium chloride staining) was 36.0 +/- 12.9% hemisphere (mean +/- SEM). Both clot lysis rate and infarct size were very similar to that previously seen following administration of t-PA alone (58% and 31.6 +/- 6.4% hemisphere, respectively) but in marked contrast to previous results seen with intravenous aspirin (no clot lysis). These results suggest that antiplatelet agents used clinically for stroke prophylaxis (aspirin or ticlopidine) may influence the success rate of thrombolysis following initiation of thrombolytic therapy for acute thromboembolic stroke.

Animals↗
PubMed2002

Pulmonary thromboembolism in beta-thalassemia intermedia: are we aware of this complication?

We describe a case of pulmonary thromboembolism in a 61-year-old woman with beta-thalassemia intermedia and no other risk factors for thrombosis. Thromboembolism was documented by perfusion lung scan. We review the literature on this uncommon complication of thalassemia intermedia and discuss the pathogenesis and treatment options. A significant relationship between pulmonary thromboembolism and pulmonary hypertension in these patients was noted.

Blood Proteins↗
PubMed1992

Congenital thrombophilia among patients with venous thromboembolism.

During a 3-year period we studied 393 adult patients (382 of whom were unrelated) with a history of acute venous thromboembolism. A congenital deficiency state known to predispose to thrombosis was found in 27.2%. Of these, most were due to deficiencies of protein C (9.2%), protein S (7.6%), antithrombin III (5%) or to increased plasma PAI-1 concentration (3.1%) which, in the absence of any known factor that predisposes towards thrombosis, results in a diminished fibrinolytic activity. There was a characteristic pattern between the age of onset (mean 34 years) of thrombosis and individual protein deficiency. Thrombosis appeared spontaneously in 73% of cases with recurrence in 80%. In contrast, in the remaining unrelated patients, 138 (35.1%) in whom venous thromboembolism was secondary and occurred at a mean age of 43 years, and in the other 140 (35.6%) who suffered thromboembolism spontaneously at a later age (mean age 55), there was no permanent protein deficiency state or alteration in fibrinolytic activity and thrombosis recurrence was lower (53.6% and 20.7% respectively). Of the 393 patients, deep vein thrombosis was the most common manifestation; however, in congenital thrombophilia, thrombosis of visceral vessels and Raynaud's syndrome (6%) were also detected.

Acute Disease↗
PubMed2001

Serial changes in cerebral blood flow and flow-metabolism uncoupling in primates with acute thromboembolic stroke.

The authors recently developed a primate thromboembolic stroke model. To characterize the primate model, the authors determined serial changes in cerebral blood flow (CBF) and the relation between CBF and cerebral metabolic rate of glucose (CMRglc) using high-resolution positron emission tomography. Thromboembolic stroke was produced in male cynomolgus monkeys (n = 4). Acute obstruction of the left middle cerebral artery was achieved by injecting an autologous blood clot into the left internal carotid artery. Cerebral blood flow was measured with [15O]H2O before and 1, 2, 4, 6, and 24 hours after embolization. CMRglc was measured with 2-[18F]fluoro-2-deoxy-D-glucose ([18F]FDG) 24 hours after embolization. Lesion size and location 24 hours after embolization was determined by the 2,3,5-triphenyltetrazolium chloride (TTC) staining method. The results are summarized as follows: (1) 1 hour after embolization, CBF in the temporal cortex and the basal ganglia decreased to < 40% of the contralateral values. In these regions, regarded as an ischemic core, CBF decreased further with time and CMRglc at 24 hours also decreased. Infarcted lesions as indicated by being unstained with TTC were consistently observed in these regions. (2) In the parietal cortex and several regions surrounding the ischemic core, CBF was > 40% of the contralateral values 1 hour after embolization and recovered gradually with time (ischemic penumbra). In these regions, CMRglc at 24 hours increased compared with that in the contralateral regions, indicating an uncoupling of CBF and CMRglc. No obvious TTC-unstained lesions were detected in these regions. The authors demonstrated a gradual recovery of reduced CBF, an elevated CMRglc and a CBF-CMRglc uncoupling in the penumbra regions of the primate model. Positron emission tomography investigations using this model will provide better understanding of the pathophysiology of thromboembolic stroke in humans.

Acute Disease↗
PubMedDate not supplied

Computed tomography of pulmonary thromboembolism and infarction.

Computed tomographic findings in 18 patients with pulmonary thromboembolism are retrospectively reviewed. In the majority of patients, thromboembolism was not suspected clinically. The CT findings can be divided into two groups: vascular and parenchymal changes. The most frequent vascular findings is an intraluminal filling defect or defects due to thrombus. The most frequent parenchymal finding is a triangular (wedge-shaped) pleural-based soft tissue attenuation lesion. Although CT is not a primary diagnostic tool in the evaluation of pulmonary thromboembolism, CT may be helpful in diagnosis of pulmonary embolism, when evaluating an undiagnosed parenchymal density.

Adult↗
PubMed2001

Prevention of cerebral thromboembolism by low-dose anticoagulant therapy in atrial fibrillation with mitral regurgitation.

Controversy exists regarding the influence of mitral regurgitation (MR) on thromboembolic risk in patients with atrial fibrillation. We aimed to investigate retrospectively a reduction of risk for stroke due to MR in atrial fibrillation and to evaluate the effectiveness of low-intensity anticoagulation therapy. In 313 patients with atrial fibrillation, transthoracic echocardiography was performed and MR was graded. Between the groups with no or mild MR (n = 209) and with moderate or severe MR (n = 104), age, sex, treatment, history of diabetes, hypertension, hyperlipemia and mitral stenosis, and previous stroke were compared. No significant differences in clinical characteristics, treatment, or history were observed between the two groups. The incidence of thromboembolism was significantly higher in the group with no MR (48 patients [23%]) than in the group with MR (14 patients [13%], p < 0.05). In the MR group, previous stroke was frequently observed in patients without warfarin treatment (11 of 51 patients) compared with patients with low-dose warfarin treatment (international normalized ratio of 1.6-1.8) (3 of 53 patients, p < 0.05). Consequently, the thromboembolic event was markedly prevented by low-dose warfarin treatment.

Aged↗
PubMed1997

Posttrauma thromboembolism prophylaxis.

PURPOSE: The need to study methods of thromboembolism prophylaxis in high-risk trauma patients is well established. The purpose of this study was to evaluate the feasibility of a proposed study design, including current methods of prophylaxis, performance of a risk assessment profile scale, and the use of serial color-flow duplex studies in detecting deep venous thrombosis (DVT). METHODS: Patients were enrolled into the study, stratified as to their ability to receive anticoagulation and randomized to low-dose unfractionated heparin, low molecular weight heparin, pneumatic compression devices, or foot pumps with or without vena caval filters. Serial ultrasound scans were performed at designated intervals for 4 weeks. Pulmonary angiograms were obtained for clinical signs or symptoms of pulmonary embolism. RESULTS: Fifty-three patients, 32 male and 21 female patients with a mean age of 44 years, completed the study. The incidence of DVT was 43% (23 of 53 patients) and significantly higher in older patients. There were no pulmonary embolisms. Color-flow duplex proved to be a sensitive method for detecting both proximal and distal thrombi. The risk assessment profile for thromboembolism (RAPT) scale identified a group of patients with a high incidence of DVT. However, the occurrence of DVT was not correlated with the magnitude of the RAPT score. CONCLUSION: The ability to identify a population with a high incidence of thromboembolism by using the RAPT score to detect asymptomatic DVT, and the suggested advantage of low molecular weight heparin, all support the need for an appropriately powered randomized clinical trial.

Adult↗
PubMed1999

Rates of initial and recurrent thromboembolic disease among patients with malignancy versus those without malignancy. Risk analysis using Medicare claims data.

Although the association between malignancy and thromboembolic disease is well established, the relative risk of developing initial and recurrent deep vein thrombosis (DVT) or pulmonary embolism (PE) among patients with malignancy versus those without malignancy has not been clearly defined. The Medicare Provider Analysis and Review Record (MEDPAR) database was used for this analysis. Patients hospitalized during 1988-1990 with DVT/PE alone, DVT/PE and malignancy, malignancy alone, or 1 of several nonmalignant diseases (other than DVT/PE) were studied. The association of malignancy and nonmalignant disease with an initial episode of DVT/PE, recurrent DVT/PE, and mortality were analyzed. The percentage of patients with DVT/PE at the initial hospitalization was higher for those with malignancy compared with those with nonmalignant disease (0.6% versus 0.57%, p = 0.001). The probability of readmission within 183 days of initial hospitalization with recurrent thromboembolic disease was 0.22 for patients with prior DVT/PE and malignancy compared with 0.065 for patients with prior DVT/PE and no malignancy (p = 0.001). Among those patients with DVT/PE and malignant disease, the probability of death within 183 days of initial hospitalization was 0.94 versus 0.29 among those with DVT/PE and no malignancy (p = 0.001). The relative risk of DVT/PE among patients with specific types of malignancy is described. This study demonstrates that patients with concurrent DVT/PE and malignancy have a more than threefold higher risk of recurrent thromboembolic disease and death (from and cause) than patients with DVT/PE without malignancy. An alternative management strategy may be indicated for such patients.

Aged↗
PubMed1997

Venous thromboembolism during pregnancy: a current review of diagnosis and management.

Pregnancy is widely recognized to be a physiologic state with a markedly elevated risk for thromboembolic complications. The diagnosis and management of venous thromboembolic events during pregnancy, however, remains controversial because of the lack of prospective, randomized trials that have included pregnant women. Significant progress has been made in the last 10 years in the management of these conditions in the nonpregnant patient and strong clinical guidelines have been established recently. Obstetrician-gynecologists may modify these guidelines and apply them to the pregnant patient based on their knowledge of the physiologic changes in pregnancy. Objective diagnostic techniques should be used liberally when the diagnosis of deep vein thrombosis or pulmonary emboli is considered because early intervention may prevent serious maternal sequelae including death. Heparin remains the anticoagulant of choice during pregnancy because of its proven safety for both the patient and the fetus. It is likely that long-term anticoagulation is necessary when venous thromboembolism occurs antepartum, although the most efficacious regimen has yet to be established. There is some concern about the prolonged use of heparin during pregnancy, particularly regarding the risk of osteopenia.

Anticoagulants↗
PubMed1991

Right atrial and pulmonary thromboembolism mimicking unstable angina.

Pulmonary thromboembolism is a potentially fatal disease characterized by a highly variable clinical presentation. Mortality rises dramatically with right atrial thromboembolism. In our case right atrial and pulmonary thromboembolism mimicked unstable angina. A high index of suspicion and early use of echocardiography can lead to the prompt diagnosis and timely treatment of this condition. Although the optimal treatment remains controversial, prompt therapeutic intervention is mandated by an otherwise poor prognosis.

Angina, Unstable↗