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PubMed1981

Simple mechanical method for decreasing the incidence of thromboembolism.

Increasing awareness of the dangers of low dose heparin therapy has stimulated interest in mechanical methods for decreasing the incidence of thromboembolism. Plantar flexion and dorsiflexion of the feet while the patient is on the operating table by the use of a mechanical device (the Pedi-Pulsor) significantly decreases the incidence of deep vein thrombosis (45 percent in control patients versus 18 percent with the Pedi-Pulsor [p - 0.05]). In addition, use of this machine during the postoperative period should further aid in decreasing the incidence of thromboembolism.

Adult↗
PubMed1983

Thromboembolic prophylaxis with dihydroergotamine-heparin in abdominal surgery. A controlled, randomized study.

The prophylactic affect of dihydroergotamine-heparin (0.5 mg dihydroergotamine plus 5,000 units of heparin administered twice daily) against postoperative thromboembolic complications after gastrointestinal surgery was compared with the affect of 5,000 units of heparin administered three times daily in a controlled, randomized study. Fifty patients received the dihydroergotamine and heparin combination twice daily and 50 patients received 5,000 units of heparin three times daily. The two groups were comparable with respect to age, sex, body weight, and type of operation. The presence or absence of deep venous thrombosis in the legs was determined postoperatively by the radiofibrinogen uptake test. The frequency of deep venous thrombosis in the dihydroergotamine and heparin group was 12 percent compared with 18 percent in the heparin group (0.1 greater than p greater than 0.05). Wound hematoma developed in two patients in the heparin group and in one patient in the dihydroergotamine and heparin group (4 and 2 percent, respectively). No other hemorrhagic complications occurred. By combining heparin with dihydroergotamine it is possible to reduce the daily heparin dose by one third and still obtain the same level of prophylaxis against thromboembolism. The frequency of bleeding complications was very low in both groups, since only one wound hematoma occurred in the dihydroergotamine and heparin group and two in the heparin group.

Abdomen↗
PubMed1996

Mid-term results of pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension.

BACKGROUND: In patients with chronic thromboembolic pulmonary hypertension, acute and striking decreases of pulmonary artery pressures and vascular resistance can be achieved by pulmonary thromboendarterectomy. In this study, the long-term effects of pulmonary thromboendarterectomy on hemodynamic indices and right ventricular function were investigated. METHODS: Sixty-five patients (31 women and 34 men; mean age, 47 +/- 17 years; range, 19 to 69 years; New York Heart Association [NYHA] functional class II, n = 3; class III, n = 38; class IV, n = 24) were reassessed 13 to 48 months (mean, 27 months) after pulmonary thromboendarterectomy. Measurements are reported as mean +/- standard deviation. RESULTS: All patients reported a significant improvement of symptoms: 46 patients were in NYHA functional class I, 16 patients in class II, and 3 patients in class III. Mean pulmonary vascular resistance was significantly reduced compared with preoperative and postoperative values (preoperative: 1,015 +/- 454 dynes.s.cm-5; postoperative: 322 +/- 154 dynes.s.cm-5; follow-up: 198 +/- 72 dynes.s.cm-5; p < 0.001 versus preoperative; p < 0.025 versus postoperative). Concomitantly, cardiac index was significantly increased compared with preoperative values (preoperative: 2.0 +/- 0.7 L.min-1.m-2; follow-up: 2.9 +/- 0.5 L.min-1.m-2; p < 0.001). Significant reductions of right ventricular dimensions and recovery of right ventricular function could be demonstrated radiologically and echocardiographically. In 3 patients (preoperative NYHA class IV, NYHA class III at follow-up) with proven coagulation abnormalities, pulmonary vascular resistance was moderately increased at follow-up compared with postoperative measurements. CONCLUSIONS: In patients with chronic thromboembolic pulmonary hypertension, a persistent decrease of pulmonary vascular resistance and improvement of right ventricular function and NYHA functional status can be achieved by pulmonary thromboendarterectomy.

Adult↗
PubMed1992

Use of low molecular weight heparin for prophylaxis and treatment of thromboembolism in pregnancy.

Low molecular weight heparin (LMWH) preserves the antithrombotic action but not the anticoagulant activity of heparin. LMWH is safe, does not cross the placenta and is administered as a single daily injection. We report our experience with 6 pregnant women given LMWH for treatment or prophylaxis of thromboembolism. The drug was successfully given to 5 women for periods of 6 weeks--6 months and no thromboembolic complications occurred during pregnancy or pueperium. There were no hemorrhagic complications and no excessive bleeding was observed during delivery. The sixth patient relapsed after 6 weeks of therapy. This patient also showed resistance to standard heparin administered intravenously at a very high dose. LMWH should be considered an alternative to standard heparin in pregnant women requiring antithrombotic prophylaxis and therapy.

Adult↗
PubMed1995

Umbilical artery occlusion and fetoplacental thromboembolism.

BACKGROUND: To our knowledge, fetoplacental thromboembolism has been described only in autopsy specimens. We report the antepartum diagnosis of an umbilical artery occlusion and neonatal diagnosis of an aortic thrombus and placental emboli. CASE: A gravida at 31 weeks' gestation was referred for evaluation of decreased fetal movement and an enlarged fetal bladder. A two-vessel umbilical cord with a collapsed, echogenic third vessel was noted, whereas views of a normal three-vessel cord were available from an examination 5 weeks earlier. A positive oxytocin contraction test prompted delivery. Neonatal color flow Doppler imaging demonstrated an aortic thrombus below the renal arteries and above the bifurcation. Gross and microscopic study of the placenta demonstrated necrosis of the collapsed umbilical artery and numerous placental emboli. The aortic thrombus resolved gradually, and the infant went home on the 39th day of life. CONCLUSION: Umbilical artery occlusion can be diagnosed ultrasonographically and may be a sign of fetoplacental thromboembolism. Assessment of fetal oxygenation status by biophysical profile or contraction stress test may be helpful in the evaluation of umbilical artery occlusion.

Abortion, Threatened↗
PubMed1988

Venous thromboembolism and transient thrombocytopenia in a patient with diabetes insipidus treated with desmopressin acetate (DDAVP).

A 22 year-old woman with diabetes insipidus on chronic therapy with desmopressin acetate (DDAVP) developed recurrent venous thromboembolism and transient thrombocytopenia temporally related to the administration of DDAVP. Large increases in plasma von Willebrand factor (vWF), vWF-activity, and relative increases in the concentrations of the larger multimeric forms of vWF-antigen were observed, as well as a plasma factor which sensitized normal platelets to undergo spontaneous aggregation in vitro. Additional studies showed that the patient's plasma retained the platelet aggregation inducing activity after selective removal of vWF by immunoabsorption. The nature of the platelet activating factor and the relationship of this factor and the excessively increased and transiently abnormal vWF to the recurrent venous thromboembolism in this patient remain uncertain. Although the findings do not implicate definitively DDAVP in the elevation of vWF in this patient, it is suggested that its use be considered with caution in patients with diabetes mellitus and increased levels of vWF.

Adult↗
PubMed1990

Influence of thromboembolism prophylaxis by low molecular weight heparin CY 216 (Fraxiparine) on several parameters of haemostasis in patients under dialysis and receiving either unfractionated heparin or CY 216.

The hemorrhagic risk of an association of the low molecular weight (LMWH), Fraxiparine injected intravenously at the dose of 7.500 AXalCU or of unfractionated heparin (UFH) injected intravenously at the usual dose used during hemodialysis (3.750 +/- 1.280 IU + 1.000 IU after 2 hours of dialysis) to the subcutaneous administration once daily of a thromboembolism preventive dose of Fraxiparine (7.500 AXalCU) was evaluated on the modification of the following hemostasis parameters: thrombin time, activated partial thromboplastin time (APTT), anti Xa activity, in 13 uremic patients on hemodialysis. The association of intravenous and subcutaneous Fraxiparine prevented efficiently the clotting of the extracorporeal circulation without inducing a detectable antithrombinic activity. In contrast, the association of I.V. UFH to subcutaneous Fraxiparine induced a significant increase of the thrombin time and of the APTT, so explained by the activity of UFH. It is concluded that subcutaneous Fraxiparine at the thromboembolism preventive dose can be associated as well to I.V. Fraxiparine as to UFH without increasing the potential hemorrhagic risk. Nevertheless the association of SC and IV Fraxiparine 7.500 AXalC u seems preferable to the association of SC Fraxiparine with UFH.

Aged↗
PubMed1995

Clinical relevance of the fibrinogen uptake test in patients undergoing elective general abdominal surgery--relation to major thromboembolism and mortality. Fragmin Multicentre Study Group.

Postoperative thromboembolic complications were evaluated in 2578 patients undergoing elective abdominal surgery, all receiving prophylaxis with low molecular weight heparin. A positive fibrinogen uptake test (FUT) developed in 217 patients (8.4%), while 37 patients (1.4%) had major thromboembolism (TE, defined as proximal deep vein thrombosis and/or pulmonary embolism, verified with phlebography, pulmonary scintigraphy or autopsy). In only 14% a positive FUT was associated with a major TE event. In 19% of the patients with major TE the FUT was negative. In multiple logistic regression the independent predictors for major TE were partially different from those for positive FUT. Thirty day mortality was 3.0%. There were significant associations between both positive FUT and major TE on one hand and mortality on the other (relative risks 2.4 and 5.8, respectively). FUT is not a good predictor of major TE. Both positive FUT and major TE indicate a significant risk of postoperative death.

Abdomen↗
PubMed1977

Prevention of venous thromboembolism with low doses of heparin in urologic patients.

The effectiveness of low doses of heparin was investigated for the prevention of clinically manifested thromboembolic disease. In the group of 125 patients, who received 5,000 units of subcutaneous heparin two hours before the operation, and postoperatively 15,000 units per day for seven to ten days, deep vein thrombosis was not observed, and in only 1 patient (0.8%) pulmonary embolism was suspected. Of 216 patients from the control group, pulmonary embolism was clinically diagnosed in 4 (1.9%), deep vein thrombosis in 7 (3.4%), and in 2 patients (0.9%) fatal pulmonary embolism was found at autopsy. The difference between total thromboembolic disease of the control group (6.2%) and heparinized group was highly significant (p less than 0.02). Postoperative bleeding was seen two times more often in the heparin group, but bleeding was not severe and was easily controlled.

Female↗
PubMed1993

Low molecular weight versus standard heparin for prevention of venous thromboembolism after major abdominal surgery. The Thromboprophylaxis Collaborative Group.

Low-molecular-weight heparin (LMWH) is effective in the prevention of postoperative venous thromboembolism but does it have the safety advantages over standard heparin (SH) that have been claimed? In a multicentre randomised trial in 3809 patients undergoing major abdominal surgery (1894 LMWH, 1915 SH) heparin was given preoperatively and continued for at least 5 postoperative days. Patients were assessed in the postoperative period and were followed up for at least 4 weeks, the emphasis being on safety. Major bleeding events occurred in 69 (3.6%) patients in the LMWH group and 91 (4.8%) patients in the SH group (relative risk 0.77, 95% confidence interval 0.56-1.04; p = 0.10). 93 indices of major bleeding were observed in the 69 LMWH patients and 141 in the SH patients. (p = 0.058). Severe bleeding was less frequent in the LMWH group (1.0% vs 1.9%; p = 0.02), as was wound haematoma (1.4% vs 2.7%; p = 0.007). Bleeding episodes with LMWH were less likely to lead to further surgery to evacuate a haematoma or to control bleeding, and injection site bruising was also less common in the LMWH group. No significant differences were found in the efficacy of the two agents. Perioperative death rates were 3.3% in the LMWH group and 2.5% in the SH group; pulmonary emboli were detected in 0.7% and 0.7%; and deep-vein thrombosis was diagnosed in 0.6% of patients in each group. Follow-up was done on 91% of 3699 evaluable patients. There were 19 further deaths (10 LMWH, 9 SH group) and 25 patients with thromboembolic complications (15 and 10). Of the 3 patients with fatal pulmonary emboli during follow-up 2 had received LMWH and 1 SH. The two drugs were of similar efficacy. The primary end point, the frequency of major bleeding, showed a 23% reduction in the LMWH group, but this difference was not significant. The secondary safety end points revealed that LMWH was significantly better than SH. Fatal pulmonary embolism occurs rarely (0.09%) following discharge from hospital so the cost benefit ratio would not justify prolonged prophylaxis in this setting.

Abdomen↗
PubMed1993

Hematologic correlates of left atrial spontaneous echo contrast and thromboembolism in nonvalvular atrial fibrillation.

OBJECTIVES: This study examined the relation between left atrial spontaneous echo contrast, hematologic variables and thrombo-embolism in patients with nonvalvular atrial fibrillation. BACKGROUND: Left atrial spontaneous echo contrast is associated with left atrial stasis and thromboembolism in patients with nonvalvular atrial fibrillation. However, its hematologic determinants in patients with nonvalvular atrial fibrillation are unknown. METHODS: Clinical, hematologic and echocardiographic variables were prospectively measured in 135 consecutive patients with nonvalvular atrial fibrillation undergoing transesophageal echocardiography. RESULTS: Patients with left atrial spontaneous echo contrast (n = 74, 55%) had an increased fibrinogen concentration (p = 0.029), platelet count (p = 0.045), hematocrit (p = NS) and left atrial dimension (p = 0.005). Multivariate analysis showed that left atrial spontaneous echo contrast was independently related to hematocrit (odds ratio = 2.24, p = 0.002), fibrinogen concentration (odds ratio = 2.08, p = 0.008) and left atrial dimension (odds ratio = 1.90, p = 0.004) but not platelet count. It was also associated with left atrial thrombus (n = 15, p = 0.001) and with recent embolism (n = 40, p < 0.001). In 40 clinically stable outpatients without previous embolism, left atrial spontaneous echo contrast was significantly related to hematocrit (p = 0.005), fibrinogen concentration (p = 0.035) and left atrial dimension (p = 0.029) but not to coagulation factor VII, D-dimer, erythrocyte sedimentation rate, platelet count, plasma beta-thromboglobulin, plasma glycocalicin or glycocalicin index. CONCLUSIONS: Left atrial spontaneous echo contrast in patients with nonvalvular atrial fibrillation is independently related to hematocrit, fibrinogen concentration and left atrial dimension, indicating a relatively hypercoagulable state in addition to stasis. These findings support the hypothesis that left atrial spontaneous echo contrast is due to erythrocyte aggregation. Hematologic factors may contribute to its association with thromboembolism.

Aged↗
PubMed1993

Is there still an avoidable fraction of post-operative thromboembolic complications with heparin prophylaxis? The results of a case-control surveillance. Collaborative Group on Heparin Prophylaxis in Surgery (S.E.P.E.C.).

A case-control multicenter study was set up in 68 general and specialistic wards in Italian regional hospitals in order to assess whether underuse of heparin prophylaxis may account for at least a fraction of the thromboembolic events still occurring in surgical patients. 100 cases with clinically relevant thromboembolic or hemorrhagic events occurring during hospitalization for major surgery and 200 controls were identified. Controls were selected among patients not presenting any of the events under study during the same period of observation and were matched with cases for age, sex, and type of surgery. The results of the study suggest that heparin use in routine conditions of care closely reflects the "consensus" knowledge, patients at higher risk (specifically orthopedic surgical patients, those with varicose veins or with preoperative bed rest longer than 3 days) being treated more frequently with heparin. Absence of heparin prophylaxis does not appear to represent a specific risk factor for the occurrence of index events (OR 0.73, 95% CI = 0.42-1.26). Despite the higher rates of heparin exposure, the presence of varicose veins is associated with a statistically significant increase in the risk of postoperative complications (OR 2.23, 95% CI = 1.07-4.65). This study indicates that among known pre- and peri-operative risk factors only varicose veins may be unprotected by the current prophylaxis practice.

Adult↗
PubMed2004

Short-term prevention of thromboembolic complications in patients with atrial fibrillation with aspirin plus clopidogrel: the Clopidogrel-Aspirin Atrial Fibrillation (CLAAF) pilot study.

BACKGROUND: We evaluated the short-term safety and efficacy of aspirin-plus-clopidogrel as antithrombotic therapy in nonvalvular atrial fibrillation (AF). METHODS AND RESULTS: Thirty patients (11 women, 45 to 75 years of age) with non-high-risk permanent (n = 12) or persistent AF awaiting cardioversion (n = 18) underwent transesophageal echocardiography to exclude left heart thrombi and were then randomly assigned to receive warfarin (international normalized ratio, 2 to 3 for 3 weeks) or aspirin (100 mg/d alone for 1 week)-plus-clopidogrel (75 mg/d added to aspirin for 3 weeks). Bleeding time and serum thromboxane B2 were measured at entry and at 3 weeks. Bleeding time, not affected by warfarin, was prolonged by 71% by aspirin (P <.05) and further, by 144%, by adding clopidogrel (P <.01 vs aspirin alone; +319%, P <.01, vs baseline). Thromboxane B2, not affected by warfarin, was reduced by aspirin (-98%, P <.01) but not further by clopidogrel. No thrombi or dense spontaneous echo-contrast were found at the 3-week transesophageal echocardiography. Seven of 9 patients receiving warfarin and 7 of 9 patients receiving aspirin-plus-clopidogrel, undergoing electrical cardioversion, achieved sinus rhythm. No thromboembolic or hemorrhagic events occurred in both arms throughout the 3-week treatment and a further 3-month follow-up. CONCLUSIONS: Aspirin-plus-clopidogrel and warfarin were equally safe and effective in preventing thromboembolism in this small group of patients with non-high-risk AF.

Aged↗
PubMed2005

Comparison of frequency of thromboembolic events and echocardiographic findings in patients with chronic nonvalvular atrial fibrillation and coarse versus fine electrocardiographic fibrillatory waves.

In patients with nonvalvular atrial fibrillation, the electrocardiographic fibrillatory wave reflects the structural and electrical remodeling of the atria. This study examined whether the fibrillatory wave amplitude could predict the risk of thromboembolism and demonstrated that this amplitude was related to the duration of atrial fibrillation. We also showed that the presence of fine fibrillatory waves (<1 mm in amplitude) could predict the thromboembolic potential in patients with chronic nonvalvular atrial fibrillation.

Aged↗
PubMed2005

Risk of thromboembolism and bleeding after general surgery in patients with atrial fibrillation.

We provide insight into the risk of perioperative thromboembolism and bleeding in patients who have atrial fibrillation, use anticoagulants, and undergo a surgical procedure. Ninety-four patients underwent 121 noncardiac operations during a mean follow-up of 29 months. There was a 3.6-fold increased risk for all bleeding complications within 1 month after surgery compared with the control period (95% confidence interval 1.05 to 12.0). No thromboembolic event occurred in the first month after surgery compared with 11 events in the remaining period (0.4% per month).

Aged↗
PubMed2004

Usefulness of clinical prediction rules for the diagnosis of venous thromboembolism: a systematic review.

PURPOSE: To summarize the evidence on the predictive value of clinical prediction rules for the diagnosis of venous thromboembolism. METHODS: We selected all studies in the English literature in which a clinical prediction rule was prospectively validated against a reference standard, and calculated likelihood ratios, predictive values, and the area under the receiver operating characteristic (ROC) curve for each prediction rule. RESULTS: Twenty-three studies met our eligibility criteria: 17 evaluated prediction rules for the diagnosis of deep venous thrombosis and six evaluated rules for pulmonary embolism. The most frequently evaluated prediction rule for deep vein thrombosis was the Wells rule, which had median positive likelihood ratios of 6.62 for patients with a high pretest probability, 1 for moderate pretest probability, and 0.22 for low pretest probability. The median area under the ROC curve was 0.82. Addition of the D-dimer test to the prediction rule increased the median area under the curve to 0.90. The Wells prediction rule was the most commonly studied for pulmonary embolus and had median positive likelihood ratios of 6.75 for those with high pretest probability, 1.82 for moderate pretest probability, and 0.13 for low pretest probability. The median area under the ROC curve was 0.82. CONCLUSION: The Wells prediction rule is useful in identifying patients at low risk of being diagnosed with venous thromboembolism. The addition of a rapid latex D-dimer assay improved the overall performance of the prediction rule.

Clinical Trials as Topic↗
PubMed2005

[Prevention of venous perioperative thromboembolism in ENT and maxillofacial surgery].

There are few studies of poor methodological quality on the risk of thromboembolism in head and neck surgery. The incidence of symptomatic deep vein thrombosis is estimated between, 0.1% and 0.6%. The patient's risk factors (cancer, alcoholism, smoking, malnutrition) determine for the assessment of the potential benefit of thromboembolism prophylaxis. No method can be recommended based on the literature. In patients receiving anticoagulant therapy undergoing superficial head and neck surgery or dental extraction, the literature suggest to continue anticoagulation throughout the perioperative period.

Humans↗
PubMed2006

Efficacy of combined modality prophylaxis including short-duration warfarin to prevent venous thromboembolism after total hip arthroplasty.

This study reviewed the effectiveness of a trimodality deep venous thrombosis (DVT) prophylactic regimen after primary and revision total hip arthroplasty. Seven hundred five patients were treated with pneumatic compression, adjusted dose warfarin (7 days), and early mobilization. Bilateral lower extremity venous ultrasonography was obtained on postoperative day 3 or 4. The incidence of asymptomatic DVT, symptomatic DVT/pulmonary embolus events within 90 days of surgery, and potential influence of risk factors was retrospectively assessed. Deep venous thrombosis incidence was 4.4% with one (0.1%) nonfatal pulmonary embolus. Increased age, male sex, and DVT history were significant risk factors for thromboembolic events within 90 days of hip arthroplasty. The combination of short-duration warfarin and mechanical prophylaxis with predischarge ultrasound screening was safe and effective in limiting the occurrence of venous thromboembolism.

Adolescent↗