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PubMed1990

The risk and efficacy of anticoagulant therapy in the treatment of thromboembolic complications in patients with primary malignant brain tumors.

Twenty-three patients with malignant glial neoplasms were treated with anticoagulant therapy for thromboembolic complications. Fifteen patients had deep vein thrombosis alone, and 8 patients had both deep vein thrombosis and pulmonary embolism. Serum prothrombin times were maintained at 1.25 times control for an average of 5.8 months per patient, for a total patient exposure to warfarin therapy of 132 patient-months (11 patient-years). Only 1 patient suffered a recurrent pulmonary embolism, and this occurred during an episode of gastrointestinal bleeding, when anticoagulant therapy had to be discontinued prematurely. All patients were followed with serial computed tomographic or magnetic resonance imaging scans, and no patient showed radiographic evidence of intratumoral hemorrhage either during or after warfarin therapy. One patient, who died from a large recurrent glioblastoma, was found at autopsy to have scattered foci of intratumoral hemorrhage. This series, together with a review of the available literature, suggests that oral anticoagulant therapy is both a safe and effective means of treating thromboembolic complications in patients with residual malignant glial tumors.

Adult↗
PubMed1996

Thrombolytic therapy in pulmonary embolism of Behçet's disease.

We report the case of a patient with Behçet's disease who presented with deep vein thrombosis and pulmonary embolism. In spite of being treated initially with anticoagulants, corticosteroid and oral cyclophosphamide, the patient presented again with a new pulmonary embolism. This critical situation made us initiate thrombolytic therapy with a urokinase "bolus' followed by continuous infusion through a catheter into the pulmonary artery. Treatment response was good and 2 years later there was no evidence of new thrombotic episodes.

Behcet Syndrome↗
PubMed1995

A new sensitive membrane based ELISA technique for instantaneous D.Dimer evaluation in emergency.

D.Dimer is currently used as a diagnotic help in thromboembolic events. The first application widely validated concerns the exclusion diagnosis of deep vein thrombosis and pulmonary embolism. In this context D.Dimer measurements must be performed individually and they must offer a good accuracy in evaluating the clinical decision threshold which is of 0.5 micrograms/ml when D.Dimer is expressed as initial fibrinogen equivalent. For this objective we report a new membrane based ELISA technique, which uses an immunofiltration device and two complementary monoclonal antibodies. The first one is coated onto the membrane and is used for the D.Dimer capture. The bound analyte is then revealed later using the second monoclonal antibody coupled to alkaline phosphatase. The assay is performed in less than 10 minutes and it can be used instantaneously by the clinical laboratories in emergency situations. Only 200 microliters of a standard citrated plasma are required. All samples containing more than 0.5 micrograms/ml D.Dimer produce a color development which intensity is a relation of the D.Dimer concentration. All specimen with levels below 0.3 micrograms/ml give negative tests, whereas a grey zone is present between 0.3 and 0.5 micrograms/ml. This assay offers all the specifications required by its applications to the exclusion diagnosis of deep vein thrombosis and pulmonary embolism.

Enzyme-Linked Immunosorbent Assay↗
PubMed2005

[Vena cava filter -- is there an indication for implantation?].

The indication of vena cava filter implantation is controversially discussed. On the basis of the available literature and our own results a critical analysis of this issue is given. Between 1994 and 2003, we inserted a total of 29 vena cava filters; 24 temporary and 5 permanent filters. In twelve patients, the placement of the filter was indicated due to pulmonary embolism and a contra-indication to dose adjusted heparin therapy. Seven additional patients experienced a recurrent pulmonary embolism despite adequate heparin therapy. An additional prophylactic filter insertion was carried out in ten patients. The temporary vena cava filters were left in place between 7 to 38 days with an average of 17 days. Total implantation time of temporary filters was scheduled until complete mobilisation of the patients, generally in conjunction with an effective dosage of oral anticoagulants. No patient died in connection with the insertion of the filter and no further pulmonary embolisms occurred. One case of inferior vena cava thrombosis occurred in each group of temporary and permanent filters. In one third of the removed filter systems, thrombi in the filter were found. Local infections of the catheter and introducer sets were observed in two patients. Moreover, in one case the strut of a temporary filter broke and subsequently dislocated 17 days after insertion. However, there is little evidence concerning vena cava filters, and further investigations are necessary. Until additional data are available, filters should generally be restricted to patients with deep venous thrombosis and pulmonary embolism who cannot receive anticoagulation, and highly selected cases.

Adult↗
PubMed1996

Thrombotic tendency in 75 symptomatic, unrelated patients with APC resistance.

Resistance to activated protein C (APC resistance) was measured in 284 individuals (169 females, 115 males) with a history of objectively confirmed venous thrombosis and/or pulmonary embolism. A decreased APC resistance ratio was found in 75 patients (26%), 47 were females, 28 males. Factor V Leiden was investigated in 60 of 75 patients with APC resistance, of whom 46 were heterozygous, 4 homozygous. In 10 APC resistant patients the Arg 506 Glu mutation was not identified. The median age of the first thromboembolic event in patients with APC resistance was 42 years (range 15-82 years). Most patients had a history of deep vein thrombosis (83%), 28% had experienced pulmonary embolism. More unusual sites of thrombosis were the deep arm veins (7%) and mesenteric veins (one patient, 1.3%). 53% of patients developed the first thromboembolic event spontaneously. Precipitating conditions for thromboembolism were surgery in 9.3% and trauma in 8%. In one third of female patients the first thromboembolic event occurred in conjunction with pregnancy and delivery (14.8%) or oral contraceptives (19%). At the time of investigation 40% of patients with APC resistance had experienced recurrent thromboembolic events. The family history was positive in 60% of patients. We conclude that the clinical feature of APC resistance is similar to the feature of a deficiency of antithrombin, protein C and protein S. Pregnancy, delivery and oral contraceptives seem to be a relevant additional risk factors for thrombosis in females with APC resistance.

Adolescent↗
PubMed2000

Haemodilution for acute ischaemic stroke.

BACKGROUND: Ischaemic stroke interrupts the flow of blood to part of the brain. Haemodilution is thought to improve the flow of blood to the affected areas of the brain. OBJECTIVES: The objective of this review was to assess the effects of haemodilution in acute ischaemic stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group trials register, Medline and conference abstracts. We contacted manufactures and investigators in the field. SELECTION CRITERIA: Randomised trials of haemodilution treatment in people with acute ischaemic stroke. Only trials where treatment was started within 72 hours of stroke onset were included. DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and independently extracted the data. MAIN RESULTS: Sixteen trials were included. A combination of venesection and plasma volume expander was used in eight trials. Eight trials used plasma volume expander alone. The plasma volume expander was dextran 40 in 11 trials, hydroxyethyl starch in four trials and albumin in one trial. Two trials tested haemodilution in combination with another therapy. Evaluation was blinded in 11 trials. Five trials probably included some patients with intracerebral haemorrhage. Haemodilution did not significantly reduce deaths within seven to 28 days (odds ratio 1.12, 95% confidence interval 0.88 to 1.43). Similarly, haemodilution did not influence deaths within three to six months (odds ratio 1.02, 95% confidence interval 0.85 to 1.23), or death and dependency or institutionalisation (odds ratio 1.01, 95% confidence interval 0.86 to 1.19). The results were similar in confounded and unconfounded trials, in trials of isovolaemic and hypervolaemic haemodilution, and in trials using different types of hemodiluting agents. Six trials reported venous thromboembolic events. There was a tendency towards reduction in deep venous thrombosis and/or pulmonary embolism at three to six months follow-up (odds ratio 0.59, 95% confidence interval 0.33 to 1.06). REVIEWER'S CONCLUSIONS: The overall results of this review are compatible both with a modest benefit and a moderate harm of haemodilution therapy for acute ischaemic stroke. As used in the randomised trials, this therapy has not been proven to improve survival or functional outcome.

Brain Ischemia↗
PubMed1997

Current status on new anticoagulant and antithrombotic drugs and devices.

Several new drugs for the management of thromboembolic disorders have recently become available. Low-molecular-weight heparins are being evaluated for the prophylaxis of medical and surgical deep venous thrombosis and pulmonary embolism; for the treatment of pre-existing thrombosis; and for cases of coronary syndrome (unstable angina, myocardial infarction), thrombotic and ischemic stroke, interventional cardiology, pregnancy, cancer, and transplantation-associated thrombosis. A chemically synthesized heparin pentasaccharide, which has purely anti-factor Xa activity and does not induce thrombocytopenia, is also in clinical trial. Thrombin inhibitors, such as hirudin and argatroban, are a practical anticoagulant substitute where heparin cannot be used. They are also useful for the management of coronary syndrome and as adjunct therapy. The antiplatelet agent ticlopidine and its analogue, clopidogrel, which does not produce blood dyscrasia, are effective for the secondary prevention of thrombotic stroke and the management of combined arterial thrombotic syndromes. Glycoprotein-targeting antibodies, synthetic derivatives, and peptides (some of which are orally bioavailable) have added a new dimension to the management of arterial thrombosis and high-risk patients having angioplasty. Plasma-derived agents, such as antithrombin III, are available for the management of thrombophilia and disseminated intravascular coagulation. Compression devices and the foot pump, alone and in combination with pharmacologic agents, have been used successfully. Combination therapy using various agents in different proportions have also been found useful. Although there is much enthusiasm in this quickly developing area and clinical trials are demonstrating the antithrombotic efficacy of the new drugs, safety considerations require additional clinical validation. Long-term outcomes and costs also need to be addressed objectively.

Adult↗
PubMedDate not supplied

Subcutaneous low-molecular-weight heparin versus standard heparin and the prevention of thromboembolism in medical inpatients. The Heparin Study in Internal Medicine Group.

In a multicenter, double-blind clinical trial in 1,968 inpatients 1 daily subcutaneous administration of LMW heparin plus 2 placebo injections or 3 x 5,000 IU unfractionated (UF) heparin was given for 10 (8-11) days. The primary end point was the incidence of proximal deep-vein thrombosis or pulmonary embolism. Patients were assessed during the study period for development of proximal deep-vein thrombosis by compression sonography at days 1 and 10 and for pulmonary embolism by scintigraphy in symptomatic patients. Aim of the study was to demonstrate the equivalence of both treatment regimens. A total of 1,968 patients were randomized to receive UF or LMW heparin. Of these, 378 patients were excluded during the study period, so that 780 patients on UF and 810 on LMW heparin were included in the efficacy analysis. Four primary end points were observed with UF and 6 with LMW heparin, demonstrating the equivalence of treatments (p = 0.012). Additionally, pulmonary embolism was suspected as the cause of death in 6 patients who died during the study (3 per treatment group). A higher frequency of death (n = 32) was observed in the LMW-heparin group (p = 0.02) particularly documented in a part of the centers. Safety analysis showed a higher frequency of local pruritus, local erythema and subcutaneous hematoma, a higher increase in plasma levels of triglycerides, total cholesterol, alanine aminotransferase and aspartate aminotransferase, and a decrease of antithrombin III in patients receiving UF heparin. A decrease in platelet count (values ranging between 40,000 and 80,000/microliter) was observed in 4 patients with UF and in none with LMW heparin. No severe thrombocytopenia was observed. Subcutaneous LMW heparin is as effective as UF heparin for prophylaxis of thromboembolism in bedridden, hospitalized medical patients.

Aged↗
PubMedDate not supplied

Use of deep venous thrombosis prophylaxis by family physicians.

BACKGROUND: Accumulated data indicate that the administration of low-dose subcutaneous heparin reduces the incidence of deep venous thrombosis in high-risk surgical and medical patients. Because deep venous thrombosis predisposes to pulmonary embolism, it is generally accepted that reducing deep venous thrombosis will reduce pulmonary embolism, the most common preventable cause of death in hospitalized patients. There are few data, however, regarding physicians' use of heparin for deep venous thrombosis prophylaxis in medical patients. METHODS: We reviewed charts of medical patients aged 50 years and older who were admitted to family practice services in a community teaching hospital and excluded patients who were not candidates for heparin prophylaxis. RESULTS: Eighty (65 percent) of 123 patients received heparin for deep venous thrombosis prophylaxis. Patients admitted to a residency teaching service were more likely to receive heparin for deep venous thrombosis prophylaxis than were patients admitted to nonteaching services (odds ratio 3.37, 95 percent confidence interval 1.26-9.21, P = 0.012). An association between the patient's number of risk factors for deep venous thrombosis and likelihood of receiving deep venous thrombosis prophylaxis approached statistical significance (P = 0.078). CONCLUSIONS: In our institution, heparin for deep venous thrombosis prophylaxis is frequently but not uniformly prescribed for appropriately selected family practice inpatients. No similar data for nonsurgical patients were found for comparison.

Aged↗
PubMed2004

Laparoscopic procedures as a risk factor of deep venous thrombosis, superficial ascending thrombophlebitis and pulmonary embolism--case report and review of the literature.

UNLABELLED: Since its introduction laparoscopic surgery has been used for many indications, e.g., cholecystolithiasis, hernia, appendicitis, fundoplication, benign large bowel disease and gynaecological disorders. It has been considered as safe and efficient procedure for most patients with only few contraindications, mostly heart-lung disease. When the initial enthusiasm has been replaced by a more critical observation, more complications of laparoscopy or laparoscopic surgery were not only discovered but also reported. In laparoscopic hernia repair there is a tendency for severe complications when compared to open surgery. There is a controversy on possible side-effects of laparoscopic surgery, e.g., thrombosis, and the increased necessity of prophylaxis for thromboembolic events. Recently a growing number of reports on thromboembolic complications in association with laparoscopic surgery were published. Thrombosis may be caused by detrimental effects of pneumoperitoneum on venous flow (increased abdominal pressure and negative Trendelenburg position) and activation of the haemostatic system. Further risk factors may contribute to the risk to develop venous thrombosis. It is well accepted that varicose veins are associated with an increased risk for the thrombosis. However, the association of varicose veins with complications of laparoscopic surgery is unclear. The possible impact of thrombotic complications makes an analysis of the association of varicose veins or a history of deep vein thrombosis on the development of thrombosis after laparoscopic surgery mandatory. Although this is the first report on ascending thrombophlebitis and thrombosis of the sapheno-femoral junction after laparoscopic surgery, the incidence of deep vein thrombosis or superficial thrombophlebitis after laparoscopic surgery or laparoscopy may be much higher according to the pathophysiological changes during and after these procedures. In many patients venous thrombosis may not be recognized or it appears when the patient is already discharged. CONCLUSION: Laparoscopy and laparoscopic procedures may have an increased risk for the development of thrombosis due to increased abdominal pressure and negative Trendelenburg position. Patients with varicose veins and a history of thromboembolism may aggravate laparoscopy associated risks for the development of thromboembolic complications. Superficial thrombophlebitis in the thigh is not a benign disease entity and may lead to deep vein thrombosis (DVT) and pulmonary embolism (PE). Urgent surgical treatment (high ligation) may be warranted together with low-molecular weight heparin (LMWH) and compressions therapy. Patients with varicose veins and a history of venous thrombosis may not be suitable candidates for laparoscopic surgery. Family practitioners may be confronted with this complication more often since patients are discharged earlier from hospital after laparoscopic interventions due to legislative regulations.

Diverticulitis, Colonic↗
PubMed2004

Pacemaker lead thrombosis treated with atrial thrombectomy and biventricular pacemaker and defibrillator insertion.

Right atrial thrombosis and pulmonary embolism are infrequent complications of pacemaker insertion. We report a patient with a large mobile thrombus on an endocardial DDD pacing lead and probable pulmonary embolism. We believe that this is the first case of pacemaker lead thrombosis in which treatment included insertion of an epicardial biventricular pacemaker and an implantable cardioverter-defibrillator.

Angioplasty, Balloon, Coronary↗
PubMedDate not supplied

Assessing thrombosis risk in patients with idiopathic, diabetic, and postsurgical gastroparesis.

Patients with severe gastrointestinal motility disorders are often found to have intravenous access clots or deep venous thrombosis. It has previously been reported that many patients who have intravenous access thrombosis have concomitant thrombotic risk factors. In this study, the goal was to determine the underlying prevalence of hypercoagulable risk in a series of patients with documented gastroparesis. Investigators studied 62 consecutive patients (52 female; mean age, 42 y) who had symptoms of gastroparesis. All patients were evaluated for placement of a gastric neural stimulation device, or they had had one placed previously. Patients underwent a hematologic interview and standardized coagulation measures of thrombotic risk. Laboratory studies measured acquired elevations of Factor VII, Factor VIII, fibrinogen, lupus anticoagulant panel, antiphospholipid antibody panel, homocysteine (in the setting of kidney disease), and activated protein resistance. Investigators also measured congenital factors: Factor VIII (with C-reactive protein levels), antithrombin III, protein C, protein S (total and free), Factor II mutation, Factor V Leiden, methylenetetrahydrofolate reductase, and homocysteine. Fifty-five patients (89%) were found to have detectable hypercoagulable risk factors. Twenty-five of the 62 patients (40%) had a documented history of abnormal clotting, including deep venous thrombosis, intravenous access thrombosis, and pulmonary embolism. All patients with a previous history of thrombosis had detectable clotting abnormalities. Of 56 patients, 40 (71%) had hypercoagulability and did not have diabetes (P=.036), and 20 (36%) had hypercoagulability and no known history of infection. However, this value was not statistically significant when infection and hypercoagulability were compared (P=.408). A high prevalence of acquired and congenital hypercoagulable defects has been observed in patients with gastroparesis, which may predispose them to arterial and venous clots. This unique finding warrants consideration of coagulation evaluation in patients with severe gastroparesis, especially when these patients are placed in high-risk thrombophilic situations, such as hospitalization, prolonged intravenous access, and surgery.

Adult↗
PubMed2002

[Low molecular weight heparins after orthopedic and traumatologic operations in geriatrics].

Deep vein thrombosis and pulmonary embolism are common complications after orthopedic and trauma surgery. To prevent these complications, the use of low-molecular-weight heparins (LMWH) as prophylaxis is well proved and accepted. We reviewed 203 patients undergoing geriatric rehabilitation in our hospital after orthopedic and trauma surgery. Despite a prophylaxis with LMWH, 23 (11.3%) of these patients were diagnosed with having a clinically apparent and sonographically confirmed thromboembolic event. The average age of all patients was 81.8 years; the time between surgical or orthopedic intervention and thrombembolic event was on average 29.4 days. Using evidence-based medicine, a search of the literature showed 34 clinical trials concerning the prophylaxis of thrombembolic events with LMWH after orthopedic or trauma surgery. All studies have been reviewed for age of patients and for duration of prophylaxis with LMWH. The average age of all patients involved is 65.8 years. There are only 4 trials with an average age of 75 years or more, with a total number of less than 250 patients. The mean duration of prophylaxis with LMWH is 12.5 days. Only 6 trials concern thromboprophylaxis given longer than 3 weeks after surgical intervention. We conclude that there are no clear data about safety, efficiency and optimal duration of prophylaxis with LMWH in geriatric patients undergoing orthopedic or trauma surgery.

Aged↗
PubMed2003

Novel anticoagulants for the prevention and treatment of venous thromboembolism.

Unfractionated heparin, low molecular weight heparin and vitamin K antagonists are anticoagulants currently used for the prevention and treatment of deep vein thrombosis and pulmonary embolism. Considerable limitations of these agents, such as a narrow therapeutic window, a variable dose response or lack of oral bioavailability, created the need for new anticoagulants. Numerous new compounds with different mechanisms of action have been developed and some have been already approved for clinical use. Quite recently, fondaparinux, an indirect anti-factor Xa inhibitor, has been licensed in Europe and in the US for prevention of VTE in patients undergoing hip or knee replacement surgery. In addition, lepirudin, a recombinant hirudin derivative, and the heparinoid danaparoid, have been approved in Austria for treatment of heparin-induced thrombocytopenia. Recombinant nematode anticoagulant protein c2, the orally available thrombin inhibitor ximelagatran and ART-123, a recombinant soluble thrombomodulin, are in advanced stages of clinical development. This article reviews mechanisms and sites of action, and the current state of preclinical and clinical research of these and various other agents with respect to the prevention and treatment of venous thromboembolism).

Anticoagulants↗
PubMed2005

Venous thromboembolism in the ICU and reversal of bleeding on anticoagulants.

Venous thromboembolic disease is a very common complication in the ICU. This article reviews incidence, prevention, and therapy related to venous thromboembolism, including both deep venous thrombosis and pulmonary embolism. Special diagnostic and treatment considerations in the ICU setting are highlighted. The increased use of antithrombotic agents has led to an increased number of patients who experience bleeding complications on anticoagulant therapy. This review also addresses the methods of reversing various anticoagulants.

Anticoagulants↗