An 8-year history of pulmonary emboli, deep-vein thrombosis.
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Adult↗
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Temporary transvenous pacing and femoral vein thrombosis.
The true incidence of thrombosis and pulmonary embolism in patients requiring temporary transvenous pacing via the femoral vein in unknown. Twenty-nine patients, mean age 66.2 years (range 38-79 years) who required temporary pacing were studied by bilateral contrast venography and perfusion lung scanning after removal of the pacing catheter. The patients were subdivided into two subgroups based on hemodynamic status. There was no statistical difference between the two groups with respect to mean age or the time the pacer catheter was in place and all patients were placed on low-dose heparin therapy. Ten patients (34%) had venographic evidence of thrombosis; six of them (60%) showed lung scan evidence of pulmonary emboli. The hemodynamically compromised group consisted of seven patients, six (85%) of whom had thrombosis; three of these six (50%) had pulmonary emboli. Of the 22 patients in the hemodynamically stable group, four (18%) had thrombosis and two of these (50%) had pulmonary emboli. Venous thrombosis, with subsequent pulmonary emboli, is a serious complication of temporary transvenous pacing using the femoral approach, despite the use of prophylactic low-dose heparin.
Adult↗
Homocysteine and cardiovascular disease: evidence on causality from a meta-analysis.
OBJECTIVE: To assess whether the association of serum homocysteine concentration with ischaemic heart disease, deep vein thrombosis and pulmonary embolism, and stroke is causal and, if so, to quantify the effect of homocysteine reduction in preventing them. DESIGN: Meta-analyses of the above three diseases using (a) 72 studies in which the prevalence of a mutation in the MTHFR gene (which increases homocysteine) was determined in cases (n=16 849) and controls, and (b) 20 prospective studies (3820 participants) of serum homocysteine and disease risk. MAIN OUTCOME MEASURES: Odds ratios of the three diseases for a 5 micromol/l increase in serum homocysteine concentration. RESULTS: There were significant associations between homocysteine and the three diseases. The odds ratios for a 5 micromol/l increase in serum homocysteine were, for ischaemic heart disease, 1.42 (95% confidence interval 1.11 to 1.84) in the genetic studies and 1.32 (1.19 to 1.45) in the prospective studies; for deep vein thrombosis with or without pulmonary embolism, 1.60 (1.15 to 2.22) in the genetic studies (there were no prospective studies); and, for stroke, 1.65 (0.66 to 4.13) in the genetic studies and 1.59 (1.29 to 1.96) in the prospective studies. CONCLUSIONS: The genetic studies and the prospective studies do not share the same potential sources of error, but both yield similar highly significant results-strong evidence that the association between homocysteine and cardiovascular disease is causal. On this basis, lowering homocysteine concentrations by 3 micromol/l from current levels (achievable by increasing folic acid intake) would reduce the risk of ischaemic heart disease by 16% (11% to 20%), deep vein thrombosis by 25% (8% to 38%), and stroke by 24% (15% to 33%).
Cohort Studies↗
The O blood group protects against venous thromboembolism in individuals with the factor V Leiden but not the prothrombin (factor II G20210A) mutation.
We investigated the influence of the ABO blood group in the observed prevalences of the recently described factor V R506Q and factor II G20210A mutations in a thrombotic population. We determined the ABO blood group in a sample of 178 unselected patients (aged 17-83 years), diagnosed at our center with deep vein thrombosis or pulmonary embolism. The results of this study show a high prevalence of thrombosis in the non-O blood group. In the general population, the prevalence as a fraction of the O blood group was 2.69 (confidence interval 1.90-3.82). Of the factor V R506Q carriers (n = 28), only one had O group blood and 27 of 28 were non-O (24 A, one B and two AB). However, within the group of factor II G20210A carriers (n = 17), seven had O, nine A and one B type blood. The prevalence of the factor V R506Q mutation within the O blood group was 2.4% (one of 42), significantly lower than in the A group (23.3%, 24 of 103; P = 0.002), or in the overall non-O group (19.9%, 27 of 136; P = 0.006). This prevalence was similar to that observed previously in the non-thrombotic population in our area (3.5%; P = 0.9). We analyzed the clotting activity of factor VIII and we found higher levels in the non-O group (1.78+/-0.61 U/ml) than in the O blood group (1.30+/-0.51 U/ ml; P < 0.0001). We speculate that factor Va in individuals with the factor V Leiden mutation could interact with the high levels of factor VIII clotting activity as a necessary cofactor.
ABO Blood-Group System↗
[Thromboembolism complications in orthopedics and traumatology. A prospective study of 598 operated patients].
From 1.10.-31.12. 1989, 598 patients who underwent orthopaedic surgery in the Staatliche Orthopädische Klinik were examined by a pre-, intra- and postoperative questionnaire up to 3 months from the date of operation. All patients were separated into 4 groups corresponding to the calculated risk and duration of the operation. 46 patients in Group I, who underwent minor surgery, received 3 x 5000 I.E. Heparin subcutaneously. 243 patients in Group II received besides 3 x 5000 I.E. Heparin, 500 ml HAES 6% preoperatively. They underwent operations of greater intensity and duration at the upper and lower extremities. 302 patients of Group III were given 3 x 5000 I.E. heparin and 500 ml 6% dextrane 60 preoperatively because of severe operations (pelvis, hip). 7 high-risk patients received apart from 3 x 5000 I.E. Heparin subcutaneously 500 ml 6% dextrane 60 preoperatively and 250ml 10% dextrane 40 postoperatively for 5 days. In Group I we had 2.2% thromboembolic complications, whereas in Group II 1.7% and in Group III 3.3% complications with thrombosis and pulmonary embolism occurred. This was proved by pulmonary scintigraphy and phlebography. No such complications were seen in Group IV. The total incidence of deep vein thrombosis was 2.0% and of pulmonary embolism 0.5%. These results show the importance of preoperative risk check and individual prophylaxis of thromboembolic complications in orthopaedic and traumatologic surgery.
Adolescent↗
[Pulmonary embolism: the past and . . . the future].
The history of pulmonary embolism cannot be reconstructed reliably beyond the last two centuries, starting with the Napoleon's times by the works of Laennec. We owe the first pathological and clinical descriptions to European scientists, especially French, German and Italian. Interestingly, some ideas regarding pathophysiology and even hemodynamics can be found in papers published as early as the end of the 19th century. Of note, the strong relationship between venous thrombosis and pulmonary embolism, suspected already in the middle of the 19th century, resulted later in a new clinical entity named venous thromboembolic disease. Only just before the second world war "modern" diagnostic tests entered into the clinical arena. Beginning with electrocardiography and X-ray techniques including pulmonary angiography, the progress in the field of imaging continued with lung scan, echocardiography, computed tomography, and finally still largely unexplored ultra-fast magnetic resonance imaging techniques: despite this technological development the correct diagnosis of pulmonary embolism in daily practice remains an important challenge. This is due to the lack of a single test which would combine high diagnostic power, round-the-clock availability and reasonably low cost. Though thrombotic origin of pulmonary embolism was well documented for almost two centuries, anticoagulation as a treatment for venous thromboembolism dates back much less than a century and thrombolysis was initiated only 30 years ago. What is even worse, those 30 years were not enough for us to identify clear-cut criteria in the selection between thrombolysis and anticoagulation in individual patients. Not to speak about the problem regarding optimal duration of secondary prophylaxis after a thromboembolic episode. Still how long shall we be debating about the same problems at the bed of our patients with venous thromboembolism? Or maybe the near future will bring completely new answers to our old questions? What type of case report related to pulmonary embolism will have the chance to be accepted for publication in the Italian Heart Journal in the year ... 2050? Future will show? But only if we help it....
Forecasting↗
The clinical picture of deep vein thrombosis correlated to the frequency of pulmonary embolism.
Pain and swelling of the leg have been studied in 27 patients with deep vein thrombosis (DVT). Twenty-three of them were also examined for pulmonary embolism (PE) after one week of heparin treatment. Scoring systems were constructed to quantitate pain, size of DVT and PE. A ratio between swelling and pain (S/P ratio) was calculated for each patient. Actual size of the DVT, as estimated with venous phlebography, was correlated to swelling (rs = 0.51, p less than 0.01), S/P ratio (rs = 0.53, p less than 0.01) and PE (rs= 0.57, p less than 0.01). DVTs with not pain at all or just tenderness on palpation were more often associated with PE (p less than 0.05) and elevated blood pressure (p = 0.02) than DVTs with pain on walking. A free floating proximal end of DVT proved unreliable for predicting PE. It is concluded that the risk of developing PE depends not only on DVT size, but also on factors related to pain.
Adult↗
Deep venous thrombosis after posterior spinal surgery.
STUDY DESIGN: A prospective clinical study using venography to evaluate deep venous thrombosis after posterior spinal surgery. OBJECTIVES: To demonstrate the prevalence of deep venous thrombosis after posterior spinal surgery with no prophylaxis. SUMMARY OF BACKGROUND DATA: There have been few studies about the occurrence of deep venous thrombosis after spinal surgery in which venography was used for screening. METHODS: Of the enrolled 134 patients undergoing posterior spinal surgery, 110 (82.1%) were examined with complete surveillance for deep venous thrombosis by venography. There were 64 males and 46 females. The average age at operation was 59.0 years (range, 14-86 years). The levels of the operation were cervical in 54, thoracic in 7, and lumbar in 49. All procedures were performed with patients under general anesthesia. Neither mechanical methods nor anticoagulation medications were used for prophylaxis against thromboembolism. Bilateral ascending venography was performed within 14 days after surgery. RESULTS: There were no patients with clinical signs of deep venous thrombosis and pulmonary embolism. However, 17 patients (15.5%) showed venographic evidence of deep venous thrombosis, of whom 16 had distal thrombi, and only one had a proximal thrombus. Deep venous thrombosis was venographically evident in 3 (5.6%) of 54 patients who underwent cervical procedures, and it was evident in 13 (26.5%) of 49 patients who underwent lumbar procedures. This difference was statistical significant (chi2 test, P = 0.003). Statistical comparison between patients who did and did not have deep venous thrombosis showed that age was statistically significant (Mann-Whitney test; P < 0.05). CONCLUSIONS: The prevalence of deep venous thrombosis after posterior spinal surgery is higher than generally recognized. Therefore, further study is necessary to clarify the appropriate method for screening and the effect of prophylaxis against thromboembolism after spinal surgery.
Adolescent↗
The relative frequency of hereditary thrombotic disorders among 107 patients with thrombophilia in Israel.
Since most patients with thrombophilia in Israel are referred for diagnosis to our center, it was possible to estimate the relative frequency of the hereditary disorders leading to thrombophilia. 107 unrelated patients were evaluated over 4 years. Diagnoses were established in 23 patients (21.5%) while in 84 (78.5%) no abnormality was detected. Antithrombin III deficiency was found in 8 patients (7.5%), dominant protein C deficiency in 6 (5.6%), recessive homozygous protein C deficiency in 1, protein S deficiency in 3 (2.8%) and dysfibrinogenemia in 1. Four additional patients (3.7%) had a lupus anticoagulant. The frequency of deep vein thrombosis and pulmonary embolism was similar in patients with and without a definite diagnosis. Thrombosis of visceral or cerebral vessels and a positive family history were more frequent among patients in whom a definite diagnosis was made. In both groups there was a substantial lag between the time of presentation of the first thrombotic episode and the time of evaluation. Since the number of referred patients with thrombophilia has gradually increased over the period of the study, it is at present impossible to establish the prevalence of the various hereditary disorders leading to thrombophilia in the population.
Adolescent↗
Thromboembolism after total hip replacement: role of epidural and general anesthesia.
The effects of continuous epidural anesthesia and of general anesthesia on the incidence of thromboembolism following total hip replacement were studied. Sixty patients were randomly allotted to one of two groups receiving either epidural or general anesthesia. Epidural anesthesia (N = 30) consisted of 0.5% bupivacaine with epinephrine intraoperatively; for pain relief in the postoperative period (24 h), 0.25% bupivacaine with epinephrine was given every 3 h. General anesthesia (N = 30) consisted of controlled ventilation with N2O-O2 and intravenous fentanyl and pancuronium bromide; postoperatively, narcotic analgesics were given intramuscularly on demand for pain relief. Significantly lower frequencies were found following epidural anesthesia than after general anesthesia in deep venous thrombosis involving the popliteal and femoral veins (13% and 67%, respectively), deep venous thrombosis involving both calf and thigh veins (40% and 77%), and pulmonary embolism (10% and 33%). Possible explanations for these differences include increased circulation in the lower extremities, less tendency for intravascular clotting to occur, and more efficient fibrinolysis in association with continuous epidural anesthesia. The decrease in blood loss associated with epidural anesthesia with lower transfusion requirements also might play a role. Epidural analgesia prolonged into the postoperative period, in addition to other appropriate thromboprophylactic measures, should be of value in patients undergoing operations associated with a high risk of thromboembolic complications.
Aged↗
Prophylaxis against fat and bone-marrow embolism during total hip arthroplasty reduces the incidence of postoperative deep-vein thrombosis: a controlled, randomized clinical trial.
BACKGROUND: Clinical and experimental studies have suggested that the maximum risk of thrombogenesis occurs during, rather than after, total hip arthroplasty. With use of conventional cementing techniques, insertion of a femoral component results in marrow embolization of tissue thromboplastin into the veins of the proximal part of the femur, leading to activation of the clotting cascade and thrombogenesis. We hypothesized that an operative technique designed for the prevention of fat and bone-marrow embolism can also reduce the incidence of postoperative deep-vein thrombosis and pulmonary embolism. METHODS: A total of 130 consecutive patients with osteoarthritis who were to have a primary total hip arthroplasty were randomly assigned to one of two groups. One group consisted of sixty-five patients (sixty-five hips) who had the femoral component inserted with our standard cementing technique without use of a bone vacuum, and the other group included sixty-five patients (sixty-five hips) who had the femoral component cemented with use of a bone-vacuum technique. In the hips managed with the bone vacuum, suction (-800 mbar) was applied to a drainage cannula placed along the linea aspera of the femur in order to prevent an increase in intramedullary pressure during the insertion of the stem. We measured the incidence of intraoperative fat and bone-marrow embolism with use of echocardiography and a transesophageal probe and the incidence of deep-vein thrombosis with use of serial duplex ultrasonography on the day before the operation and on postoperative days 4, 14, and 45. All patients were managed with prolonged pharmacological prophylaxis (low-molecular-weight heparin) against deep-vein thrombosis. RESULTS: The control group had significantly more severe and prolonged echocardiographic embolic events than did the group managed with the bone-vacuum technique (p < 0.05). A cascade of fine echogenic particles or embolic masses with a diameter of < or =5 mm was observed during the insertion of the stem in fifty-nine hips (91%) in which our standard cementing technique was used and in ten hips (15%) in which the bone-vacuum cementing technique was used. Deep-vein thrombosis was detected on postoperative day 4 in twelve patients (18%) in the control group and in two patients (3%) in the group managed with the bone-vacuum technique; the difference was significant (p < 0.05). CONCLUSIONS: Intraoperative prophylaxis against fat and bone-marrow embolism during total hip arthroplasty with cement can reduce the incidence of postoperative deep-vein thrombosis. We now use the bone-vacuum technique routinely in all total hip arthroplasties performed with cement.
Arthroplasty, Replacement, Hip↗
[Thrombectomy of the infra- and suprarenal cava to prevent pulmonary embolism in the presence of deep venous thrombosis. Personal experience with 11 surgically-treated cases].
DVT is a fairly frequent event and often fails to be recognised. Its main complication, pulmonary embolism, is the third cause of death in Italy with more than 70,000 deaths per annum. In the presence of infra- and suprarenal floating thrombi, cases in which the application of neither intraluminal nor extraluminal filters is indicated, the treatment of choice is thrombectomy with direct surgical access to the cava. Personal experience of 11 patients operated in the past 16 months with excellent surgical success is analysed. The indications and surgical techniques adopted are described.
Adult↗
Should patients with deep vein thrombosis alone be treated as those with concomitant asymptomatic pulmonary embolism? A prospective study.
BACKGROUND: The established initial treatment of patients with deep vein thrombosis (DVT) or pulmonary embolism (PE) consists of the administration of subcutaneous, weight adjusted, low-molecular weight heparin (LMWH). However, the use of the same LMWH dosages for patients with either DVT or PE is not supported by data from comparative studies. PATIENTS AND METHODS: 1,000 consecutive patients with acute, proximal DVT were prospectively evaluated. All patients underwent a ventilation-perfusion lung scan on admission, and remained in hospital for at least 7 days. Patients with silent PE received once daily 10,000 to 15,000 IU subcutaneous LMWH dalteparin according to body weight for 7 days, and then vitamin K antagonists. Patients with DVT alone received LMWH in a fixed dose of 10,000 IU once daily for at least 5 days, and then vitamin K antagonists. The rate of both, major bleeding and symptomatic PE episodes during the 7-day study period was evaluated. RESULTS: Thirteen patients (1.3%) developed recurrent PE (1 died) and 16 patients (1.6%) had major bleeding (7 died). Recurrent PE was significantly more common in patients with silent PE (9 of 258 patients, 3.5%) than in those with DVT alone (4 of 742 patients, 0.5%. Odds ratio: 6.5; p <0.001). There were no significant differences in bleeding rate between patients with silent PE and those with DVT alone. However, the use of a fixed 10,000 IU dose in patients with DVT alone led to a significantly lower bleeding rate in patients weighing over 70 kg: 1 of 349 patients (0.3%) as compared to 9 of 393 patients (2.3%) in those weighing less than 70 kg (odds ratio: 0.12; p = 0.018). CONCLUSIONS: Fixed-dose 10,000 IU of LMWH dalteparin once daily proved to be both effective and safe in patients with DVT alone. The observed recurrence rate of 0.5% in these patients compares favourably with the 3.5% rate in patients with silent PE. Furthermore, this fixed-dosage was also safe. Patients weighing over 70 kg had a significant decrease in the rate of major bleeding, and no compensatory increase in the rate of recurrent PE.
Anticoagulants↗
Increased risks of circulatory diseases in late pregnancy and puerperium.
We studied a nationwide Swedish cohort with 654,957 women who had 1,003,489 deliveries from 1987 through September 1995 to assess late pregnancy and puerperal risks of circulatory diseases. We used standardized incidence rate ratios to calculate relative risks [with 95% confidence intervals (CIs)]. Compared with unexposed (nonpregnant and early pregnant) women, relative risks of venous thrombosis and pulmonary embolism during the third trimester were 6.7 (95% CI = 5.7--7.8) and 2.7 (95% CI = 1.7--4.2), respectively. Around delivery (from 2 days before to 1 day after delivery), the relative risks of all assessed circulatory diseases were dramatically increased: venous thrombosis, 115.1 (95% CI = 96.4--137.0); pulmonary embolism, 80.7 (95% CI = 53.9--117.9); subarachnoid hemorrhage, 46.9 (95% CI = 19.3--98.4); intracerebral hemorrhage, 95.0 (95% CI = 42.1--194.8); cerebral infarction, 33.8 (95% CI = 10.5--84.0); and myocardial infarction, 27.0 (95% CI = 0.6--180.0). During the rest of the first 6 weeks postpartum, the risks declined but were still substantially increased for all diseases, with the exception of subarachnoid hemorrhage. The results suggest that the increased risk for circulatory diseases related to pregnancy is mainly confined to a few days around delivery.
Adolescent↗
[Pulmonary embolism and disseminated intravascular coagulation after being bitten by a Bothrops lanceolatus snake. Apropos of a case].
The authors report the case of a Bothrops lanceolatus snake bite complicated by severe pulmonary embolism a few hours after admission. This thromboembolic complication developed despite heparin therapy and was followed by disseminated intravascular coagulation (DIC). Vascular thrombosis and pulmonary embolism are rare after Bothrops lanceolatus snake bite as patients are usually hypocoagulable due to DIC. In this case, the thromboembolism was probably caused by the procoagulant effect of the thrombin-like enzymes of the snake venom which may have been injected directly into the vein of a young woman taking a contraceptive pill. A specific antivenin which has recently become available fort treatment may decrease the complications of Bothrops lanceolatus snake bite.
Adult↗
[Incidence and clinical significance of thromboses and thrombo-embolic complications in nephrotic syndrome patients].
Chest X-ray, pulmonary isotopic photoscanning. Doppler sonography of iliac and femoral veins, inferior venacavagram and phlebography of the renal veins have been performed in 26 patients with nephrotic syndrome in order to determine the frequency and localization of thromboses and thromboembolic complications in these patients. 7 of 26 patients (26.9%) exhibited thromboses or thromboembolic complications (2 left sided renal vein thromboses, 1 right sided ileofemoral thrombosis and 1 bilateral ileofemoral thrombosis with occlusion of the vena cava inferior). In one patient renal vein thrombosis caused pulmonary embolism. In 3 other cases with life-threatening severe episodes of pulmonary embolism, the origin of the emboli could not be detected. Serum albumin level was found to be an appropriate parameter to assess the risk of thrombosis development in these patients. In 7 patients with thromboses or thromboembolic complications the serum albumin level was below 2 g/dl, whereas in 19 patients without these complications the serum albumin level was, with one exception, higher than 2 g/dl (1.5 +/- 0.3 g/dl vs. 2.6 +/- 0.5 g/dl; p less than 0.001). The possible pathophysiologic mechanisms for this observation are discussed. Our results help to identify the population of nephrotic patients who are most likely to experience thromboembolic disease. It therefore would be justifiable to carry out a prospective controlled study examining the question, whether this group of patients with benefit from prophylactic anticoagulation.
Adult↗
Silent pulmonary embolism in patients with deep venous thrombosis. Incidence and fate in a randomized, controlled trial of anticoagulation versus no anticoagulation.
OBJECTIVES: A high frequency of asymptomatic pulmonary embolism (PE) in patients with deep venous thrombosis (DVT) has been reported, but information about the outcome of the patients with PE remains sparse. The aims of the present study were to assess the prevalence of silent PE in patients with symptomatic, venographically proven DVT, and to evaluate the natural history of silent PE. DESIGN: Consecutive patients from one centre of primary care were included in a randomized, open study with blinded control. All patients gave written, informed consent. SUBJECTS: Eighty-seven consecutive patients with venographically proven DVT and with a perfusion-ventilation lung scintigraphy performed within 48 h of the DVT diagnosis were included. On the 10th and 60th days the lung scintigraphy was repeated in 80 and 60 patients, respectively. All the patients were followed for 3 months in the out-patient clinic. INTERVENTIONS: All patients were ambulated from the first day and were allocated randomly to no anticoagulant (non-AC) therapy or to AC therapy with intravenous heparin infusion for at least 6 days and oral AC therapy for 3 months. RESULTS: Forty-three of these patients had a high probability lung scintigraphy for PE. Distal vein and femoral vein thrombosis embolized in 33 and 53% of patients, respectively. The progression rate after 60 days was 3% in both the AC and the non-AC group and after 10 days the rates were 13 and 8%, respectively. CONCLUSIONS: A high frequency of silent PE in patients with DVT both above and below the knee is demonstrated. AC treatment did not influence the resolution rate of PE or the rate of clinical PE in a 3-month follow-up period.
Adolescent↗
Once-daily enoxaparin in the outpatient setting versus unfractionated heparin in hospital for the treatment of symptomatic deep-vein thrombosis.
BACKGROUND: Once- and twice-daily low-molecular-weight heparin administered in hospital have been shown to be effective and safe for treating deep-vein thrombosis. The aim of this study was to compare the efficacy and safety of deep-vein thrombosis treatment using once-daily subcutaneous enoxaparin in the outpatient setting with intravenous unfractionated heparin in hospital. METHODS: This randomized, parallel-group, open-label study was conducted in 18 centers in 4 countries. In total, 298 patients with symptomatic deep-vein thrombosis who were eligible for home treatment were randomized to treatment with enoxaparin in the outpatient setting (1.5 mg/kg subcutaneously once-daily) or unfractionated heparin in hospital (5000 IU bolus and 1250 IU/hour intravenous infusion) for > or =5 days. Clinical endpoints were assessed during a 6-month follow-up period. RESULTS: Among all patients treated with enoxaparin, there was a trend towards fewer recurrent deep-vein thromboses (1.3% vs. 5.4%; p = 0.060) and pulmonary emboli (1.3% vs. 4.1%; p = 0.17) compared with patients treated with unfractionated heparin. When considering a post-hoc combined endpoint of deep-vein thrombosis and pulmonary embolism, significantly fewer events occurred in the enoxaparin group than in the unfractionated-heparin group (2.7% vs. 8.8%; p = 0.026). The incidences of bleeding events and adverse events in the enoxaparin and unfractionated-heparin groups were similar. CONCLUSIONS: Once-daily subcutaneous enoxaparin in the outpatient setting is at least as effective and as well tolerated as in-hospital intravenous unfractionated heparin for treatment of deep-vein thrombosis.
Adult↗