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PubMedDate not supplied

Diagnostic problems with venous thromboembolic disease in pregnancy.

In the pregnant patient with suspected deep vein thrombosis (DVT) or pulmonary embolism (PE), accurate diagnosis is required to identify patients with DVT or PE who would benefit from appropriate anticoagulant therapy, and to exclude DVT and PE in the majority of patients so they are not exposed to the risks of anticoagulants. The diagnosis of DVT and PE during pregnancy is problematic. The use of invasive diagnostic tests, such as venography and pulmonary angiography, is limited because of the potential risks to the fetus of radiation exposure. Due to hemodynamic changes associated with pregnancy, noninvasive diagnostic tests such as impedance plethysmography and venous Doppler may be falsely abnormal. Diagnostic approaches for DVT and PE will be outlined that can accurately and safely confirm or exclude suspected DVT and PE during pregnancy.

Female↗
PubMed2004

49, XXXXY syndrome with unilateral renal aplasia, proteinuria, and venous thromboembolism.

A 28-year-old man presented with mental retardation, peculiar facial features, radioulnar synostosis, hypogonadism, aplasia of the right kidney, a moderate degree of proteinuria, and peripheral cyanosis. The activated partial thromboplastin time was shortened, and the level of plasma factor VIII was high. A chromosomal analysis revealed a 49, XXXXY karyotype. From the 10th hospital day, he suffered from sudden dyspnea following swelling of the left leg. He was diagnosed as having deep vein thrombosis and pulmonary embolism, and was successfully treated with anticoagulant therapy. This is the first case of the 49, XXXXY syndrome complicated with unilateral renal aplasia, proteinuria, and venous thromboembolism.

Abnormalities, Multiple↗
PubMed2003

Incidence of venous thromboembolism in patients undergoing craniotomy and motor mapping for glioma without intraoperative mechanical prophylaxis to the contralateral leg.

OBJECT: Evidence-based reviews support the use of venous thromboembolism (VTE) prophylaxis in the form of compression devices and/or stockings for patients undergoing craniotomy. In patients undergoing craniotomy with motor mapping for glioma, the contralateral lower extremity should remain visible so that motor responses can be accurately identified. As a consequence, these patients could be placed at a higher risk to develop VTE. The authors have quantified the incidence of VTE in patients undergoing craniotomy with motor mapping and have shown that there is no increased risk of developing a VTE in the contralateral lower extremity when compression devices are not used. METHODS: One hundred eighty consecutive cases (1997-2000) of craniotomy with motor mapping for glioma were retrospectively reviewed to determine the incidence and location of VTEs during the early postoperative course. Intraoperative VTE prophylaxis in all patients consisted of ipsilateral (that is, ipsilateral to the hemisphere being mapped) lower-extremity mechanical prophylaxis (antiembolism stocking plus compression device). Postoperatively, all patients received bilateral mechanical prophylaxis. Patients were observed until discharge and received clinical follow up. Venous thromboembolism, classified as deep venous thrombosis (DVT) or pulmonary embolism (PE) occurring within 6 weeks postoperatively, was confirmed by Doppler ultrasonography, spiral computerized tomography scanning, or both. The average duration of postoperative hospitalization was 5 days (range 2-59 days). Six patients (3.3%) experienced VTE. Of those, in four (2.2%) the DVT was localized to the contralateral (three patients) or ipsilateral (one patient) lower extremity. Two other patients (1.1%) only had PE. There were no deaths from thromboembolic complications and no statistically significant predisposition to VTE in the contralateral lower extremity among patients not receiving intraoperative prophylaxis. CONCLUSIONS: The incidence of VTE in patients undergoing craniotomy with motor mapping is comparable to that in patients receiving bilateral lower-extremity mechanical VTE prophylaxis. The practice of leaving the contralateral lower extremity free from intraoperative prophylaxis does not appear to place patients at a higher risk for developing VTE. There appears to be no preferential distribution of VTE in contralateral lower extremities that do not receive immediate preoperative and intraoperative mechanical prophylaxis.

Adult↗
PubMed2000

Cost effectiveness of outpatient anticoagulant prophylaxis after total hip arthroplasty.

Guidelines for deep venous thrombosis (DVT) and pulmonary embolism (PE) prophylaxis have been developed for patients undergoing total hip arthroplasty (THA). Studies suggest that risk for developing these complications may exist for as long as 3 months following surgery. Cost-effectiveness analyses were performed on three pharmacoprophylaxis regimens administered over a 30-day period using literature-reported values for incidences of DVT and PE in patients postdischarge following THA. A cost savings of $21,466.89 will occur for each thromboembolic event avoided if low-dose warfarin daily is used routinely compared to enoxaparin 40 mg daily. Additionally, a cost savings of $18,618.10 is experienced if enoxaparin 40 mg daily for 4 days plus low-dose warfarin daily is administered versus enoxaparin 40 mg daily. Clinicians may choose to continue prophylaxis postdischarge with enoxaparin 40 mg daily for 4 days in combination with warfarin for 30 days in these patients until results of more definitive studies become available.

Adult↗
PubMed1999

Hormone replacement therapy with estradiol and risk of venous thromboembolism--a population-based case-control study.

Recent epidemiological studies on hormone replacement therapy (HRT) containing mainly conjugated equine estrogens indicate increased risk for venous thromboembolism (VTE). The purpose of the present epidemiological study was to evaluate the effect of HRT containing natural estrogens, i.e., estradiol, on the risk of VTE. HRT formulations containing estradiol are commonly used in Scandinavia. The study was a population-based case-control study. Cases were consecutive females, aged 44-70 years, discharged from Ullevål University Hospital with the diagnosis of deep venous thrombosis or pulmonary embolism during 1990-1996. Fifty-one women with cancer-associated thrombosis were excluded from the study. Controls were randomly collected from the same source population and matched by age. The material comprised 176 cases and 352 controls, i.e., 2 controls for each case. Only formulations containing estradiol were used. The frequency of HRT use was 28% (50/176) in cases and 26% (93/352) in controls. The estimated matched crude odds ratio with 95% confidence interval was 1.13 (0.71-1.78), which indicates no significant association of overall use of HRT and VTE. The estimated adjusted odds ratio was 1.22 (0.76-1.94) performing multi-confounder adjustment using the conditional logistic model and adjusting for hypertension, coronary heart disease, diabetes mellitus, smoking habit, BMI, and the presence of previous VTE. Stratification for time of exposure indicated an increased risk of VTE during the first year of use with a crude odds ratio of 3.54 (1.54-8.2). This effect was reduced by extended use to a crude odds ratio of 0.66 (0.39-1.10) after the first year of use. We conclude that use of HRT containing estradiol was associated with a threefold increased risk of VTE, but this increased risk was restricted to the first year of use.

Aged↗
PubMed2000

The rationale for long-term prophylaxis of venous thromboembolism.

Prophylaxis for venous thromboembolism (VTE) after surgery has traditionally been given from the time of surgery until hospital discharge, typically ranging from 5-14 days. Recently, there has been a trend toward shorter periods of hospitalization. Furthermore, a number of prospective studies have demonstrated that a significant proportion of patients develop deep vein thrombosis (DVT) or pulmonary embolism (PE) up to 5 or 6 weeks following general or orthopedic surgery. Therefore, prolonged prophylaxis during the post-discharge period may provide clinical benefits in high-risk patients. However, the optimal duration of prophylaxis for VTE after surgery remains unclear. In elective hip replacement, four studies of prolonged prophylaxis with low-molecular-weight heparin (LMWH) for 3- 4 weeks after hospital discharge demonstrated a significant reduction in the incidence of venography-confirmed DVT. These results support the use of prolonged thromboprophylaxis in the outpatient setting. Effective outpatient prophylaxis must be safe and convenient for patients to maximize compliance and clinical benefits. Low-molecular-weight heparins are safe and effective when given at a fixed daily dose, and pharmacoeconomic studies suggest that prolonged prophylaxis with these agents may be cost-effective. Key challenges for the future include identifying the patients who require prolonged prophylaxis and determining the duration of treatment.

Anticoagulants↗
PubMed2000

Experience using a programmable rules engine to implement a complex medical protocol during order entry.

WizOrder, Vanderbilt University Medical Center's (VUMC) clinician order entry system, is an excellent platform for delivering high-quality decision support to clinical end-users. A scripting language designed to make it easy for non-programmer domain experts to enter rules helps distribute the generation and maintenance of the knowledge-base necessary to drive effective decision support. Domain-experts have used this system to successfully implement relatively simple protocols. The VUMC Care Improvement Committee identified diagnosis of and treatment for suspected or confirmed deep venous thrombosis or pulmonary embolism as an area where decision-support could improve clinician compliance with established evidence-based protocols. The authors describe our experience with using our existing scripting system to implement decision support for a complex medical protocol.

Clinical Protocols↗
PubMed2006

Spontaneous superficial venous thrombophlebitis: does it increase risk for thromboembolism? A historic follow-up study in primary care.

OBJECTIVE: To determine the risk of arterial and venous complications after a spontaneous superficial venous thrombophlebitis (SVTP) in the leg in a general practice population. STUDY DESIGN: Retrospective cohort study (LOE: 2b [CEBM]). Exposure consisted of the diagnosis of SVTP of the lower limbs on an index date. The exposed cohort was compared with an (unexposed) cohort of practice-, age-, and sex-matched controls without SVTP. POPULATION: Patients with spontaneous SVTP in the leg were identified through diagnostic coding in the medical registers of 40,013 patients, enlisted with 5 health centers in Amsterdam, The Netherlands. OUTCOMES: Primary outcomes were deep venous thrombosis (DVT), pulmonary embolism (PE), acute coronary events, or ischemic stroke over a 6-month follow-up period. Odds ratios (OR) were used to quantify the associations between SVTP and outcome events. RESULTS: No statistically significant odds ratios were found for PE, coronary events or stroke. DVT was the only primary outcome to show a significant relationship. DVT occurred in 2.7% of all SVTP patients as compared with 0.2% in the controls (OR=10.2; 95% confidence interval [CI], 2.0-51.6). When controlling for prior history of DVT, the OR decreased to 7.1 and the confidence interval crossed 1.0 (95% CI, 0.9-65.6). DISCUSSION: Spontaneous SVTP in the leg is a risk factor for DVT, but is less predictive in patients with prior DVT. Although effective treatments for the prevention of DVT are available, the absolute risk is too low to advocate prophylaxis in a general practice population. More research on prophylaxis is needed to stratify these patients at risk.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed1980

Experimental evaluation of Tc-99m sulfur colloid as a potential imaging agent in thromboembolic disease: concise communication.

Based on literature reports suggesting the possible incorporation of Tc-99m sulfur colloid (Tc-SC) into fibrin deposits, this study was undertaken to evaluate the potential of this radiopharmaceutical as an imaging agent in thromboembolic disease. Animal models of deep-vein thrombosis and pulmonary embolism were used. The mean thrombus-to-blood (T/B) uptake ratios were comparable for fresh and older thrombi (up to 72 hr). Thrombus uptake was significantly lower in a group of five control dogs that received pertechnetate instead of Tc-SC. Intravenous heparin administration (5,000 IU) 2 hr before injection of Tc-SC caused a depression in T/B ratios but did not totally block Tc-SC uptake. Gamma imaging with Tc-SC allowed demonstration of deep-vein thrombi, but imaging of pulmonary emboli as areas of increased activity was not satisfactory. This study supports the concept of thrombus detection with radiolabeled particles but not the extension of this principle to the imaging of pulmonary emboli.

Animals↗
PubMed1997

[Venous thromboembolic disease and occult cancers: what investigations should be done? Apropos of 204 patients].

There is no consensus about the investigations which should be performed to detect occult malignancy after an episode of venous thromboembolism. The authors studied 204 patients (167 in-patients and 37 day hospital patients) with deep venous thrombosis or pulmonary embolism to determine the incidence of cancers detected during or after the thrombosis and the diagnostic value of abdomino-pelvic ultrasonography. Of the 167 in-patients, 18 (10.7%) had a known malignancy. After the initial investigations, 7 tumours were detected (4.6%). In all cases, clinical history and examination or chest X-ray were suggestive of neoplasia. Abdomino-pelvic ultrasonography did not detect any cases of occult malignancy. Of the 37 patients seen in the day hospital, only one had known malignant disease and no other cases were detected. After exclusion of the 26 patients with known malignancies or tumours discovered after the initial investigations, the remaining 178 patients were followed up for an average of 27 months. Four cancers (2.5%) were detected in this period. The authors conclude that the occurrence of deep venous thrombosis should lead to investigation for malignant disease: clinical examination, chest X-ray and laboratory tests are sufficient to orientate this investigation. Systematic abdominopelvic ultrasonography does not seem to be worthwhile in this indication.

Abdomen↗
PubMed2000

Extra-thoracic findings on the venous phase of combined computed tomographic venography and pulmonary angiography.

A growing consensus is that pulmonary embolism and thrombosis represent different aspects of the same disease, and a single study that accurately defines both pulmonary emboli and deep venous thrombosis would be a desirable examination. The purpose of this pictorial review is to demonstrate the extra-thoracic findings on the venous phase of such a study, which combines computed tomographic venography and pulmonary angiography.

Aged↗
PubMed1984

Prevention of postoperative venous thromboembolism by external pneumatic calf compression in patients with gynecologic malignancy.

One hundred seven patients undergoing major surgery for gynecologic malignancy participated in a controlled trial evaluating the effectiveness of pneumatic calf compression in the prevention of postoperative deep venous thrombosis and pulmonary embolism. External pneumatic calf compression was applied intraoperatively and for five postoperative days. All patients were prospectively screened for deep venous thrombosis with impedance plethysmography and 125I-fibrinogen leg counting. Deep venous thrombosis and/or pulmonary emboli were detected in 18 of 52 control group patients (34.6%) whereas in seven of 55 (12.7%) of those treated with external pneumatic calf compression (P less than .005). External pneumatic calf compression was most effective during the first five days postoperatively and also reduced the incidence of deep venous thrombosis in patients at highest risk. When applied during surgery and for five days postoperatively, external pneumatic calf compression significantly reduces the incidence of postoperative venous thrombosis.

Adult↗
PubMed1997

Use of Greenfield filters in pregnant women at risk for pulmonary embolism.

A 3-year retrospective study (1992 to 1995) was done to identify all cases of Greenfield filter use in pregnant patients cared for by the Maternal-Fetal Medicine Service of our institution. The patient selection criteria included placement of a Greenfield filter in the index pregnancy or placement of a Greenfield filter before conception and in a patient who subsequently became pregnant. A series of eight pregnant patients with Greenfield filters was identified, the largest to date in a single institution. Management of the pregnant patient at risk for pulmonary embolism or its recurrence is problematic. Hypercoagulability occurs during pregnancy and predisposes the at-risk patient to thromboembolic phenomena such as deep venous thrombosis and pulmonary embolism. This study, though limited, indicates that Greenfield filters may be used safely in pregnant women and are effective in preventing pulmonary embolism or its recurrence.

Adult↗
PubMed1998

[Inferior vena cava filters. Indications and results in 111 patients].

BACKGROUND: Anticoagulation is the treatment of choice for deep vein thrombosis and pulmonary embolism. Occasionally this treatment is contraindicated or fails to prevent pulmonary embolism. In these patients, inferior cava vein interruption is indicated and filter insertion is the procedure commonly performed. AIM: To report the results of inferior cava vein filter insertions in 111 patients. PATIENTS AND METHODS: A retrospective review of patients in whom inferior cava vein filters were inserted was performed. RESULTS: During the period 1983-1997, filters were inserted in 111 patients (56 female) aged 15 to 93 years old. Indications were pulmonary embolism with contraindication or failure of anticoagulation therapy or poor respiratory function (58 patients), deep vein thrombosis and contraindication for anticoagulation (32 patients) and other indications in 20 patients. In 47 patients, treated before 1993, the insertion required a cut-down. Since then, a percutaneous approach was used in the remaining 64 cases. Three insertion attempts failed, all using cut-down. One of these patients died due to a massive pulmonary embolism. In 88% of the patients the jugular vein was the access site and in 10 patients, the filter was deliberately deployed above the renal veins. There was no mortality or complications. Patients were followed during a maximal period of 147 months and 27 died of unrelated disorders. Survival at 5 and 10 years was 63 and 47% respectively. Symptomatic inferior cava vein obstruction was detected in 5 patients during the follow up period. CONCLUSIONS: Inferior cava vein filter insertion is a safe measure to prevent pulmonary embolism and its consequences.

Adolescent↗
PubMed1992

Experience with the Cardial inferior vena cava filter as prophylaxis against pulmonary embolism in pregnant women with extensive deep venous thrombosis.

OBJECTIVE: To report the use of the Cardial inferior vena caval filter as prophylaxis against pulmonary embolism in pregnant women with extensive iliofemoral thrombosis. SETTING: Leicester Royal Infirmary. SUBJECTS: Four pregnant women with extensive iliofemoral thrombosis, deemed to be at high risk of pulmonary embolism, managed over a period of one year. TECHNIQUE: In addition to standard full anticoagulation with heparin, the Cardial inferior vena cava filter was introduced percutaneously under local anaesthesia through the unaffected contralateral femoral vein and positioned in the inferior cava below the renal veins. RESULTS: The procedure was uncomplicated and did not compromise feto-maternal condition. There was no evidence of pulmonary embolism after filter insertion. CONCLUSION: The use of inferior vena cava filters should be considered as an adjunct to intravenous anticoagulation in pregnant women with extensive deep vein thrombosis of the lower limbs.

Adult↗
PubMed2003

Clinical significance of gene-diagnosis for defects in coagulation factors and inhibitors.

cDNA sequences of all known coagulation factors and inhibitors of coagulation have been described and an enormous number of disease generating mutations in these factors has been found by genetic analysis of affected families. The vast majority of these defects have severe clinical consequences such as spontaneous bleeding or predisposition to venous thrombosis and pulmonary embolism. While all the genetic defects described so far cause disease, or at least represent a risk factor for diseases such as bleeding or thrombosis, only a minority of these conditions actually need DNA analysis to be detected and/or treated properly. The purpose of this review is therefore to describe clinical situations in which the knowledge of the underlying genetic defect is important for decision making in patients with inherited hemophilia or thrombophilia.

Adolescent↗