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PubMed2005

[Epidemiology of venous thromboembolic disease].

BACKGROUND: The wide variations in reported incidence and mortality rates reflect gaps in the epidemiology of venous thromboembolic disease (VTD), a clinical entity with two different manifestations--deep vein thrombosis and pulmonary embolism. We reviewed recent studies and data sources to find the most useful estimates of its epidemiologic indicators in France. METHODS: We used international medical databases to conduct a systematic literature review. Our search focused on the incidence and mortality rates of VTD in France and examined epidemiologic studies, autopsy studies, clinical trials, and national morbidity and mortality databases. RESULTS: The annual incidence of deep vein thrombosis is approximately 120 per 100,000 in France and 60-100 per 100,000 worldwide; the annual incidence of pulmonary embolism, the principal serious complication of deep vein thrombosis, is between 60 to 111 per 100,000 in France and between 23 and 107 per 100,000 internationally. The reported mortality rate for VTD in France is 7.2 per 100,000, but estimates from international autopsy series suggest a pulmonary embolism prevalence among hospital patients of 0.8 to 1%. CONCLUSION: This study demonstrates the limitations of current epidemiologic knowledge about VTD. Improved information about this disease requires better case reporting and large population-based longitudinal cohort studies.

Databases, Factual↗
PubMed1980

["Low-dose heparin" and other methods to prevent thrombo-embolism in gynaecological surgery (author's transl)].

The effectiveness of low-dose heparin has been compared with other methods of thrombo-embolism prophylaxis, on the basis of 892 gynaecological operations. No case of acute venous thrombosis or lethal pulmonary embolism was established in the Infukoll-M-40 group. No effective prophylaxis against thrombo-embolism was obtainable from acetylsalicylic acid (Micristin). More postoperative bleeding was recorded from the low-dose heparin group. Two far-reaching thromboses and three cases of lethal pulmonary embolism occurred in the wake of low-dose heparin prophylaxis. The most favourable effect, in terms of preventing postoperative leg thrombosis and pulmonary embolism, was recorded from low-molecular dextran (Infukoll M 40). Anaphylactoid reactions, such as bronchospasm, flush, urticaria, and hypotension, were not observed. A therapy standard for gynaecological operations is recommended, with reference being made to the authors' own findings.

Aspirin↗
PubMed1999

Bed rest in deep vein thrombosis and the incidence of scintigraphic pulmonary embolism.

In several countries of central Europe, patients with acute proximal deep vein thrombosis (DVT) are treated not only by anticoagulation and compression therapy but additionally by strict bed rest for 6-8 days. Until now the theoretical assumption that bed rest substantially reduces the incidence of pulmonary embolism has not been subjected to empirical verification. Patients with acute proximal DVT proven by ultrasonography were randomly assigned to strict bed rest for 8 days (treatment group) or to stay mobilised (control group). In both groups, basic treatment consisted in anticoagulation by subcutaneous low molecular weight heparin/vitamin-K-antagonist and compression therapy. The incidence of pulmonary embolism was assessed by serial ventilation/perfusion SPECT on day 1 and days 8-10. Of the 309 patients with proximal DVT considered for inclusion, 180 were excluded according to the study protocol, and 3 did not give informed consent. One hundred and twenty-six patients were randomly assigned to observe bed rest (n = 62) or to keep mobilised (n = 64). Four patients refused follow-up lung scan. A new lung perfusion defect was detected in 10/59 patients in the treatment group compared to 14/63 patients in the control group (one-sided p-value = 0.25; power 0.8). Bed rest as an additional measure in the treatment of DVT is not able to substantially reduce the incidence of scintigraphically detectable pulmonary embolism. The discomfort and costs associated with the prescription of bed rest in DVT are obviously inappropriate.

Adult↗
PubMed2000

Low-molecular-weight heparin in the treatment of pulmonary embolism.

Unfractionated heparin is the traditional treatment of choice for patients presenting with submassive pulmonary embolism. However, newer low-molecular-weight heparins have been developed and tested in several clinical trials in the last 2 decades because of the many limitations of unfractionated heparin. The pharmacologic properties of the low-molecular-weight heparins allow them to be administered subcutaneously in fixed, weight-adjusted doses without need for laboratory monitoring. Different studies have recently proved their efficacy in the treatment of patients with deep vein thrombosis. Because there is good evidence that deep vein thrombosis and pulmonary embolism are 2 expressions of a single disease, the use of low-molecular-weight heparins has been extended to patients presenting with clinically stable pulmonary embolism. In particular, the results of 2 important clinical trials, the Columbus and the Thésée, have conclusively proved that the low-molecular-weight heparins are as safe and effective as unfractionated heparin. In some centers, approximately 80% of patients with deep vein thrombosis are treated at home. This suggests that carefully selected patients with clinically stable pulmonary embolism can receive home treatment with low-molecular-weight heparins.

Anticoagulants↗
PubMed1996

[Venous thromboembolic disease and pregnancy].

Venous thrombo-embolic disease is the most common cause of maternal death during pregnancy. Haemodynamic, anatomical and biological changes support the notion that normal pregnancy in a prethrombotic state. But thrombotic events remain unusual episodes. A pre-thrombotic disease has to be investigated in such cases. Accurate diagnosis of deep vein thrombosis or pulmonary embolism is imperative, using non-invasive approaches. Heparin is the anticoagulant of choice to treat objective thrombosis. Thrombo-embolism prophylaxis using compression stockings and heparin has to be discussed in hypercoagulable disorders.

Female↗
PubMed1976

Postoperative deep vein thrombosis in the lower extremity amputee: A prospective study with Doppler ultrasound.

The incidence of postoperative venous thrombosis and pulmonary embolism was assessed in 87 patients undergoing 96 major lower extremity amputations for ischemia. Prospective surveillance for deep leg vein thrombosis was carried out by Doppler ultrasound in 35 patients. There was no instance of major leg vein thrombosis and only one episode of a small non-fatal pulmonary embolus in a patient suffering trauma to the amputation stump after discharge from the hospital. This study suggests that clinically significant venous thromboembolism following current techniques of lower extremity amputation is not as common as previously reported. Doppler ultrasound is the most suitable technique for surveillance of venous thrombosis in these patients.

Adult↗
PubMed2003

Bilateral adrenal hemorrhage after anticoagulation prophylaxis for bilateral knee arthroplasty.

After joint arthroplasty, the risk of deep vein thrombosis and pulmonary embolism increases exponentially. Inadequate anticoagulation prophylaxis may not sufficiently reduce the risk of thrombosis, whereas excessive anticoagulation therapy may predispose the patient to a bleed. Bilateral adrenal hemorrhage is a relatively rare but potentially catastrophic life-threatening event. An 82-yr-old woman is described who was rehospitalized from a subacute rehabilitation facility complaining of epigastric pain radiating into her flank. Eight days previously, she had undergone an uncomplicated bilateral total knee arthroplasty and was subsequently administered subcutaneous heparin and warfarin. An abdominal computed tomographic scan subsequently demonstrated bilateral small adrenal hemorrhages. Acute adrenal insufficiency (Addison's disease) caused by hemorrhage within the adrenal cortices, although still uncommon, can be expected to increase as anticoagulation prophylaxis after joint arthroplasty becomes routine.

Adrenal Gland Diseases↗
PubMed1995

Treatment of venous thromboembolism.

This review provides meta-analytic data of studies aiming at improved treatment of deep vein thrombosis and pulmonary embolism. The introduction of low molecular weight heparin has considerably ameliorated the initial treatment of deep vein thrombosis, and should now be regarded as the treatment of choice for most patients with deep vein thrombosis. Oral anticoagulant treatment is presently considered safe and effective for the long-term treatment of venous thromboembolism, provided that the INR is maintained at 2.0-3.0. However, the optimal duration as well as the optimal intensity of anticoagulation have still to be determined. Patients with submassive pulmonary embolism should presently be treated with adjusted dose unfractionated heparin and coumarins. Studies determining the efficacy and safety of low molecular weight heparin in this condition deserve priority. Thrombolytic therapy should be restricted to patients with massive pulmonary embolism, unless safer methods of thrombolysis have been developed. Surgical embolectomy and catheter fragmentation of emboli seem alternative options but deserve further investigations.

Anticoagulants↗
PubMed1994

A prospective study of venous thromboembolism after major trauma.

BACKGROUND: Although deep-vein thrombosis and pulmonary embolism are considered common complications after major trauma, their frequency and the associated risk factors have not been carefully quantified. METHODS: We performed serial impedance plethysmography and lower-extremity contrast venography to detect deep-vein thrombosis in a cohort of 716 patients admitted to a regional trauma unit. Prophylaxis against thromboembolism was not used. RESULTS: Deep-vein thrombosis in the lower extremities was found in 201 of the 349 patients (58 percent) with adequate venographic studies, and proximal-vein thrombosis was found in 63 (18 percent). Three patients died of massive pulmonary embolism before venography could be performed. Before venography, only three of the patients with deep-vein thrombosis had clinical features suggestive of the condition. Deep-vein thrombosis was found in 65 of the 129 patients with major injuries involving the face, chest, or abdomen (50 percent); in 49 of the 91 patients with major head injuries (53.8 percent); in 41 of the 66 with spinal injuries (62 percent); and in 126 of the 182 with lower-extremity orthopedic injuries (69 percent). Thrombi were detected in 61 of the 100 patients with pelvic fractures (61 percent), in 59 of the 74 with femoral fractures (80 percent), and in 66 of the 86 with tibial fractures (77 percent). A multivariate analysis identified five independent risk factors for deep-vein thrombosis: older age (odds ratio, 1.05 per year of age; 95 percent confidence interval, 1.03 to 1.06), blood transfusion (odds ratio, 1.74; 95 percent confidence interval, 1.03 to 2.93), surgery (odds ratio, 2.30; 95 percent confidence interval, 1.08 to 4.89), fracture of the femur or tibia (odds ratio, 4.82; 95 percent confidence interval, 2.79 to 8.33), and spinal cord injury (odds ratio, 8.59; 95 percent confidence interval, 2.92 to 25.28). CONCLUSIONS: Venous thromboembolism is a common complication in patients with major trauma, and effective, safe prophylactic regimens are needed.

Adult↗
PubMed2001

Thrombosis associated with cytomegalovirus infection in patients with ANCA-positive vasculitis.

Three cases of venous thrombosis with pulmonary embolism in two patients associated with underlying antineutrophil cytoplasmic autoantibody (ANCA)-positive vasculitis and reactivated cytomegalovirus (CMV) infection are described. In vitro studies previously have shown that infection of endothelium with CMV increases the release of procoagulant factors and stimulates the expression of adhesion molecules. Because the endothelial cell plays a pivotal role in maintaining the equilibrium between procoagulant and anticoagulant states, injury by ANCA-positive vasculitis and additional infection with CMV may ignite a local thrombosis easily. Although venous thrombosis is uncommon in CMV infection (eg, in the immunosuppressed state after organ transplantation), the combination of vasculitis and reactivated CMV infection may have contributed to injury of the vessel wall with subsequent development of thrombosis. A better awareness of this association could improve morbidity and may lead to prevention of potentially life-threatening pulmonary embolism. Patients with ANCA-positive vasculitis and CMV infection may profit from prophylactic anticoagulant therapy with heparin or low-molecular-weight heparin.

Adult↗
PubMed1998

Unfractionated versus low-molecular-weight heparin in the treatment of venous thromboembolism.

Low-molecular-weight heparin (LMWH) fractions are prepared from standard unfractionated heparin (UFH) and are thus similar to UFH in many aspects. The main advantages of this new class of antithrombotic agents as compared with UFH are: (1) an improved bioavailability and a prolonged half-life, which alleviate cumbersome laboratory monitoring and may permit one single daily subcutaneous injection; and (2) an improved efficacy-to-safety ratio, with less bleeding despite similar or improved efficacy. For these reasons, LMWH is progressively replacing UFH for preventing postoperative thromboembolism and for treating established deep vein thrombosis and pulmonary embolism. However, the effects of the new compounds need to be evaluated carefully in some other indications (arterial thrombosis, unstable angina, or myocardial infarction-the latter also in conjunction with thrombolytic treatment) before they can generally replace UFH in pharmacotherapy.

Anticoagulants↗
PubMed2000

Primary antiphospholipid antibody syndrome with mutations in the phospholipid binding domain of beta(2)-glycoprotein I.

beta(2)-Glycoprotein I, an anionic phospholipid-binding 50-kDa plasma protein, circulates in the plasma at a concentration of 30-200 microg/ml. Its physiological role remains uncertain, but an important clue to this role is suggested by the finding that antibodies to this protein are frequently found in patients with antiphospholipid antibodies and thrombosis. beta(2)-Glycoprotein I belongs to the complement control protein (CCP) superfamily with five CCP domains. The fifth CCP domain of beta(2)-glycoprotein I has a unique structure and contains a stretch of positively charged amino acids that mediates the binding to phospholipids. This interaction may mediate the clearance of anionic phospholipid-containing surfaces from the circulation. Mutations in this domain affect its binding to phospholipids. We have identified a patient with primary antiphospholipid syndrome who is a compound heterozygous for two mutations in the fifth CCP. One mutation is located in exon 7 (codon 306), and the second mutation is in exon 8 (codon 316). The mutant beta(2)-glycoprotein I was present in normal quantities in his plasma but did not bind to cardiolipin. He had recurrent deep vein thrombosis and pulmonary embolism at age 28 and a thrombotic stroke at age 35, with no other identifiable risk factor for a hypercoagulable state. This report offers some insight into the mechanism of formation of antiphospholipid antibodies and suggests the possible role of the deficiency of beta(2)-glycoprotein I in the pathogenesis of thrombosis.

Adult↗
PubMed1990

Stroke due to paradoxical embolism.

We present a case of stroke in a young girl, preceded by a deep vein thrombosis and pulmonary embolism, both clinically asymptomatic, and accompanied by upper limb acute ischemia. Diagnosis of paradoxical embolism through a patent foramen ovale was made on clinical grounds and with contrast echocardiography. We discuss the main points leading to diagnosis, stressing the importance of contrast echocardiography. We also suggest that paradoxical embolism could be a more frequent cause of stroke than usually suspected.

Adolescent↗
PubMed1992

Post-surgical deep vein thrombosis prevention: evaluation of the risk/benefit ratio of fractionated and unfractionated heparin.

An open controlled study was carried out to assess the efficacy and tolerance of a new low molecular weight heparin for the prevention of post-surgical deep vein thrombosis and pulmonary embolism. Forty-five patients undergoing abdominal surgery mainly for neoplasm, gallstones and gastric ulcers were administered 7,500 AXaU of low molecular weight heparin subcutaneously, 2 hours before surgery and once a day for 7 days after. Heparin calcium (15,000 IU subcutaneously per day) was used as a comparison drug in 45 control subjects, matched for age, sex and type of operation. Deep vein thrombosis was identified with clinical parameters, radio-labelled fibrinogen uptake test, echo-doppler and venography; pulmonary embolism with clinical examination, chest X-rays and/or scintigraphy. No episodes of deep vein thrombosis occurred in the low molecular weight heparin-treated patients, whilst there was 1 episode, without pulmonary embolism, in the control group. The consumption of blood and haemoderivatives for transfusions was higher in the heparin calcium group. Only in this group, furthermore, did 5 patients have to suspend antithrombotic treatment due to severe haemorrhages. General tolerance of the two drugs was identical and very good.

Aged↗
PubMed2006

Fatal pulmonary embolism following ankle fracture in a 17-year-old girl.

We report a case of fatal pulmonary embolism following a simple ankle fracture in a 17-year-old girl. The diagnosis was confirmed at post-mortem. The risk factors for deep venous thrombosis and pulmonary embolism and their significance in orthopaedic fracture management are discussed.

Adolescent↗
PubMed1980

[Pulmonary embolism in leg and pelvic vein thrombosis. Results of a prospective study - diagnosis, frequency, nuclearmedical and clinical appearance (author's transl)].

In a prospective study 169 patients with clinically suspected leg/pelvic-vein thrombosis were tested by 131 I fibrinogen uptake-test and radionuclide venography for confirmation of this diagnosis and also by a nuclearmedical lung investigation. In all cases of an abnormal perfusion scan a supplementary ventilation scan was performed. The perfusion scan has a sensitivity for pulmonary embolism of near 1.0 but its specificity is only 0.57. An additional ventilation study (133 Xenon, 81m Krypton) improves the specificity to 0.95. A mismatch of regional ventilation and perfusion is the nuclearmedical substrate of pulmonary embolism. The diagnosis of thrombosis was confirmed in 105 of 169 cases (62%). Thrombosis was located in the lower legs in 56%, in the thigh veins in 23% and in the external iliac veins in 21%. From 105 patients with leg/pelvic-vein thrombosis 60 (57.1%) had pulmonary emboli, from 64 patients with negative tests concerning thrombosis only 3 (4.7%) (p < 0.001). Pulmonary emboli were present in 46% when thrombosis was located in the lower legs, in 67% when thigh veins and in 77% when pelvic veins were involved. The average frequency of 57% emboli found in patients with leg and pelvic vein thrombosis agrees with data from pathologic-anatomical studies. An analysis of these patients with embolism showed that 70% of them were over 70 years old, that 52% of the emboli originated from thigh and pelvis and 43% from the lower leg and that 59% had no clinical signs of embolism. 80.4% of the patients had multiple perfusion defects (up to 9) which correlated in size with the severity of the clinical symptoms and which were about equally distributed in both lungs. Larger perfusion defects occure more frequently with thromboses of the thigh and pelvis than in thromboses of the lower leg. According to the chest x-ray pulmonary emboli were suspected to only 6 of 26 patients with clinical evidence of embolism (23%).

Adult↗
PubMed2003

DVT prophylaxis and anticoagulation in the surgical patient.

One of the most common postoperative complications is venous thromboembolism, a term encompassing deep vein thrombosis and pulmonary embolism. This article reviews the epidemiology, natural history, difficulties in diagnosis, and strategies for the prevention of postoperative venous thromboembolism. We thoroughly review the currently available methods for thromboprophylaxis including: early ambulation, elastic compression stockings, pneumatic compression devices, inferior vena cava filters, and a variety of pharmacologic agents such as unfractionated heparin, warfarin, aspirin, low molecular weight heparin, and pentasaccharides. Finally, we review the perioperative management of patients on long-term oral anticoagulation.

Anticoagulants↗