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PubMed1999

Puerperal septic pelvic thrombophlebitis: incidence and response to heparin therapy.

OBJECTIVE: Before the availability of modern imaging studies the diagnosis of septic pelvic thrombophlebitis causing prolonged puerperal fever was difficult to confirm without surgical exploration. With the use of computed tomography infection-related pelvic phlebitis can now be confirmed, and this study was designed to determine its incidence after delivery. We also designed a randomized clinical trial to evaluate the efficacy of heparin added to antimicrobial therapy for treatment of women with septic phlebitis. STUDY DESIGN: We studied women who had pelvic infection and fever that persisted after 5 days despite adequate antimicrobial therapy with clindamycin, gentamicin, and ampicillin. After giving consent study participants underwent abdominopelvic computed tomographic imaging. Women with pelvic thrombophlebitis were randomly assigned to 1 of 2 management schemes that included continuation of antimicrobial therapy, either alone or with the addition of heparin, until the temperature was </=37.5 degrees C for 48 hours. RESULTS: During the 3-year study period 44,922 women were delivered at Parkland Hospital; among these 8535 (19%) were delivered by the cesarean route. There were 69 women who met criteria for prolonged infection, and 15 (22%) of these were found to have septic pelvic thrombophlebitis. Four had infection after vaginal delivery and 11 had been delivered by the cesarean route. Of 14 women randomly assigned to therapy, 8 were assigned to receive continued antimicrobial therapy without the addition of heparin and the other 6 were assigned to receive heparin therapy in addition to the antimicrobial agents. According to an intent-to-treat analysis there was no significant difference between the responses of women with pelvic infection who were and were not given heparin therapy. Specifically, women not given heparin were febrile for 140 +/- 39 hours compared with 134 +/- 65 hours for women who received heparin (P =.83). Duration of hospitalization was also similar between the 2 groups at 10.6 +/- 1.9 days for those with thrombosis who were given antimicrobial agents alone and 11.3 +/- 1.2 days for women who also received heparin (P >.5). The 54 women with persistent fever but without computed tomographic evidence of septic pelvic thrombophlebitis were hospitalized for a mean of 12.0 +/- 4.1 days, compared with 10.9 +/- 2.9 days for women in whom thrombosis was diagnosed (P =.14). These women were followed up for >/=3 months post partum and none showed evidence of reinfection, embolic episodes, or postphlebitic syndrome. CONCLUSIONS: The overall incidence of septic pelvic thrombophlebitis was 1:3000 deliveries. The incidence was about 1:9000 after vaginal delivery and 1:800 after cesarean section. Women given heparin in addition to antimicrobial therapy for septic thrombophlebitis did not have better outcomes than did those for whom antimicrobial therapy alone was continued. These results also do not support the common empiric practice of heparin treatment for women with persistent postpartum infection.

Adult↗

PubMed1998

Central venous catheter related thrombosis in children: analysis of the Canadian Registry of Venous Thromboembolic Complications.

BACKGROUND: Central venous lines (CVLs) are frequently associated with deep venous thrombosis (DVT) in children; however, little is known about the epidemiologic characteristics or outcome of CVL-related DVT. METHODS: The Canadian Childhood Thrombophilia Registry monitored 244 consecutive patients with objectively diagnosed CVL-related DVT for a median duration of 24 months (range 3 months to 7 years). RESULTS: The incidence of CVL-related DVT was 3.5 per 10,000 hospital admissions. CVL-related DVTs were more frequent in the upper venous system. Ultrasonography or echocardiography were the most commonly used diagnostic tests (n = 183 patients). Venograms were performed on 82 (34%) patients. A variety of therapies were used. Thirty-nine children had pulmonary emboli, but most were not investigated for pulmonary emboli. Nine (3.7%) children died as a consequence of their thromboembolic disease. Recurrent DVT occurred in 16 (6.5%) children, and postphlebitic syndrome occurred in 23 (9.5%) children. CONCLUSION: Currently no uniform guidelines exist for the prevention and management of CVL-related DVT in children. The frequency and clinical consequences of CVL-related DVTs justify controlled trials of primary prophylaxis in children requiring central venous access.

Adolescent↗

PubMedDate not supplied

The natural history and epidemiology of venous thrombosis.

Epidemiologic studies over the past 30 years have provided much of the basis for the understanding of venous thromboembolic disease. There has been an evolution from simple descriptive studies using clinical diagnosis to various forms of comparative studies using objective diagnoses. Identification of high-risk cases in the hospitalized population has led to the development of both general and specific antithrombotic prophylactic regimens. This has occurred against a background of an increased understanding of the pathophysiology of venous thrombosis. Inhospital case interventions have allowed direct questions concerning pathophysiology to be addressed. Examples would include the use of certain types and dosages of anticoagulants and the use of mechanical devices to avoid stasis. Despite these advances, there are still areas that require further attention. One aspect of importance is to evaluate the thrombotic risk of new procedures. The possibility that a new procedure may be either less or more thrombotic than its predecessor should be addressed. In the case of the former, additional antithrombotic measures are needed. An example of this is the relatively disappointing results of regular low-dose heparin treatment in some orthopedic procedures. In the case of the latter, less severe measures may be indicated. Current antithrombotic methods are not without risks and may not be necessary with some of the new endoscopic surgical procedures. Another area of importance relates to the monitoring of compliance. The information on antithrombotic methods has been available for two decades, yet surveys of the application of these methods consistently show that antithrombotic protocols are used less in North America relative to their use in equivalent institutions in Europe. A third area that still needs further epidemiologic study is the incidence and effects of venous thrombosis in the general community. Despite the two recent descriptive studies cited above, relatively little, as compared with the in-patient perspective, is known about community risk factors and their prevention. With respect to the natural history of hospital-based cases it seems unlikely that much is to be gained from surveying the efficacy of heparin or heparin-like treatment for mortality end points. However, a large and still unsatisfactorily examined area is the true frequency and impact of the postphlebitic syndrome. This aspect is germane to both hospital- and community-acquired DVT and, with an aging population, clearly deserves a lot more attention.

Epidemiologic Methods↗

PubMed1991

Deep venous thrombosis and pulmonary embolism.

All surgical patients are at risk for the development of deep venous thrombosis and subsequent pulmonary embolism or postphlebitic syndrome. The evolution of ultrasonographic imaging has increased the awareness of prevention, diagnosis, and treatment of deep venous thrombosis. Duplex imaging and Doppler color flow imaging have made the diagnosis of deep venous thrombosis relatively simple, painless, inexpensive, and definitive. These procedures have gained acceptance by both patients and physicians. Several risk factors have been identified that increase the chance of the development of deep venous thrombosis. These factors include a history of deep venous thrombosis, presence of a malignant process, increasing age, cigarette smoking, obesity, prolonged bed rest, and general anesthesia. The greater the number of risk factors, the more aggressive prophylaxis should be. Means of prophylaxis have improved, and surgeons now generally agree that some form of prophylaxis is required. Heparin and intermittent compression devices appear to be equally effective in preventing deep venous thrombosis. The addition of venous monitoring in high-risk patients permits immediate identification of the presence of deep venous thrombosis. During the last decade, the treatment of patients with deep venous thrombosis has changed little. Heparin followed by warfarin remains the treatment of choice. A small group of patients receive fibrinolytic therapy for deep venous thrombosis. Although the incidence of postoperative deep venous thrombosis has decreased during the last decade, it remains a significant complication.

Humans↗

PubMed1991

Thrombolytic therapy for noncoronary diseases.

Thrombolytic therapy has been used fairly extensively in the management of acute proximal deep-vein thrombophlebitis of the extremities, acute pulmonary embolism, and acute peripheral arterial thrombosis and embolism in addition to acute thrombotic coronary events. In the presence of acceptable indications and a favorable benefit to risk ratio, this form of therapy, when successful, has served as a useful adjunct in the management of these disorders. In deep-vein thrombophlebitis, lysis of the thrombus before permanent pathological changes (eg, organization, scarring) have occurred can prevent venous valvular dysfunction and postural venous hypertension and its complications, especially the postphlebitic syndrome. In the more severe forms of acute pulmonary embolism, thrombolytic therapy, when applied early after symptom onset, decreases morbidity and is likely to prevent a chronic increase in pulmonary vascular resistance and persistent pulmonary hypertension. In peripheral arterial thrombo-occlusive events, early restoration of flow through thrombolysis has been shown to limit ischemic damage and serve as a useful supplement to angioplasty or surgery. Thrombolytic therapy has been used less extensively in acute strokes. Here the danger of reperfusion causing bleeding into a softened area of brain undergoing infarction has slowed its evaluation for this disorder; its application to stroke remains experimental.

Acute Disease↗

PubMed1989

Future role of thrombolytic therapy in emergency medicine.

Thrombolytic therapy offers the promise of major therapeutic intervention in many areas as well as in the treatment of patients with acute myocardial infarction who present to the emergency department. Infusion of tissue-type plasminogen activator (tPA) during field transport has been proven safe, but optimal methods for reliably diagnosing acute myocardial infarction in the prehospital setting have yet to be delineated. A major advance would be achieved if thrombolysis were proven effective in preventing the progression of unstable angina to actual infarction. However, early studies have yielded contradictory results. The use of tPA in dissolving peripheral arterial clots appears very promising, but long-term limb survival has yet to be demonstrated. Unlike heparin, thrombolytic agents can also lyse clot in peripheral deep veins and possibly lessen the tendency toward postphlebitic syndrome. The proper dosage regimen to minimize hemorrhage has not been determined. Pulmonary emboli can be lysed by tPA. IV infusion is as effective as intrapulmonary. Significant complications can be minimized, particularly if major vessel catheterization can be avoided for diagnosis. Even after catheterization for pulmonary angiography, however, thrombolytic therapy appears quite promising. The use of thrombolytic agents for embolic-thrombotic stroke is less promising: therefore, the risk of hemorrhagic complication may not outweigh the potential benefit. Thrombolytic therapy thus offers the potential for significant impact on the practice of emergency medicine.

Embolism↗

PubMed1979

Therapeutic and economic implications of emergency department evaluation for venous thrombosis.

Records of 160 emergency department patients with lower extremity complaints were reviewed to determine the economic and therapeutic impact of noninvasive venous impedance testing. Venograms obtained in 86 extremities were used to determine diagnostic accuracy. The incidence of pulmonary thromboembolic events, postphlebitic syndrome and complications of anticoagulation was ascertained. Outflow impedance testing correctly identified all patients with deep venous thrombosis and overall diagnostic accuracy was 95% (41/43 patients). In 123 patients (33 positive results, 90 negative) therapeutic decisions were based solely on impedance test results. Examination required 20 to 30 minutres at a cost of $35. Follow-up ranging from 4 to 60 weeks failed to reveal documented thromboembolic complications or recurrence of lower extremity symptoms. In 37 patients (six positive results, 31 negative) impedance test results were ignored and inpatient workup, including invasive venography, was undertaken. Hospital charges for these patients averaged $1,500. In addition to its ease of performance and high degree of accuracy, comparison with inpatient evaluation documents its cost effectiveness. Impedance testing for emergency department evaluation of suspected deep vein thrombosis appears appropriate.

Cost-Benefit Analysis↗

PubMed1989

Surgical thrombectomy versus conservative treatment for deep venous thrombosis; functional comparison of long-term results.

It is known that deep venous thrombosis (DVT) of the ilio-femoro-popliteal axis is frequently associated with irreversible damage to valvular competence of the veins and consequently with varying degrees of chronic venous insufficiency. Because preservation of the valvular function of deep veins can play an important role in preventing the postphlebitic syndrome we analysed and compared the long-term functional outcome of two equally large cohorts of patients treated either surgically for restoration of venous patency and valvular function (24 patients) or medically with heparin, oral anticoagulants and compression stockings (25 patients). The study was also intended to examine the impact of duration and extent of DVT as predictive factors of late outcome. Follow-up time was 7.6 and 7.9 years respectively, operative mortality nil. Assessment of venous function was based on clinical observations as well as on measurement of haemodynamic parameters. Non-fatal pulmonary embolism after onset of treatment occurred in both cohorts with an equal frequency of 13%. Patients operated on for ilio-femoral DVT were with few exceptions totally independent of any form of adjunctive hosiery which was in sharp contrast to the conservatively managed group. If onset of DVT had occurred more than 3 days earlier and extended from the ilio-femoral axis to the popliteo-crural level, surgery usually failed and patients were no better off than in the comparable medical group. The same pattern of late outcome was found for all other clinical and haemodynamic parameters; i.e. clinical signs of venous hypertension, valvular competence as judged by sonography, patient's self-assessment and the expelled volume and refilling time measured by dynamic plethysmography after standardised leg work. The mean expelled volume was 1.1 +/- 0.5 ml/100 g/min. for the surgical group treated early for ilio-femoral DVT and 0.7 +/- 0.5 ml/100 g/min for the corresponding medical group (P = 0.05). Recovery or refilling time was 50 +/- 21 s for the surgical group and 28 +/- 26 s for the medical group (P = 0.03). Thus, the clinical and haemodynamic effect of surgical thrombectomy was significantly superior to conservative management in ilio-femoral thrombosis treated within 3 days. For extensive thrombosis treated early the advantage of surgical thrombectomy was also evident, but the difference between the two treatment groups was not significant. The advantage of surgery was however totally lost in patients operated on for extensive DVT of long duration (i.e. greater than 3 days).(ABSTRACT TRUNCATED AT 400 WORDS)

Bandages↗

PubMed1996

Platelet aggregation and coagulation inhibitors in leech saliva and their roles in leech therapy.

Prolonged bleeding by the host after the leech ceases to feed and several reports that the use of leeches restores blood flow in the microcirculation after plastic surgery led us to search for inhibitors of platelet aggregation in Hirudo medicinalis saliva. Dilute leech saliva was collected by phagostimulating starved leeches with a solution of arginine in saline. The saliva is shown to inhibit human platelet aggregation induced by thrombin, collagen, adenosine diphosphate (ADP), epinephrine, platelet activating factor (1-O-alkyl-2-acetyl-sn-3-glycerophophoryl choline [PAF]), and arachidonic acid. We have isolated the PAF inhibitor and found it to be an amphipathic phosphoglyceride. We have also purified apyrase adenosine triphosphate ([ATP] diphosphohydrolase), which inhibits ADP-induced platelet aggregation, and have described collagenase. Besides well-known hirudin, Hirudo saliva contains a potent inhibitor of coagulation factor Xa. We also report antiaggregant and anticoagulant activities in the crop content of the closely related Nile leech, Limnatis nilotica. Anticoagulants of hematophagous species are surveyed. We have used medicinal leeches in plastic surgery for decompression of skin flaps and in patients with postphlebitic syndrome and peripheral arterial occlusions. Preliminary results indicate certain beneficial effects of leech therapy.

Animals↗

PubMed1985

Arteriovenous shunting in varicose veins. Its diagnosis by Doppler ultrasound flow detector.

The use of the Doppler ultrasound detector is described for the diagnosis of arteriovenous (AV) shunting in varicose veins. This investigation was carried out in 34 patients, 27 women and seven men. A total of 68 limbs with varicose veins and 48 control limbs with either no varicose veins or occlusive arterial disease are the basis for the clinical material. Twenty patients had had no prior surgery for their varicose veins and 14 had recurrent varicosities after bilateral ligation and stripping. Five patients had postphlebitic syndrome associated with varicose veins. All five had venous stasis ulcerations and edema. The Doppler flow detector uncovered AV shunting in areas outside the location of known arterial pulsations. The pulsatile venous flow was obtained at sites of "hot spots" and along markedly dilated veins. Maximum AV shunting was found in the lower third of the leg but much less often in the upper leg or thigh. The clinical implications of the role of AV shunting are discussed. The Doppler ultrasound findings appear to offer a simpler method to detect AV shunting than serial arteriography or thermography.

Adult↗

PubMed1989

Abnormalities of lymphatic drainage in lower extremities: a lymphoscintigraphic study.

Chronic lower-leg edema in patients with venous disorders was studied by means of lymphoscintigraphy. Lymphatic patterns of flow were evaluated prospectively in 26 patients with technetium 99m antimony trisulfide colloid injected subcutaneously in the interdigital web spaces on the feet. Most patients in this study had postphlebitic syndrome, and all of these patients had abnormal lymphoscintigraphic flow patterns. Nine had evidence of lymphatic obstruction, and one had an enhanced flow pattern. Three patients had veins used for distal arterial bypass, and all these veins showed decreased lymphatic flow. Two patients with Klippel-Trenaunay syndrome (congenital varicose veins associated with limb elongation, a capillary nevus, and an abnormal deep venous system) had obstruction to lymphatic flow, and two others had normal and enhanced patterns. Normal studies were seen in four of five patients who had veins used for coronary artery bypass grafting. The finding of decreased lymphatic flow in patients appears to be the result of the length of time from an episode of deep venous thrombosis, the occurrence and number of episodes of cellulitis and lymphangitis, and mobilization of the vein for use in distal arterial bypass surgery. This study shows that the edema attributed previously to primary venous disorders may have a significant lymphatic component. The degree of lymphatic obstruction can be determined by lymphoscintigraphy with technetium-labeled antimony trisulfide colloid.

Adult↗

PubMed1987

Pulmonary embolus after treatment for subclavian-axillary vein thrombosis.

Treatment of effort-induced subclavian-axillary vein thrombosis of the upper extremity is aimed at elimination of the chronic symptoms of the postphlebitic syndrome. Various treatments have been tried, with varied success. Recently, fibrinolytic therapy with streptokinase (Abbokinase) or urokinase (Kabikinase, Streptase) has gained popularity as a treatment option. In the case presented here, complete lysis of effort-induced subclavian-axillary vein thrombosis was achieved with the use of catheter-directed infusion of streptokinase. Subsequently, a pulmonary embolus developed, causing marked morbidity. It is likely that fibrinolytic therapy was directly responsible for this complication. The current literature does not support routine use of fibrinolytic agents in the treatment of effort-induced thrombi of the upper extremity, since these agents can cause significant morbidity. We conclude that fibrinolytic therapy should be reserved for life-threatening conditions, such as myocardial infarction, massive pulmonary emboli, and significant arterial occlusions.

Adult↗

PubMed1998

Meta-analysis of streptokinase and heparin in deep vein thrombosis.

The efficacy and safety of streptokinase and heparin in deep vein thrombosis (DVT) were compared in a meta-analysis. Randomized trials in which streptokinase (followed by heparin) and heparin alone were compared in treating phlebographically documented acute DVT were identified from MEDLINE and other sources for a meta-analysis. Odds ratios (ORs) and 95% confidence intervals (CIs) based on the logit method were computed for each study. A fixed-effect model was used to combine the study results, enabling differences between streptokinase recipients and recipients of heparin alone to be expressed as summary ORs with 95% CIs. Significantly more streptokinase recipients achieved thrombolysis than recipients of heparin alone (summary OR, 6.24; 95% CI, 3.62 to 10.78). One study was identified as an outlier and excluded from the analysis. The meta-analysis then showed that streptokinase recipients were significantly less likely to have postthrombotic changes (summary OR, 0.40; 95% CI, 0.18 to 0.88) and postphlebitic changes (summary OR, 0.32; 95% CI, 0.12 to 0.86) in phlebographic evaluation. The frequency of major bleeding was significantly higher among streptokinase recipients than recipients of heparin alone (summary OR, 3.78; 95% CI, 1.26 to 11.32). A meta-analysis showed that, compared with heparin alone, streptokinase therapy for DVT was associated with significantly more frequent thrombolysis and major bleeding; after exclusion of one outlying study, analysis showed that streptokinase therapy was associated less frequently than heparin alone with postthrombotic changes (assessed by phlebographic evaluation) and postphlebitic syndrome.

Fibrinolytic Agents↗

PubMed2004

The prevention of venous thromboembolism in older adults: guidelines.

The rationale for thromboprophylaxis is based on the high prevalence of venous thromboembolism (VTE), a disorder involving deep vein thrombosis (DVT) and pulmonary embolism (PE), among hospitalized patients, the clinically silent nature of VTE in most patients, and the morbidity, cost, and potential mortality associated with unprevented thromboembolism. Both DVT and PE cause few specific symptoms, and the clinical diagnosis is unreliable. Since the first clinical manifestation of VTE may be fatal PE, it is inappropriate to wait for symptoms before treatment. Unrecognized and untreated DVT may also cause the postphlebitic syndrome and predispose patients to subsequent episodes of recurrent VTE. Routine screening for VTE has also not been shown to reduce the incidence of symptomatic VTE or fatal PE. Use of effective methods of prophylaxis is more cost effective and is safer than selective, intensive screening for VTE. This article reviews current recommendations for the prevention of VTE as they apply to older adults. The recommendations discussed are based on the Sixth American College of Chest Physicians Consensus Conference on Antithrombotic Therapy reported in Chest. 2001;119:132S-175S.

Age Factors↗

PubMed1996

Prophylactic Greenfield filters: acute complications and long-term follow-up.

The efficacy of prophylactic vena caval filters (VCF) in reducing morbidity and mortality from pulmonary embolism (PE) in high-risk trauma patients has been shown, but minimal follow-up data is currently available. VCFs were prophylactically placed in 110 patients between August 1991 and June 1995. There was an early VCF complication rate of 7%. Twenty-two patients died; the remaining 88 patients formed the basis for the follow-up study. Forty-five patients were located and interviewed by phone, and 30 of these patients (34%) returned for evaluation. The mean follow-up time was 18 months (range, 4-42 months). There was no incidence of caval thrombosis on follow-up. Eleven patients had physical findings, and duplex evidence consistent with postphlebitic syndrome. An additional three patients had evidence of old deep venous thrombosis (DVT) by duplex, but no significant symptomatology. VCF are effective in preventing PE related deaths and have few major complications. The long-term morbidity associated with posttraumatic venous thrombosis is significant. This morbidity is related not to PE or VCF, but to the underlying DVT. Improved strategies against DVT are necessary.

Adult↗

PubMedDate not supplied

Deep venous thrombosis: implications for orthopaedic nursing.

Deep venous thrombosis (DVT) and its complications, pulmonary embolism (PE), and postphlebitic syndrome (PPS) affect millions of Americans. The risk is especially high in surgical patients in general, and orthopaedic patients in particular. Virchow's triad describes the three factors that affect coagulation within a blood vessel: stasis, vessel injury, and coagulation factors. Risk factors, which relate to these factors, can predict which patients will be most likely to develop DVT. Prophylactic regimens should be tailored to patient risk. Nursing care is the key to implementation, maintenance, and compliance with any prophylactic program and its ultimate success.

Humans↗

PubMedDate not supplied

Outcome of noncatheter-related thrombosis in children: influence of underlying or coexisting factors.

PURPOSE: To determine the hereditary and nonhereditary risk factors contributing to the development of noncatheter-related thrombosis in children. PATIENTS AND METHODS: Ninety-five children with noncatheter-related thrombosis from a single center were analyzed for clinical manifestations and outcome during a period of 3.5 years. Patients with thrombosis were evaluated for congenital and acquired risk factors, and patients were screened for factor V Leiden, prothrombin 20210A mutations, protein C, protein S, antithrombin III deficiencies, and antiphospholipid antibodies. RESULTS: Twelve patients (12.5%) died of thrombosis that was associated with a nonmalignant underlying disorder, and 19 patients (20%) had significant complications, including amputation of extremities, epilepsy, hemiplegia, portal hypertension, recurrence of deep vein thrombosis, and postphlebitic syndrome. Two common mutations (factor V Leiden and prothrombin 20210A) were found in 32.5% of the patients with thrombosis. The most frequent underlying disorder was infection (68%). Ninety-three patients (98%) had one or more risk factors. CONCLUSIONS: The coexistence of an underlying disorder and the presence of predisposing factors such as infection and the factor V Leiden mutation may cause high rates of death and complications in children with noncatheter-related thrombosis. The results of this study indicate that the underlying disorder and the site of thrombosis determine the rates of death and complications in children with thrombosis.

Adolescent↗

PubMed1992

Light reflection rheography. A non-invasive diagnostic tool for screening for venous disease.

Light reflection rheography has been increasingly used in the last few years to screen for chronic venous insufficiency. It is non-invasive, easy to perform, and well-suited for repetition and standardization. Light reflection rheography is appropriate for the global assessment of calf-pump insufficiency regardless of whether it is caused by varicosis, the postphlebitic syndrome, or deep venous thrombosis. For this reason, it is a good method to use as a pretreatment selection test, especially for varicose veins. With the application of tourniquets, it can help to predict treatment results. When it is used in combination with ultrasound venous Doppler, a simple decision can be made for the treatment of nearly all venous patients.

Humans↗