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PubMed1990

Thrombolytic agents: balancing cost, efficacy, and side effects.

Balancing the benefits, risks, and cost of thrombolytic treatment is a complex issue which depends considerably upon the variable threat of the thrombus to organ physiology and patient survival. For example, after deep vein thrombosis (DVT), the major risk is long-term disability due to the postphlebitic syndrome, while in pulmonary embolism (PE) patients, the risks concern short-term mortality and impaired pulmonary physiology. Thus, for treating DVT or PE, the question is whether thrombolytic therapy would be valuable in addition to other antithrombotic approaches. Clearly, the best indication for thrombolytic therapy is in acute myocardial infarction (MI) patients, because this therapy has the potential for reducing coronary artery thrombus mortality. In acute MI the major issues concern the choice of thrombolytic agent and the relative merits of nonpharmacologic interventions such as angioplasty and bypass surgery. An optimal window of treatment opportunity exists for all of the indications. The window is shortest for MI, intermediate for PE, and longest for DVT patients.

Cost-Benefit Analysis↗

PubMed1977

Thrombophlebitis. Prevention, recognition, and management.

Thrombophlebitis is a common disease entity with characteristic features of edema, inflammation, and tenderness. If the disease process is extensive, the postphlebitic syndrome, which is characterized by persistent edema, pigmentation, dermatitis, ulceration, and varicose veins, invariably occurs.

Anticoagulants↗

PubMed1989

Extended indications for placement of an inferior vena cava filter.

To study the morbidity and mortality rates after placement of an inferior vena cava filter and to define the appropriate indications for interruption of the inferior vena cava, the records of all patients who underwent insertion of a Greenfield filter during the decade January 1978 to December 1987 were reviewed. Patients were designated as having either a traditional or extended indication for placement of an inferior vena cava filter. Two hundred sixty inferior vena cava filters were placed in 264 attempts, with no deaths related to insertion of the filter. An extended indication was the primary reason for placement of the Greenfield filter in 66 (25%) of the patients. In patients with extended indications there were no cases of air embolism or filter misplacement and only three wound complications (4.5%). Pulmonary embolism after insertion of the inferior vena cava filter occurred in three patients (4.5%), with one fatality (1.5%). Inferior vena cava occlusion was documented in three cases (4.5%), and manifestations of the postphlebitic syndrome in early follow-up were present in two patients (3.0%). As the procedures to prevent fatal pulmonary embolism have become safer, more efficacious, and less morbid, the number of patients in whom the potential benefits of insertion of an inferior vena cava filter outweigh the risks has become larger. Our results support the liberalized use of Greenfield filters in those patients who do not necessarily have one of the traditional indications for placement of an inferior vena cava filter but are at a high risk of having a fatal pulmonary embolus.

Anticoagulants↗

PubMed1989

[Evaluation of our results after emergency thrombectomy in acute iliofemoral venous thrombosis].

The massive thrombosis of deep venous system of the lower extremities has become object of surgical treatment lately. The authors presented of I-F acute venous thrombosis of the leg upon which was an urgent thrombectomy made. The investigated clinilac material was divided in to 2 groups: I (A) were 78 patients, where as thrombectomy was made in the first 24-48 hours. In group II (B)-18 patients were presedented the control group (C) which were conservatively treated. Results obtained by early thrombectomy justified our active opinion in acute I-F thrombosis. There was no embolisation, no rethrombosis, no postphlebitic syndrome and no mortality.

Acute Disease↗

PubMedDate not supplied

[Current status of fibrinolysis--a literature review of 25 years of fibrinolytic treatment].

Thrombolytic therapy is an effective, rapid method in treatment of massive lung embolism and major deep venous thrombosis extending to the caval vein. Besides resolution of the thrombus and improving hemodynamics, it prevents evolution to chronic pulmonary hypertension or postphlebitic syndrome. To have a beneficial effect in the early course of acute myocardial infarction, thrombolytic therapy should be instored within about three hours after the onset of pain; a real brief time limit. Intracoronary or systemic fibrinolysis later than the three hours period does not improve cardiac wall motion and hemodynamics and cannot assure infarct size reduction in spite of reestablished coronary flow. In peripheral arterial disease, fibrinolytic therapy of thrombosed grafts or vessels facilitates detection and unmasking of the underlying anatomical lesion permitting definite therapy (graft revision, percutaneous transluminal angioplasty). Selective intraarterial infusion has given encouraging results. Thrombolysis is a reasonably safe therapeutic method, on the condition of respecting all contraindications and avoiding unnecessary punctions. Allergy and hyperthermia are mostly benign and responsive to medical treatment. Cost-effectiveness renders streptokinase the most applicated thrombolytic agent.

Fibrinolysis↗

PubMedDate not supplied

Late results of Linton flap operation.

Linton flap operation was performed in 202 patients with postphlebitic syndrome complicated by evident ulceration 64% of patients were followed up for 1-14 years. Complete cure was obtained in 87.7%.

Adult↗

PubMedDate not supplied

Reconstruction with insertion of expanded polytetrafluoroethylene (EPTFE) for iliac venous obstruction.

Surgical therapy for DVT in the legs, including reconstruction of the blood circulation system and thrombectomy with a Fogarty catheter, is not always satisfactory, as indicated by the variety of opinions both for and against them. However, it is also a fact that postphlebitic syndrome can result from incomplete treatment. Therefore, surgical approaches should by given priority in the acute stage of the disease. In 5 patients who showed either complete obstruction or insufficient removal of thrombi from the proximal region in leg DVT, we performed crossover femoro-femoral bypass using EPTFE (including two wire reinforced grafts) and were able to obtain good long-term patency over periods of 8-18 months.

Aged↗

PubMedDate not supplied

Temporary arteriovenous fistula for venous reconstruction using synthetic graft: a clinical and experimental investigation.

This report discusses venous reconstructive surgery combined with a temporary distal arteriovenous fistula creation for ilio-femoral vein obstruction. One patient who had long standing, high degree edema of the left lower extremity due to postphlebitic syndrome and four patients who had acute occlusion of the iliac vein were treated by means of extra-anatomical femoro-femoral vein bypass grafting combined with temporary distal femoro-saphenous arteriovenous (a-v) fistula creation. An expanded polytetrafluoroethylene (EPTFE) graft was selected for this procedure instead of a cross-over saphenous vein. The surgically created a-v fistula was effective in keeping the implanted grafts patent for a long time in three out of the five patients. In animal experiments, the bilateral iliac veins of mongrel dogs were replaced with several kinds of synthetic graft. Femoro-femoral a-v fistulae were made only on the left side. In 26 animals, 84.6% of the synthetic grafts on the a-v fistula side were patent, whereas only 11.5% of the grafts on the control side were patent. This investigation clearly demonstrates that the increased blood flow velocity through the created distal a-v fistula preserved the patency of synthetic vein grafts.

Adult↗

PubMed1985

Thrombotic vascular disease.

Thrombovascular disease represents one of the most important causes of morbidity and mortality. Although coronary artery disease attracts most attention, other types of vascular disease also make a substantial contribution to the overall statistics. These include microangiopathy, particularly in relation to diabetes mellitus, and deep vein thrombosis and its associated complications of pulmonary embolus and postphlebitic syndrome.

Arteries↗

PubMed1985

Venous claudication successfully treated by distal superficial femoral-to-greater saphenous venous bypass.

Chronic venous disease of the lower extremities is a clinical entity that is commonly encountered by practicing physicians. The problem is usually a direct consequence of a previous episode of deep venous thrombosis. Patients so afflicted suffer from a distinct series of symptoms that are grouped under the term "postthrombotic" or "postphlebitic" syndrome. These consist of leg edema, stasis dermatitis, ulceration, and sometimes claudication. The causative pathophysiologic features consist of either valvular incompetence and/or main channel obstruction. This report offers a new method of relieving symptoms caused by a superficial femoral vein obstruction.

Adult↗

PubMed1985

[Light-reflexion rheography--possibilities and limitations].

Light reflection rheography (LRR) is a new technique for quantitative diagnostics of venous functions. It is non-invasive, easy to handle, well-suited for repetition and standardization, and there is no strain for the patient. This method is appropriate for global assessment of calf pump insufficiency regardless whether it may be caused by varicosis, postphlebitic syndrome, or deep venous thrombosis. With the application of tourniquets, LRR helps to predict the possible result of vein stripping and is likewise useful for the follow-up period. LRR promises to become a valuable screening method regarding the detection of deep venous thrombosis of the lower leg. A useful methodic variation is the passive manual compression of the calf instead of active dorsiflexion; thus the measurement becomes independent of the patient's cooperation. We must take into account, however, the high sensitivity of LRR depending on various known and still unknown factors. The measured values may differ to a considerable degree in one single patient, even under exact conditions of examination. Therefore we always perform three measurements and then take the average value. Critically applied, LRR represents a valuable technique of quantitative phlebological examination.

Ankle Joint↗

PubMedDate not supplied

[Sclerotherapy in postphlebitic disease].

Sclerotherapy can be used for the postphlebitic syndrome as long as two important precautions are observed. First, the inflammatory phase must be resolved, usually taking one year for thromboplhebitis of the deep venous system and six months for that of the superficial venous system. Secondly, always begin progressively with small, doses, after having initially tested the effect of the sclerosing agent on a secondary vein.

Humans↗

PubMed1983

Direction of flow in superficial veins as a guide to venous disorders in lower limbs.

Clinical methods and directional Doppler velocimetry applied to superficial veins have been used to study 527 patients with venous disorders in the lower limbs. Phlebography assisted by the image intensifier has been carried out in 80 of these patients. All examinations have been done with the patient upright, exercising, and without use of any artefact, such as a tourniquet. By these combined means Doppler flow patterns in the superficial veins of five groups of patients have been identified: (1) a highly distinctive downward flow in the upright exercising patient (retrograde circuit) in simple incompetence of the superficial veins (82.1%); (2) a characteristic pattern of upward flow accentuated by exercise, indicating collateral function past deep veins impaired by previous thrombosis (postphlebitic syndrome) (5.7%); (3) a surge back and forth on exercise in patients with valveless deep veins, probably of cogenital origin (8%); (4) sustained upward flow, accentuated by exercise, in veins acting as collaterals to occluded iliac veins (1.5%); (5) a variety of flow patterns in congenital states, including Klippel-Trenaunay syndrome (2.7%). Approximately one half of patients with venous stasis were in the first group and therefore probably had curable conditions; the remainder had the deep vein problems. The incidental role of the "perforator" is discussed and attention drawn to the significance of the retrograde circuit based upon the foot. The directional Doppler flowmeter provides an important screening test that positively identifies simple superficial vein incompetence, suitable for treatment, or gives clear warning of unsatisfactory deep veins that should be investigated further.

Blood Flow Velocity↗

PubMed1982

Vein valve transplant.

The sequelae of deep vein thrombophlebitis, such as postphlebitic syndrome with or without ulcer, can be treated by direct surgery on the valve. The present surgical treatment of stasis ulcer includes removal of the incompetent communicating veins with excision of the ulcer and skin graft. If this operation is performed on patients who actually have deep venous incompetence, then a high incidence of reulceration and skin graft slough may be expected if there is no concommitant correction of deep venous incompetence. Experimental studies to restore venous valve function such as autogenous vein valve transplant, valvoplasty, homologous vein transplant, and synthetic valve procedures have been tried. It has been shown that with autogenous vein graft there are a lower incidence of thrombosis and a more effective restoration of valve competency than with other procedures. We operated on six patients utilizing an autogenous vein valve from the upper extremity to achieve hemodynamically functioning venous system of the lower extremity. Data on pre- and postoperative noninvasive evaluations and ascending and descending venography with the results of surgery will be discussed.

Adult↗

PubMedDate not supplied

Iliofemoral venous thrombectomy (follow-up studies of 88 patients).

A review of our 93 consecutive thrombectomies performed on 88 patients for acute and subacute iliofemoral venous thrombosis led us to the following conclusion. 1. Venous thrombectomy is an effective and safe operation and should be continued to be utilized in the management of iliofemoral venous thrombosis. 2. Thrombectomy should be recommended for in many types of patients, and the indication should include not only those whose symptoms occurred less than 2 weeks prior to the operation, but also those whose symptoms had been present for more than 2 weeks before surgery, in as much as the patients are suffering from severe pain, swelling and incapacity to walk. 3. The thrombectomy is useful for relief of complaints and plays an important role in the prevention of postphlebitic syndrome.

Adult↗

PubMed1980

Combined radionuclide phlebography and lung scanning in patients operated on for scoliosis with the Harrington procedure.

Iliac vein thrombosis is an uncommon type of deep vein thrombosis (DVT) that occurs in young patients following surgical procedures for scoliosis. The symptomatology is diffuse and this type of DVT carries a risk for fatal pulmonary embolism as well as the development of a postphlebitic syndrome. Combined radionuclide phlebography and lung scanning were performed in 16 patients operated on for scoliosis with the Harrington procedure. In three patients with diffuse pain in the inguinal region, iliac vein thrombosis was easily visualized in the radionuclide phlebogram and confirmed by conventional phlebography in two cases. Six patients without lung symptoms had perfusion defects typical for pulmonary embolism. It is concluded that radionuclide phlebography can be recommended as a diagnostic procedure for iliac vein thrombosis in patients with diffuse symptoms in the inguinal region or the lower abdomen after scoliosis surgery. Advantages include the ease of performance, good patient acceptance and low radiation dose compared with conventional phlebography. Asymptomatic pulmonary embolism as diagnosed by the perfusion lung scan was an unexpected finding which raised clinical considerations that require further investigations.

Adolescent↗

PubMed1980

Fibrinolytic therapy.

Fibrinolytic therapy is a useful addition to the armamentarium of most clinicians. Patients with fibrin-based intraluminal clots are seen by almost all physicians. With proper patient selection and careful physician adherence to dosage schedule and monitoring, the incidence of significant complications with fibrinolytic agents is about the same as with heparin therapy. Heparin stops the thrombotic process, whereas fibrinolytic therapy not only stops the thrombotic process, but often reestablishes a normal, hemodynamic state. Patients who undergo fibrinolytic therapy are spared long-term problems like amputation and the postphlebitic syndrome.

Arterial Occlusive Diseases↗

PubMed1995

Management of venous thromboembolic disease. The impact of low-molecular-weight heparin.

Prophylaxis for DVT unequivocally is beneficial in patients identified to be at high risk. Heparin prophylaxis with subcutaneous low-dose UFH is adequate in some clinical settings but less effective in others. LMWH preparations are effective and safe as prophylaxis in certain medical patients as well as in general surgery and elective hip replacement. Efficacy and safety are demonstrated in the therapy of established venous thromboembolism. Subcutaneous administration of LMWH once or twice daily may prove more convenient from both the patient and nursing viewpoint, particularly in the treatment of established DVT. Monitoring is not necessary when using LMWH preparations as prophylaxis, and a fixed-dose without weight adjustment has been used in most prophylaxis trials. When treating established DVT, less monitoring is likely to be required than currently is the case with UFH. Although the cost of LMWH preparations is greater than that of UFH, the decrease in the occurrence or recurrence of thromboses that has been demonstrated in some trials might prove an effective balance. Future avenues to explore include discovery of better means to standardize the LMWH preparations and determination of the efficacy and safety of LMWH in specific populations, such as those in intensive care units, cancer patients, nursing home patients, and outpatients in general. Although cost-benefit is favorable thus far, meticulous assessment in other settings may enhance the acceptance of these agents. Long-term follow-up could be helpful in determining the relative effect of different heparin preparations on the frequency of postphlebitic syndrome. Comparison of different LMWH fractions may follow, as well as further investigations of newer ultra-low-molecular-weight agents. One LMWH preparation (enoxaparin) already has been approved in the United States for prophylaxis in the setting of elective hip replacement; and dalteparin has been approved here for use as DVT prophylaxis in patients undergoing abdominal surgery when there appears to be a significant risk of thromboembolism. It is likely that LMWH preparations will become even more widely used in North America and that the approved indications will expand to include prophylaxis in numerous settings and the treatment of established venous thromboembolism.

Clinical Trials as Topic↗