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PubMed1997

Pulmonary embolism in deep venous thrombosis of the upper extremity: more often in catheter-related thrombosis.

BACKGROUND: Pulmonary embolism (PE) is a major complication of deep venous thrombosis (DVT) of the lower extremities. The incidence is approximately 50%. The incidence of DVT of the upper extremity (DVTUE) is increasing mainly due to the increasing use of central venous catheters. The percentage of PE secondary to DVTUE is still being investigated. METHODS: The occurrence of PE in DVTUE was retrospectively analyzed in 78 patients with proven DVTUE. Furthermore, the literature was reviewed. RESULTS: Of the identified patients with DVTUE 16 showed a primary DVTUE and 62 a secondary DVTUE. Secondary DVTUE was catheter-related in 41 (60%), which is 53% of all DVTUE. In this study the percentage of PE as a complication of DVTUE was 6 (95% CI: 0.2-30) in primary DVTUE, 13 (95% CI: 6-24) in secondary DVTUE and 17 (95% CI: 7-32) in catheter-related DVTUE. The relative risk for PE of catheter-related DVTUE versus other causes was 3.4 (95% CI: 0.4-53.5). The overall percentage was 12 (95% CI: 5-21). The literature review showed a percentage of 7 (95% CI: 4-9) in the retrospective studies and 17 (95% CI: 12-23) in the prospective studies. CONCLUSIONS: Indwelling catheters are the most common cause of DVTUE. PE is not an uncommon complication of DVTUE, and is more common in catheter-related DVTUE. The difference between the incidence of PE in DVTUE and DVT of the lower extremity may be explained by a number of factors, such as differences in fibrinolytic activity, mechanical forces and venous flow patterns.

Adult↗
PubMed2006

Different accuracies of rapid enzyme-linked immunosorbent, turbidimetric, and agglutination D-dimer assays for thrombosis exclusion: impact on diagnostic work-ups of outpatients with suspected deep vein thrombosis and pulmonary embolism.

The requirement for a safe diagnostic strategy should be based on an overall posttest incidence of venous thromboembolism (VTE) of less than 1%, with a negative predictive value of more than 99 to 100% during 3-month follow-up. Compression ultrasonography (CUS) and spiral computed tomography (CT) currently are the methods of choice to confirm or rule out deep venous thrombosis (DVT) and pulmonary embolism (PE), respectively. CUS has a negative predictive value (NPV) of 97 to 98%, indicating the need to improve the diagnostic work-up of patients with suspected DVT by clinical score assessment and D-dimer testing. Spiral CT as a stand-alone method detects all clinically relevant PEs and a large number of alternative diagnoses. It rules out PE with a NPV of 98 to 99%. Spiral CT is expensive, emphasizing the need to improve the diagnostic work-up of patients with suspected PE by the use of clinical score assessment and D-dimer testing. Clinical score assessment for DVT and PE has not safely ruled out VTE in multicenter studies and in routine daily practices. Modification of the Wells clinical score assessment for DVT by elimination of the "minus 2 points" for alternative diagnosis will improve the reproducibility of the clinical score assessment. The combination of a first negative CUS and a negative SimpliRed or an enzyme-linked immunosorbent assay (ELISA) VIDAS D-dimer of < 1,000 ng/mL safely exclude DVT (NPV > 99%) irrespective of clinical score assessment and without the need to repeat CUS in approximately 60 to 70% of patients. The rapid quantitative and qualitative agglutination D-dimer assays for the exclusion of VTE are not sensitive enough as stand-alone tests and should be used in combination with clinical score assessment. A normal rapid ELISA VIDAS D-dimer test as a stand-alone test safely excludes DVT and PE, with a NPV of 99 to 100%, irrespective of clinical score, without the need of CUS or spiral CT. The combined strategy of a rapid ELISA VIDAS D-dimer followed by objective testing with CUS for DVT and by spiral CT for PE will reduce the need for noninvasive imaging techniques by 40 to 50%.

Algorithms↗
PubMed1994

Frequent asymptomatic pulmonary embolism in patients with deep venous thrombosis.

OBJECTIVE: To determine the frequency of pulmonary embolism in patients admitted for treatment of deep venous thrombosis. DESIGN: An open, multicenter, dose-ranging study to assess the safety and pharmacokinetic characteristics of tissue-type plasminogen activator in deep venous thrombosis and pulmonary embolism. Perfusion and ventilation lung scans, chest roentgenograms, and venograms (in deep venous thrombosis) or pulmonary angiograms (in pulmonary embolism) were obtained before and 24 hours after inception of therapy. Heparin therapy was then administered. SETTINGS: Five tertiary-care hospitals. PATIENTS: All patients with suspected deep venous thrombosis or pulmonary embolism seen from August 1987 through November 1988 entered the study if they met inclusion criteria and if the diagnosis was confirmed by venogram (deep venous thrombosis) or pulmonary angiogram (pulmonary embolism). INTERVENTIONS: All patients received tissue-type plasminogen activator followed by intravenous heparin therapy. MAIN OUTCOME MEASURES: The primary measure was the frequency of pulmonary embolism in patients with deep venous thrombosis who had no symptoms of pulmonary embolism. This was not the original purpose of the study but emerged as an important finding as the data were analyzed. RESULTS: Nearly 40% of patients with deep venous thrombosis who had no symptoms of pulmonary embolism had evidence of pulmonary embolism based on ventilation-perfusion scan and chest roentgenogram findings. CONCLUSIONS: Because all of those considered to have embolism had so-called high-probability scan results, the frequency of embolism reported likely represents the minimum incidence of pulmonary embolism in patients with deep venous thrombosis who have no embolic symptoms. These data emphasize that venous thromboembolism is one disorder.

Angiography↗
PubMed1978

[Streptokinase in the treatment of deep venous thrombosis and pulmonary embolism].

Fifty-two deep venous thromboses and 35 pulmonary emboli were treated by Streptokinase administered in accordance with a standard protocol. Radiological examinations revealed total lysis of clots in 22 cases, partial lysis in 42 and failure in 23. The latter more commonly involved venous clots than pulmonary emboli. Early treatment was more effective (21 total lyses out of 22) than late treatment. However, in venous thrombosis, late treatment may give partial lysis and free important venous junctions. With standard treatment, lysis was biologically correct in 70 p. 100 of cases. It was inadequate in 20 p 100 of cases and nil in 10 p. 100 of cases. The results could thus have been improved by treatment established and adjusted in the light of laboratory results. The extent of the thrombosis played an important role. Total lysis was obtained in 9 out of 10 cases of localised deep venous thrombosis. In pulmonary embolism there was an average gain of approximately 30 p. 100 in obstructed surface area. However, in these latter cases, it is important to take into account not only the pulmonary surface area obstructed but also the origin of the clots.

Adult↗
PubMed2003

[Therapy and prevention of deep venous thrombosis and pulmonary embolism in gynecology and obstetrics].

AIM: The aim of this paper is to present the latest developments in therapy and prophylaxis of deep vein thrombosis in gynecology and obstetrics. DATA EXTRACTION: The data presented in the paper have been extracted from the Current Contents database. In the introduction, the coagulation cascade is described, and certain coagulation abnormalities caused by deficiency or decreased activity of coagulation factors are highlighted. The most prominent signs of deep vein thrombosis in pregnant women are swelling and tenderness of the affected leg, sometimes accompanied with fever and leucocytosis. In pelvic thrombosis, swelling of the leg is often absent and such a condition may be mistaken for other abdominal emergencies. The diagnostic algorithm for deep vein thrombosis starts with the clinical Wells criteria. To confirm the diagnosis it is necessary to visualize the thrombus by one of the imaging methods. The value of D-dimer is limited by its low positive predictive value, particularly in pregnant women. Low weight molecular heparin's have lately almost replaced standard heparin in the treatment of the deep vein thrombosis in pregnant women for providing advantages of subcutaneous application, no need of laboratory control of coagulation parameters, lower risk of bleeding, and lower incidence of osteoporosis and heparin-induced thrombocytopenia. We list the recommendations of the American College of Chest Physicians published in 1991, which stratify pregnant women with deep vein thrombosis according to their medical history and laboratory parameters. We have specified the proposed approach according to: history of deep vein thrombosis due to transient risk factors; previous idiopathic deep vein thrombosis without anticoagulant therapy; previous deep vein thrombosis with thrombophylia; previous idiopathic deep vein thrombosis on anticoagulant therapy; laboratory-proven thrombophilia with no history of deep vein thrombosis; and recurrent deep vein thrombosis. Pregnant women with artificial heart valves may undergo one of three proposed treatments. Long preoperative hospitalization, prolonged operative procedures, extensive injuries of blood vein vessels on radical procedures, frequently present accompanying malignant disease or previous irradiation therapy and postoperative bed-ridden period after major gynecologic procedures increase the risk of perioperative development of deep vein thrombosis. It is necessary to appraise this risk, classify patients in one of the four groups, and administer appropriate measures. Patients at a low risk of developing thromboembolic incidents are those younger than 40, undergoing procedures lasting less than 30 minutes and without other risk factors. The risk is moderate in patients aged 40-60 without other risk factors, or those aged under 40 having malignancy have high risk. Patients at a very high risk are those with a history of deep vein thrombosis, thrombophilia or pelvic exenteration. In the last decade there has been a great advancement in the diagnostics and treatment of deep vein thrombosis. The discovery of genetic disorders predisposing the patient to the development of a thromboembolic incident (thrombophilia) has changed our position concerning the duration of anticoagulant therapy, and nowadays it can last from several months to a lifetime regimen, depending on the underlying mechanism causing the incident. A significant improvement in therapy has occurred with the introduction of low molecular weight heparins in clinical practice. Their therapeutic value is equal to standard heparin, and their advantages include easier dosage and less nursing time as well as in a lower incidence of side effects such as haemorrhage. For these reasons, low molecular weight heparin has almost completely replaced standard heparin in the western world.

Adult↗
PubMed2001

Case report: pulmonary embolism from thrombosis in a duplicated inferior vena cava developing after an electrophysiologic procedure.

Duplicated inferior cava (IVC) is an anomaly we rarely encounter during electrophysiologic procedures. We report a case with duplicated IVC who developed thrombosis of the left IVC following an electrophysiologic procedure, which resulted in an asymptomatic pulmonary embolism. It is speculated that several catheters placed in the torturous route through the left IVC caused either endothelial damage to the vessel wall, or hemostasis in the relatively narrow portion of the vessel, resulting in thrombus formation. Since the prevalence and characteristics of thrombo-embolic complications during electrophysiologic procedures in patients with a duplicated IVC remain unknown, we believe this case should be reported.

Electrophysiologic Techniques, Cardiac↗
PubMed2000

Inherited thrombophilic risk factors and venous thromboembolism: distinct role in peripheral deep venous thrombosis and pulmonary embolism.

STUDY OBJECTIVES: To investigate whether the FII A(20210) mutation is associated with isolated pulmonary embolism (PE). DESIGN: Case-control study. SETTING: Five thrombosis centers in southern Italy. PATIENTS: Six hundred forty-seven consecutive referred patients with objectively documented venous thrombosis and 1,329 control subjects. MEASUREMENTS AND RESULTS: Medical histories were collected. The G-to-A transition at nucleotide 1691 within the factor V gene (FV Leiden) and the G-to-A transition at nucleotide position 20210 within the prothrombin gene locus (FII A(20210)), levels of anticoagulant factors, and levels of antiphospholipid antibodies were determined by standard techniques. Patients with deep venous thrombosis (DVT) of the lower extremities (n = 346) or with additional PEs (n = 175) showed similar prevalences of FV Leiden mutation (24.3% and 16.6%, respectively) and FII A(20210) mutation (14.2% and 12.6%, respectively), and similar deficiencies of natural anticoagulants (4.9% and 2.3%, respectively). In both groups, the frequencies of FV Leiden and/or FII A(20210) mutation were higher than those observed among 1,329 apparently healthy control subjects (4.8% and 4.4%, respectively; p < 0.0001). Among patients with isolated PE (n = 126), prevalences of FV Leiden (7.1%) and FII A(20210) mutation (8.7%) were similar to those of control subjects. Inherited thrombophilic abnormalities were less frequent among patients with PE only (15.6%) than among those with DVT only (37.0%; p < 0.001) or whose conditions were complicated by PE (28. 0%; p = 0.020). Adjusting for age and sex, FV Leiden mutation, FII A(20210) mutation, or both mutations were associated with DVT with PE (FV Leiden mutation: odds ratio [OR], 3.0; 95% confidence interval [CI], 1.6 to 5.5; FII A(20210) mutation: OR, 2.6; 95% CI, 1. 3 to 5.2; and both mutations: OR, 82.1; 95% CI, 7.5 to 901.2) or without PE (FV Leiden mutation: OR, 6.1; 95% CI, 4.0 to 9.3; FII A(20210) mutation: OR, 2.8; 95% CI, 1.7 to 4.8; and both mutations: OR, 167.5; 95% CI, 21.6 to 1,297.7), but not with isolated PE (FV Leiden mutation: OR, 1.2; 95% CI, 0.5 to 2.8; FII A(20210) mutation: OR, 1.2; 95% CI, 0.5 to 3.1; and both mutations: OR, 22.1; 95% CI, 1. 3 to 370.2). CONCLUSIONS: FII A(20210) mutation is associated with DVT in the lower extremities alone or when complicated by PE, but it is not associated with isolated PE.

Activated Protein C Resistance↗
PubMed2004

Screening for occult cancer in patients with acute deep vein thrombosis or pulmonary embolism.

Patients with acute venous thromboembolism have an increased risk for occult malignancy. Limited screening for these malignancies has become common practice but little is known about its usefulness. This is a prospective cohort follow-up study in consecutive patients with acute venous thromboembolism. All patients underwent a routine clinical evaluation for malignancy, if negative, followed by a limited diagnostic work-up consisting of abdominal and pelvic ultrasound and laboratory markers for malignancy. Clinical follow-up was conducted to detect screening failures. The routine clinical evaluation was performed in 864 patients and revealed malignancy in 34 (3.9%) of them. Among the remaining 830 patients the limited diagnostic work-up revealed 13 further malignancies. During follow-up, cancer became symptomatic in 14 patients who were negative for cancer at screening (sensitivity of limited diagnostic work-up, 48.1%). Malignancies that were identified by the limited diagnostic work-up were early stage in 61% of cases vs. 14% in cases occurring during follow-up. Most patients with occult cancer had idiopathic venous thromboembolism and were older than 70 years. A limited diagnostic work-up for occult cancer in patients with venous thromboembolism has the capacity to identify approximately one-half of the malignancies. Identified malignancies were predominantly in an early stage.

Acute Disease↗
PubMed2003

The ACE D/D genotype is protective against the development of idiopathic deep vein thrombosis and pulmonary embolism.

The deletion/deletion (D/D) genotype of the angiotensin converting enzyme (ACE) has been purported to be a risk for post-operative thrombosis.This D/D genotype has not been evaluated as a risk factor for idiopathic venous thromboembolism (VTE). The primary objective of the present study was to determine whether the D/D genotype of ACE is independently associated with the occurrence of idiopathic venous thromboembolic disease. We prospectively enrolled consecutive patients with at least one objectively confirmed idiopathic VTE. Friends of cases were recruited as controls and matched to cases by sex, ethnicity, and age. Patients were tested for the ACE I/D polymorphism in addition to factor V Leiden, prothrombin G20210A, and factor VIII levels. Three hundred cases and 300 controls were enrolled; 97% were Caucasian. There were 148 females and 152 males in each group with a mean age of 56.21 years (SD = 15.33). The ACE D/D genotype was present in 25.3% of cases and 32.4% of controls for an adjusted odds ratio of 0.66 (95% CI = 0.433 to 0.997). We can conclude that the ACE D/D genotype is protective against idiopathic venous thromboembolism.

Adult↗