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PubMed2006

Management of the postthrombotic syndrome: the Rotterdam approach.

The postthrombotic syndrome (PTS) affects the deep venous system, and may also extend to the superficial venous system of the legs in patients with a documented history of deep vein thrombosis. Clinical symptoms of PTS may vary considerably and range from scarcely visible skin changes to changes in pigmentation, pain, discomfort, venous ectasia, edema, and ulceration. Our view based on standard investigations and the proper place of advanced investigations regarding the etiology and pathophysiology of PTS has lead to the Rotterdam approach, incorporating the evidence-based diagnostics and treatments available for PTS. High-quality duplex sonography is mandatory in all patients, providing anatomical and functional (reflux) information on both the deep and superficial venous systems, and non- or partially recanalized veins (occlusion) can also be detected using this technique. If the results of duplex sonography are not clear or a venous desobstruction procedure is to take place, phlebography will be the investigation of choice. There is a lot of evidence that medical elastic stockings (MECS) are effective in the prevention of PTS with documented reflux, obstruction, or both. When prescribing MECS, it is important to examine both elasticity and hysteresis of the fabric of the stockings to apply the correct dynamic pressure for each individual patient. Patients with documented PTS should receive life-long follow-up.

Humans↗
PubMed1997

The natural history of deep-vein thrombosis.

Symptomatic deep vein thrombosis (DVT) carries a high risk for recurrent venous thromboembolism that persists for many years. This risk is dependent on readily identifiable risk factors, being low after a trauma or a surgical intervention, and higher in all the other patient categories. Severe post-thrombotic manifestations seem related with ipsilateral recurrence of DVT but are rare in patients with a first episode of venous thrombosis adequately treated with anticoagulant drugs and wearing compression elastic stockings. In the absence of malignancy, the prognosis with regard to survival is good.

Humans↗
PubMed1991

Antithrombotic efficacy of continuous extradural analgesia after knee replacement.

We have studied the effect of extradural analgesia on postoperative venous thrombosis in patients undergoing knee arthroplasty. Forty-eight patients were allocated randomly to receive either general anaesthesia or extradural analgesia with local anaesthetics for 3 days. All patients wore compressive elastic stockings and no anticoagulant drugs were administered. Bilateral venography was performed 10 days after surgery. Continuous extradural analgesia did not impede mobilization of the patients. One case of nonfatal pulmonary embolism occurred in a patient who received general anaesthesia. The use of continuous extradural analgesia resulted in a significant difference in the total incidence of deep vein thrombosis (18% compared with 59% after general anaesthesia (P = 0.02]. The incidence of calf vein thrombosis was 12% compared with 45% after general anaesthesia (P = 0.05).

Adult↗
PubMed2000

The post-thrombotic syndrome.

One of every three patients with deep-vein thrombosis of the lower extremities will develop, within 5 years, post-thrombotic sequelae that vary from minor signs to severe manifestations such as chronic pain, intractable edema, and leg ulceration. The post-thrombotic syndrome (PTS) develops as a result of the combination of venous hypertension due to persistent outflow obstruction or valvular incompetence and abnormal microvasculature or lymphatic function. Among factors potentially related to the development of PTS, recurrent ipsilateral thrombosis plays a major role. Whether the extent and the location of the initial thrombosis are associated with the development of PTS is still controversial. The diagnosis of PTS can be accepted on clinical grounds for patients with a history of venous thrombosis. The combination of a standardized clinical evaluation with the results of compression ultrasonography and Doppler ultrasonography helps diagnose or exclude a previous proximal-vein thrombosis. Prevention of recurrent thrombosis and use of compression elastic stockings are the cornerstones of PTS prevention. The management of this condition is demanding and often frustrating. Although several surgical procedures have been tested, conservative treatment is largely preferable, as more than 50% of patients either remain stable or improve during long-term follow-up, if carefully supervised and instructed to wear proper elastic stockings. Clinical presentation helps predict the prognosis, being the outcome of patients who refer with initially severe manifestations more favorable than that of patients whose symptoms progressively deteriorate over time.

Bandages↗
PubMedDate not supplied

Treatment of diabetic ulcers.

Diabetic ulcers are chronic wounds that are the result of repetitive trauma in the insensate foot. The presence of infection and peripheral vascular disease makes the treatment of these wounds demanding and requires a multidisciplinary approach. The main principles of the management include adherence to the principles of good wound care, such as aggressive debridement of all non-viable tissue, adequate off-loading of pressure, prompt treatment of infection and moist wound dressings. Over the last decade, new therapeutic modalities, including growth factors and living skin equivalents, have been available to the practicing physicians. Judicious use of advanced wound care products may provide the best means of treating these challenging wounds in an efficient and cost-effective way.

Bandages↗
PubMedDate not supplied

Evidence for the prevention of venous thromboembolism.

Patients undergoing major orthopaedic surgery are at high risk of developing venous thromboembolism (VTE). VTE is preventable and venous prophylaxis consensus groups recommend that each patient is assessed for risk of VTE and then stratified into one of the three categories of risk. Rick stratification enables the choice of the most appropriate preventative interventions. This article examines a decision making framework for VTE prevention with particular focus on a validated risk assessment model (RAM) to facilitate risk stratification. The relevant literature is also scrutinised in terms of the best venous antithrombotic strategies, for patients undergoing major orthopaedic surgery, according to scientific evidence.

Anticoagulants↗
PubMed2006

Determining venous incompetence: a report from a specialised leg ulcer clinic.

OBJECTIVE: To analyse the diagnosis, treatment and prognosis in patients attending a specialised leg ulcer clinic at a dermatology department. METHOD: In total, 345 patients were investigated and 332 registered and followed up prospectively. All patients had their arterial and venous circulation assessed with a hand-held Doppler ultrasound. RESULTS: The most frequent diagnosis was venous ulceration (153 patients, 46%) followed by hydrostatic ulceration (70 patients, 21%). Venous incompetence was classified as isolated superficial (n=86) or deep venous incompetence (n=57) in 143 out of the 153 patients. Previous deep vein thrombosis (DVT) was more frequent in patients with deep venous incompetence. Of patients with venous ulcers, 38 (25%) healed within 92 days, 77 (50%) within 155 days and 115 (75%) within 329 days. Healing time was influenced by patient age, ulcer duration and ulcer area, but not by type of venous incompetence or ankle brachial pressure index. After healing, 19% of venous patients (28/144), dominated by those with superficial disease, were subject to venous vascular surgery. CONCLUSION: Classification of venous insufficiency should be mandatory in patients with venous ulcers since it determines suitability for venous surgery.

Adult↗
PubMed2006

Prophylaxis against venous thromboembolism in acutely ill medical patients: an observational study.

STUDY OBJECTIVES: To determine the risk factors for venous thromboembolism (VTE) and the rates of prophylactic measures used in acutely ill medical patients. DESIGN: Prospective observational study. SETTING: Academic tertiary care medical center. PATIENTS: One hundred seventy-nine patients admitted to three general medical units over 30 consecutive days and hospitalized for at least 3 days. MEASUREMENTS AND MAIN RESULTS: On concurrent review of the patients' medical records, 138 (77.1%) of 179 patients received one or more forms of VTE prophylaxis during their hospital stay. Of 41 (22.9%) patients receiving no VTE prophylaxis, 22 (53.7%) had and 19 (46.3%, or 10.6% of the total population) did not have a documented contraindication to anticoagulation. One hundred ten patients (61.5%) had three or more documented VTE risk factors for VTE. The most common prophylaxis was unfractionated heparin 5000 U injected subcutaneously twice/day. Therapeutic anticoagulation was given to 51 patients (28.5%) at some time during their hospitalization for indications other than VTE treatment. Two developed symptomatic VTE (1.1%) while hospitalized. Four patients (2.2%) receiving anticoagulants had adverse outcomes. One patient had minor bleeding, and one developed heparin-induced thrombocytopenia without thrombosis. CONCLUSION: Rates of VTE prophylaxis were higher than previously reported rates, although no formalized guidelines, standardized order sets, alerting programs, training, or risk-stratification tools were used during the study period. Rates of adverse events were low.

Academic Medical Centers↗
PubMed2001

[Is reliable prophylaxis of postoperative venous thromboembolic complications possible?].

Thrombosis of deep veins of lower extremities and pelvis is found in every third operated patient on the average, pulmonary embolism--in 0.5-0.8% cases. The results of nonspecific and specific prophylaxis of these complications are reviewed in the article. Intermittent pneumatic compression, compressive elastic stockings and standard or low-molecular heparin administration are most effective. Prophylactic measures do not exclude completely possibility of venous thromboembolic complications, but permit to control reliably this danger. The author has an experience of cavafilter implantation in 147 patients.

Anticoagulants↗
PubMed1953

ELASTIC stockings.

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Peripheral Vascular Diseases↗