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PubMed1999

Diagnostic role of ED ultrasound in deep venous thrombosis and pulmonary embolism.

Proximal deep venous thrombosis (DVT), which may lead to pulmonary embolism (PE), is one of the serious and underrecognized causes of lower extremity pain and swelling. The diagnosis of DVT requires a confirmatory objective test because clinical signs and symptoms are unreliable. Assessment of thigh vein compressibility with real-time ultrasound is an accurate test for DVT that may be performed rapidly at the bedside. Although unproven, we propose that wider use of this test in the emergency department by emergency physicians might increase the diagnosis of DVT, prevent PE, and reduce utilization of other more costly and invasive diagnostic tests. Evaluation of DVT by compression ultrasound may also be incorporated in the diagnostic workup of suspected PE. In the case of a nondiagnostic ventilation/perfusion scan, demonstration of proximal DVT by ultrasound represents a likely source of PE and an indication for anticoagulation, eliminating the need for pulmonary angiography. In the critically ill patient whose presentation is consistent with massive PE, one rapid approach to the diagnosis may be to combine transthoracic echocardiography with lower extremity ultrasound.

Compressive Strength↗
PubMed1993

Update. Deep vein thrombosis and pulmonary embolism prophylaxis in orthopedic surgery.

Deep vein thrombosis and pulmonary embolism continue to be controversial areas for prophylaxis in orthopedic surgery. This patient population continues to have the highest incidence of deep vein thrombosis and pulmonary embolism when inappropriately or not prophylaxis for this complication. This article reviews the current modalities for prophylaxis with respect to their safety and efficacy. In addition, the new modalities of low molecular weight heparin and arteriovenous impulse system are presented.

Anticoagulants↗
PubMed2005

Thrombosis and coagulation: deep vein thrombosis and pulmonary embolism prophylaxis.

Venous thromboembolism (deep venous thrombosis and pulmonary embolism, VTE) is a common complication in surgical patients and is the primary cause of preventable deaths in hospitalized patients. Despite well-known risk factors, VTE prophylaxis is frequently not practiced according to recommended guidelines. Patients can readily be stratified according to their risk of perioperative VTE, and mechanical and pharmacologic prophylactic regimens can be tailored to their individual risk. Pharmacologic VTEprophylaxis should be the standard of care in most clinical settings given its ease of administration, low risk, and cost-effectiveness.

Anticoagulants↗
PubMedDate not supplied

A prospective audit of hospital-acquired deep vein thrombosis and pulmonary embolism.

The incidence of symptomatic deep vein thrombosis and pulmonary embolism acquired in hospital was studied, and the effectiveness of current thromboprophylaxis was assessed in an open study of 8648 admissions to the Doncaster Royal Infirmary between April and July 1994. On admission, all patients were assessed for their likely risk of thromboembolic problems according to THRIFT criteria. Treatment, prophylaxis, complications and outcome were recorded on discharge. A high risk sub-group was followed up for up to 42 days after discharge. The overall rate of clinically apparent hospital-acquired thromboembolic complications was 0.4% (n = 35). The rate of clinically apparent thromboembolic disease in the high risk group was 2.1% (n = 17). The incidence of thromboembolic problems appeared not to be reduce by prophylaxis apparently even when stratified by risk group. These findings suggest that thromboembolic complications may be less common than would be expected from published literature. Thromboprophylaxis as currently practised within our institution does not seem to affect the incidence of deep vein thrombosis or pulmonary embolism, and these results would appear to argue against a 'blanket' policy for pharmacological thromboprophylaxis.

Adolescent↗
PubMedDate not supplied

Prevention and treatment of deep vein thrombosis and pulmonary embolism in critically ill patients.

Deep vein thrombosis and pulmonary embolism remain common problems in the intensive care unit, with limb- and life-threatening complications that are potentially preventable. The intensive care unit clinician is called on to be vigilant with diagnosis and facile with prevention and treatment of thromboembolic disease (venous thromboembolism). This article reviews background, current options, and recommendations regarding the occurrence of deep vein thrombosis and pulmonary embolism in the intensive care unit population.

Adult↗
PubMedDate not supplied

Bird's nest filter placement within an enlarged hemiazygos vein for prevention of pulmonary embolism.

Thrombosis of the inferior vena cava (IVC) may result in considerable enlargement of paravertebral, azygos, and hemiazygos collateral veins that may in turn serve as pathways for thromboemboli to the pulmonary circulation. Herein we describe the transfemoral placement of a Bird's Nest filter within an enlarged hemiazygos vein to provide prophylaxis against pulmonary embolism in a patient with right femoral venous thrombosis who could not tolerate systemic anticoagulation. There had been earlier transjugular placement of a Greenfield filter within the suprarenal IVC.

Femoral Vein↗
PubMed2000

Management of deep venous thrombosis and pulmonary embolism.

The management of deep venous thrombosis (DVT) and pulmonary embolism (PE) is changing dramatically. The US Food and Drug Administration has approved outpatient treatment of DVT with the low-molecular-weight heparin enoxaparin as a bridge to warfarin. Warfarin use is improved by avoiding loading doses and by recognizing previously unappreciated interactions and potentiation with commonly used medications such as acetaminophen. The importance of isolated calf and upper-extremity venous thromboses has been validated, so that patients with these conditions routinely undergo anticoagulation. Risk stratification for PE is becoming more sophisticated because practitioners now assess right ventricular function (usually by echocardiography) instead of relying solely on systemic arterial blood pressure and heart rate to determine prognosis. Among patients with massive DVT or hemodynamically unstable PE, thrombolysis, thrombectomy, and embolectomy (often performed in an interventional angiography laboratory) are being used with increasing skill and improved outcomes.

Humans↗
PubMed1990

Prevention of venous thrombosis and pulmonary embolism.

Deep vein thrombosis (DVT) leads to hospitalization for up to 600,000 persons each year in the United States. Venous thrombosis in itself may be benign, but the condition can lead to dangerous complications and has a high recurrence rate. Strategies to prevent DVT involve prevention of stasis and reversal of changes in blood coagulability that allow thrombi to form. Pharmacologic agents have been effective in reducing the incidence of DVT and pulmonary embolism. Low-dose subcutaneous heparin is considered a nearly ideal DVT preventative for surgically treated patients. The risk of hemorrhage is the main limitation to routine use of subcutaneous anticoagulants for DVT, but careful patient selection can minimize that risk. After anticoagulant therapy with heparin, generally for 7 to 10 days, oral warfarin is the drug of choice for maintenance anticoagulation to prevent DVT recurrence. Therapy for pulmonary embolism is the same as for DVT--immediate anticoagulation with heparin followed by maintenance with warfarin.

Anticoagulants↗
PubMed1999

[20210G/A mutation of prothrombin gene in a patient with deep venous thrombosis ad pulmonary embolism without other risk factors of thrombosis].

A new genetic anomaly predisposing to venous thrombosis was described in 1996, namely the transition of guanine (G) to adenine (A) at position 20210 in the 3-untranslated region of the prothrombin gene. This mutation is associated with high levels of plasma prothrombin and increased risk of thrombotic events in the venous system. We report the case of a man who, lacking known risk factors for thrombosis, suffered a massive pulmonary embolism and deep venous thrombosis in both lower legs. Thrombophilic analysis confirmed that the patient and close relatives were carriers of the heterozygotic 20210G/A variant of the prothrombin gene. Two relatives with the genetic defect had also suffered some type of deep venous thrombosis.

Adult↗
PubMed2004

Ileus following total hip or knee arthroplasty is associated with increased risk of deep venous thrombosis and pulmonary embolism.

Venous thromboembolic disease (VTD), deep venous thrombosis and pulmonary embolism, causes morbidity and mortality following total hip and total knee arthroplasties, while ileus complicates up to 4.0%. The clinical courses of 2,949 patients undergoing 3,364 consecutive primary and revision total hip and total knee arthroplasties, radical debridements, and reimplantations at one institution over a 2-year period were reviewed to examine the relationship between ileus and VTD. VTD prophylaxis consisted of aspirin and intermittent plantar pulse boots for all patients except those at high risk, who received parenteral chemical prophylaxis and boots. Ileus occurred in 62 patients (2.1%) and symptomatic DVT in 51 (1.7%). With ileus, the incidence of DVT was 8.1%: odds ratio 5.5 (P =.0036). Symptomatic pulmonary embolism occurred in 7 patients (0.24%); with ileus the incidence was 3.2%: odds ratio 19.6 (P =.0082). A significant increase was observed in rates of VTD with ileus. We recommend using parenteral chemical and mechanical prophylaxis in patients with ileus following total hip and total knee arthroplasties.

Arthroplasty, Replacement, Hip↗
PubMed1995

[Anticoagulant therapy in pulmonary embolism].

Venous thrombosis and pulmonary embolism are the two faces of thromboembolic disease. In over 90% of cases, the initial treatment of the pulmonary embolism is anticoagulant therapy, the necessity and efficacy of which were demonstrated over 30 years ago with a reduction of mortality of 25 to 6%. Intravenous heparin relayed rapidly (1st to 3rd day) is still the conventional treatment protocol. Heparin therapy adapted to the result of the activated cephalin time (two to three times the control value) and oral vitamin K antagonists with a dosage adapted to keep the International Normalized Ratio between 2 and 3 is the safest and most effective treatment to date. The efficacy is shown by the low rate of recurrency, about 5% under anticoagulant therapy, lethal recurrence being very rare (less than 1%), and safety is attested by the low rate of severe bleeding complications (3 to 5%). The introduction of low molecular weight heparin and the excellent results observed in the treatment of deep vein thrombosis will probably lead to rapid extension of its indications to mild or moderate but haemodynamically well-tolerated pulmonary embolism. Hirudine and heparinoids will probably be the next step in the treatment of pulmonary embolism.

Anticoagulants↗
PubMed1988

Use of the Greenfield filter in adolescents for deep vein thrombosis and pulmonary embolism.

Serious venous thromboembolic disease is now recognized more frequently in the pediatric age group. Caval interruption is indicated most commonly for prophylaxis against life-threatening or recurrent pulmonary embolism (PE) when anticoagulation is ineffective or contraindicated. Greenfield vena caval filters have been utilized locally in 415 adult patients with 97% long-term patency and 5% recurrent embolization. Its application in adolescents is reported herein. Standard adult (30-mm) vena caval filters were placed in ten patients, ages 13 to 18. Four filters were required following PE, six were used for deep venous thrombosis (DVT) when anticoagulation was contraindicated, and one was inserted prophylactically. In eight patients, filter insertion was accomplished with local anesthesia, while two underwent filter placement under general anesthesia administered for other procedures. One filter was misplaced into the right renal vein, requiring a second filter insertion. All patients have been followed from 1 to 11 years with yearly vascular duplex imaging and radionuclide venograms documenting caval patency without clinical embolic sequelae. This duplicates the adult experience in safety and efficacy. As recognition of venous thromboembolism becomes more frequent in the pediatric age group, safe caval interruption may be necessary for those excluded from or not responsive to anticoagulation. This technique may be extended to smaller patients with miniaturization of both filter and carrier.

Adolescent↗
PubMed2002

[Evaluation of the relationship between deep venous thrombosis and pulmonary embolism with radionuclide techniques].

OBJECTIVE: The purpose of this study was to evaluate the relation between deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE) by radionuclide imaging. METHODS: One hundred forty patients with PTE from September 1997 to March 2001 at this institution was confirmed by clinical manifestation, pulmonary perfusion (PPI)/ventilation scan (PPV) and deep venous radionuclide venography (RNV), which were performed in all patients. There were 79 males and 61 females, with an average age of 39 +/- 18 years. Twenty-six cases underwent pulmonary angiography; 11 underwent X Ray venography of lower extremities (XRV); 18 underwent impedence plethymography (IPG); and 36 underwent lower limb echocardiography (UCG). RESULTS: Of the 140 patients with PTE, 120 (85.7%) had lower limb venous pathological changes. Among them, 94 patients had risk factors for DVT. The agreement rates of RNV with XRV, UCG and IPG were 90.9%, 72.2% and 80.0%, respectively. CONCLUSIONS: The results indicated that DVT was highly prevalent in patients with acute pulmonary embolism. Thrombosis was a primary pathogenic factor for PTE, and thrombi were mostly from proximal veins. (99m)TC-MAA radionuclide imaging was a useful method for noninvasive detection of DVT and PTE.

Adult↗
PubMed1997

Diagnosis of deep venous thrombosis and pulmonary embolism.

Accurate diagnosis of deep venous thrombosis (DVT) and pulmonary embolism (PE) is required because treatment can be life-saving, while inappropriate anticoagulation exposes the mother and fetus to haemorrhage and other hazards. Clinicians must be aware of which patients are at risk because DVT is frequently asymptomatic. Clinical diagnosis is unreliable for DVT and PE so objective tests are required. Venography is the gold standard test for DVT but is invasive and has been superseded by less invasive tests such as duplex ultrasound which is now the first-line investigation in pregnancy. However, where doubt remains, venography, CT and MRI have a role. Ventilation-perfusion scanning is the pivotal test for PE in pregnancy, and need not expose the fetus to excess radiation. If the result is unclear deep venous ultrasound can guide management of suspected PE, thus avoiding pulmonary angiography, the invasive gold standard test.

Female↗