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PubMed1999

Diagnosis of deep venous thrombosis and pulmonary embolism in pregnancy.

Accurate diagnosis of deep venous thrombosis and pulmonary embolism is required because treatment can be lifesaving, although inappropriate anticoagulation exposes the mother and fetus to hemorrhage and other hazards. Clinicians must be aware of which patients are at risk, as deep venous thrombosis is frequently asymptomatic. Clinical diagnosis is unreliable for deep venous thrombosis and pulmonary thromboembolism; therefore, objective tests are required. Venography is the gold standard test for deep venous thrombosis but is invasive. It has been superseded by less invasive tests such as compression ultrasound. This test, although not yet rigorously scrutinized in pregnancy, is now the first-line investigation. Where doubt remains, venography, CT, and magnetic resonance imaging have a role. Ventilation-perfusion scanning is the pivotal test for pulmonary thromboembolism for pregnancy, and it need not expose the fetus to excess radiation. If the results of this test are unclear, deep venous ultrasound can guide management of suspected pulmonary thromboembolism, thus avoiding pulmonary angiography.

Diagnosis, Differential↗

PubMed1992

George W. Holmes Lecture. Deep venous thrombosis and pulmonary embolism: correlative evaluation and therapeutic implications.

Deep venous thrombosis and pulmonary embolism are significant causes of morbidity and mortality in the United States; estimates range from 120,000 to 150,000 deaths annually. Although usually symptomatic, deep venous thrombosis can be clinically occult, in part due to incomplete obstruction or in part related to duplication, triplication, and fenestration anomalies, primarily of the superficial femoral or popliteal vein. Additionally, pulmonary emboli caused by deep venous thrombosis may be clinically silent. Because of therapeutic implications, especially indications for insertion of inferior vena caval filters, comprehensive assessments of both the disease process (i.e., deep venous thrombosis) and the complication (i.e., pulmonary emboli) are important. Thus, when a pulmonary embolus is the presenting process, correlative assessment of deep venous thrombosis, even in the absence of symptoms or signs in the lower extremity, may be of therapeutic significance. Conversely, when deep venous thrombosis of the lower extremities involving the popliteal or superficial femoral vein is the presenting process, correlative assessment of the pulmonary circulation, even when no pulmonary symptoms or signs are present, may be of therapeutic significance. Relative to the diagnosis of pulmonary embolism, the roles of assays of D-dimer, ventilation-perfusion lung scans, and segmental occlusion studies of the pulmonary circulation are discussed. Finally, the indications for insertion of inferior vena caval filters above the renal veins are presented and examples are shown.

Adult↗

PubMed2003

Diagnosis of venous thromboembolism: factors determining individual patient probabilities of deep vein thrombosis or pulmonary embolism.

The diagnosis of venous thromboembolism, which comprises deep vein thrombosis and pulmonary embolism, remains challenging. Combining pretest probability of disease with the results of noninvasive testing, such as ventilation-perfusion lung scan and duplex ultrasound, can avoid costly and invasive testing with pulmonary angiography and contrast venography in most patients. Techniques to estimate the pretest probability of deep vein thrombosis and pulmonary embolism are described.

Humans↗

PubMed1979

Heparin and warfarin: use of anticoagulants in the prevention and treatment of venous thrombosis and pulmonary embolism.

The physician frequently encounters the problems of deep vein thrombosis and pulmonary embolism. Recently, a number of studies have been published which are of considerable help in the management of these disorders. It has been shown that in many cases, low-dose heparin is effective in the prevention of both venous thrombosis and pulmonary embolism. However, once venous thrombosis has already occurred, it is necessary to use full-dose heparin, preferably by the continuous intravenous route, with maintenance of the partial thromboplastin time (PTT) at 1 1/2 times the control at all times. Although monitoring the PTT may not prevent hemorrhage, it will help prevent further thrombosis. Heparin is generally continued for seven to ten days. During this time warfarin is generally begun, and it is important to continue the patient on warfarin for five to seven days while the patient is receiving intravenous heparin therapy. After stopping heparin, oral anticoagulation with warfarin should be continued for six weeks. Then, in the absence of a previous history of venous thromboembolism or a known predisposing condition, it is safe to abruptly discontinue anticoagulation in most patients.

Adult↗

PubMed1995

Deep venous thrombosis and pulmonary embolism after lung transplantation.

The incidence of deep venous thrombosis or pulmonary embolism after lung or heart-lung transplantation has not been well defined. Pulmonary embolism may be of particular concern in the postoperative period owing to an inadequately developed or absent collateral bronchial circulation and potential risk of pulmonary infarction. Fourteen (12.1%) of 116 patients undergoing either lung (n = 87) or heart-lung (n = 29) transplantation developed thromboembolic complications 10 days to 36 months after operation. Deep vein thrombosis developed in nine patients, including three with upper body thrombosis related to indwelling central venous catheters. Seven patients (6%) had pulmonary embolism, and three of them died. Resolution of pulmonary embolism was successfully accomplished by selective pulmonary artery infusion of urokinase in three patients without complications. Our experience indicates that deep vein thrombosis and pulmonary embolism are significant problems after lung transplantation. Mortality is high in those patients in whom pulmonary embolism develops. Therefore, a comprehensive prevention protocol is warranted.

Adult↗

PubMed1970