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[A case of jejunal vein thrombosis due to medroxyprogesterone acetate].

The patient was a 68-year-old woman with advanced breast cancer which had been treated by modified radical mastectomy two years and nine months earlier. After the surgery, tamoxifen citrate (TAM) was orally administered in addition to various types of chemotherapy. Because the patient complained of nausea and weight loss, medroxyprogesterone acetate (MPA) was orally administered instead of TAM. The patient complained of intense abdominal pain on the 35th day of administration. Laparotomy was then performed for her acute abdominal problem. Because necrosis from bleeding due to jejunal vein thrombosis was observed in the jejunum for about 15 cm, resection of the jejunum was carried out. Histological observation demonstrated thrombosis in the vein, and cellular infiltration around the thrombosis. The postoperative prognosis has been favorable and the postoperative course is now being monitored at our clinic (2 months after surgery). The patient has no complications such as diabetes mellitus or hypercholesterolemia. The thrombosis observed in the jejunal vein, which is a rare site for it on the 35th day of MPA administration was induced by MPA. Due attention must be paid to the formation of thrombosis when using MPA.

Administration, Oral↗

[Acute hepatic artery thrombosis in pediatric liver transplantation: surgical thrombectomy and in situ fibrinolysis].

In pediatric liver transplantation, hepatic artery thrombosis usually leads to graft loss, early due to hepatic necrosis when it occurs during the first week following the transplant procedure, or later due to biliary complications. Liver retransplantation is the usual attitude. However, urgent surgical hepatic arterial thrombectomy to restore the blood flow can be successful when early diagnosis is made with Doppler ultrasound examination and angiography. Four hepatic arterial thrombectomies were performed as an emergency with additional intra-hepatic arterial fibrinolytic treatment, in three children, 1.5, 3 and 5.5 years of age. Mean duration between the first signs of hepatic artery thrombosis and thrombectomy was 16 hours. None of the children had an urgent liver retransplantation. A complete success was obtained in one case, with normal liver function tests and patent hepatic artery on the Doppler ultrasound examination at the present time. In the two other cases, hepatic artery thrombosis recurred, in spite of repeated thrombectomy in one case; following this attempt complications of hepatic artery thrombosis occurred in the two patients: ischemic necrosis of the left lobe (1 case), biliary leak (1 case) and stenosis of the common bile duct (2 cases). A complete success in one case and a partial success in the two others lead us to advocate urgent thrombectomy and in situ fibrinolytic treatment when early diagnosis of hepatic artery thrombosis is made.

Acute Disease↗

[Activated protein C resistance, Leiden mutation, anticoagulant proteins and fibrinogen levels in patients with deep venous thrombosis].

Resistance to activated protein C (APC-R) is the leading cause of deep vein thrombosis (DVT). Deficiencies of protein C (PC) or its cofactor protein S (PS) are less frequent. Resistance usually results from nucleotide substitution (1691 GA) in the factor V gene (Leiden mutation). We searched for APC-R and the Leiden mutation (FVL) and measured the activities of PC, PS, antithrombin III (AT III) and Fb levels in patients with DVT. The results were analyzed against a history of thrombosis (idiopathic, risk factor related). We enrolled 29 patients aged 50 years or younger, with first symptoms of thrombosis detected before the age of 40 years. The control group consisted of 25 healthy volunteers of similar age. APC-R was established using Accelerimat (bioMerieux) assays. APC-R was diagnosed when the normalized sensitivity coefficient "r" was < 0.9. FVL was detected with the SSP-PCR (sequence specific primers-polymerase chain reaction) method. Abnormal APC-R "r" values were found in seven DVT patients (24%). Heterozygous (G/A genotype) form of the Leiden mutation was confirmed in six of them (all had a history of recurrent thrombosis). FVL carriers demonstrated lower PC levels in comparison with controls and DVT without FVL. Eight patients (27%) had PS activities below the cut-off point (60%). The deficiency in six of them was not associated with other abnormalities. Patients with recurrent thrombosis had markedly higher concentrations of Fb (usually without FVL) and reduced AT III activities. The study has shown that the APC-R test is useful for FVL screening. The Leiden mutation, elevated levels of Fb and reduced activities of PC are the main factors predisposing to DVT and its recurrence. Reduced activity of PS is usually an isolated abnormality tending to predispose to a single DVT episode.

Activated Protein C Resistance↗

Portal vein thrombosis in cirrhotics: related with anticardiolipin antibodies?

BACKGROUND/AIMS: To evaluate the relationship of antiphospholipid antibodies and portal vein thrombosis in cirrhotics. METHODOLOGY: 22 cirrhotics without portal vein thrombosis (Group I), 18 with portal vein thrombosis (Group II) and 20 healthy controls (Group III) were enrolled. Anticardiolipin IgG and IgM antibody concentrations were measured by ELISA and lupus anticoagulant by clotting. Groups were compared according to sex, age, etiology of cirrhosis, prior intraabdominal surgery, Child groups, anticardiolipin IgG, IgM and lupus anticoagulant. Then for all the 40 cirrhotics (Group IV) correlation was tested between anticardiolipin IgM, IgG, lupus anticoagulant and Child groups, etiology of cirrhosis, sex and prior surgery. RESULTS: In Group I, anticardiolipin IgG concentration was 15.3 (15.9) GPL)/mL and IgM was 8.6 (6.5) MPL/mL. In 6 (27.27%) anticardiolipin IgG, in 6 (27.27%) IgM and in 2 (9.09%) both were high. Lupus anticoagulant was positive in 7 (31.81%). In Group II anticardiolipin IgG concentration was 26.3 (14.7) GPL/mL and IgM was 15.1 (7.2) MPL/mL. In 10 (55.55%) anticardiolipin IgG, in 13 (72.22%) IgM and in 9 (50%) both were high. Lupus anticoagulant was positive in 5 (27.77%). In Group III lupus anticoagulant was positive in 1 (0.5%). Anticardiolipin IgG was 10.3 (5.9) GPL/mL, IgM 5 (3.6) MPL/mL anticardiolipin IgM level was high in 1 (0.5%). Group I and II were similar with respect to lupus anticoagulant, Child groups, prior intraabdominal surgery and etiology of cirrhosis. For anticardiolipin IgG and IgM there was a significant difference between Group I and II, I and III and II and III. In Group IV there was no correlation between prior abdominal surgery, Child groups, sex, etiology and anticardiolipin IgG, IgM or lupus anticoagulant. CONCLUSIONS: Anticardiolipin antibody concentrations were significantly higher in cirrhotics with portal vein thrombosis. Thus anticardiolipin antibodies may play a role in the development of portal vein thrombosis in cirrhosis.

Antibodies, Anticardiolipin↗

Subacute stent thrombosis following coronary angioplasty: incidence and risk factors.

BACKGROUND: Subacute stent thrombosis was a significant complication in the early years of coronary stenting, often leading to myocardial infarction, need for urgent surgery or even death. The introduction of intracoronary ultrasound enabled the identification and proper treatment of the main causes of stent thrombosis, reducing the rate of this complication to 1%. AIM: To identify risk factors of subacute stent thrombosis. METHODS: Data concerning 845 procedures with a single stent implantation in patients with stable or unstable angina, undergoing this procedure between 1998 and 2000, were analysed. RESULTS: Subacute stent thrombosis occurred in 13 (1.54%) patients. Risk factors for this complication included urgent procedures (so-called bailout stenting), improper pre-treatment with drugs ("ad hoc" procedures), dissection uncovered by stent, and poor final result of procedure (higher degree of residual stenosis). The majority of these patients developed myocardial infarction in spite of the fact that the patency of stented vessel was quickly achieved in all but one patient. CONCLUSIONS: Urgent stenting, improper drug pre-treatment and suboptimal result of the procedure are the risk factors of subacute stent thrombosis.

Aged↗

[Hyperhomocysteinemia-related cerebral venous thrombosis].

INTRODUCTION: Moderate hyperhomocysteinemia is a causal risk factor for atherosclerosis and venous thromboembolism. Recent researches have tried to find out a causal relationship. However, only a small number of cases have been reported on hyperhomocysteinemia and cerebral venous thrombosis in the world medical literature. CASE REPORT: We present the case of a 21 years old woman, and oral contraceptives taker, who consulted for a one week clinical picture of biparietal headache, nausea and vomiting. Examination revealed bilateral papilledema, and subsequent CT scan, MRI and MR angiography showed thrombosis of the left lateral sinus. Immunologic tests (antinuclear antibodies, antiphospholipid antibodies) were negative. Hypercoagulability studies showed persistent homocysteine high levels. The patient improved and was discharged after treatment with anticoagulants and therapeutic measures against brain edema. DISCUSSION: The 70 percent of the patients with thrombosis of the cerebral venous sinuses present hypercoagulable states, including moderate hyperhomocysteinemia. Several mechanisms are proposed for venous thrombosis in hyperhomocysteinemia, homocysteine induced endothelial dysfunction between others. Otherwise, oral contraceptives can increase the risk of venous thrombosis in other prothrombotic conditions. Folic acid and vitamins supplementation therapy are commented.

Adult↗

[Extent and quality of anti-coagulation treatment with coumarin derivatives by the Dutch Thrombosis Services].

OBJECTIVE: To obtain an impression of the extent and quality of the anti-coagulation treatment with coumarin derivatives carried out by the Thrombosis Services in the Netherlands. DESIGN: Descriptive. METHOD: Data were drawn from the medical annual reports of 62 of the 63 Thrombosis Services in the Netherlands over the period 1998-2002. In 2002 the Thrombosis Services treated 325,072 patients and performed 4,469,730 INR laboratory tests. The half-yearly figures produced by the Thrombosis Services were calculated as an average percentage per year per thrombosis service and then recalculated as a percentage per year. RESULTS: Seventy-three per cent of the patients were treated for an arterial and 27% for a venous indication. Depending on the required intensity of anticoagulation a mean of 74-78% of the long-term treated patients fell within the therapeutic range and a mean of 6-10% below. The mean number of major bleedings per 100 treatment years was 1.0. A mean of 79% of the patients was treated with acenocoumarol and 21% with phenprocoumon. When acenocoumarol was used, a mean of 72-77% fell within the therapeutic range and in the case of phenprocoumon 79-82%. In the last few years the number of patients had increased due to a growing number of patients treated for atrial fibrillation. The percentages of INR within the therapeutic range were unchanged or showed a slight increase. CONCLUSION: The quality of the anticoagulation therapy with coumarin derivatives was good or acceptable.

Acenocoumarol↗

A case of right loin pain: septic ovarian vein thrombosis due to Campylobacter fetus bacteraemia.

INTRODUCTION: Septic ovarian venous thrombosis is an uncommon condition. Diagnosis is often not immediately apparent clinically and there are many that mimic this condition. We described an unusual case of septic ovarian vein thrombosis associated with Campylobacter fetus (C. fetus) bacteraemia. CLINICAL PICTURE: A 46-year-old female presented with fever and acute right loin pain. Right ovarian venous thrombosis was demonstrated on sonography and confirmed with computed tomography and magnetic resonance imaging. C. fetus was isolated from the blood. TREATMENT AND OUTCOME: The patient was given antibiotics and anticoagulation therapy with good response. CONCLUSION: Septic ovarian vein thrombosis should be considered as a differential diagnosis in female patients presenting with fever associated with lower abdominal pain. C. fetus bacteraemia also predisposes to thrombophlebitis, including septic ovarian vein thrombosis. When they are diagnosed in a timely manner and treated appropriately, the response is good and potential serious complications, including thromboembolism, and death could be averted. Radiological imaging is useful in the diagnostic work-up of this condition.

Bacteremia↗

Contrast-enhanced US in the assessment of the ilio-caval axis in deep venous thrombosis.

PURPOSE: To assess the feasibility and the accuracy of a new technique in the evaluation of deep venous thrombosis (DVT) in the ilio-caval axis. MATERIALS AND METHODS: Thirty-eight patients with suspected DVT were prospectively examined with unenhanced and enhanced colour-Doppler ultrasonography, and ascending contrast venography. Thirty-five out of 38 patients underwent US phlebography, consisting in manual injection of Levovist (Schering Ag, Berlin, Germany) through a 21-G cannula in a suitable dorsal vein of the foot ipsilateral to the suspected DVT. Three patients in whom it was not possible to cannulate a dorsal vein of foot underwent contrast-enhanced US after injection of Levovist through an antecubital vein, but where excluded from the present study. A contrast venogram was nonetheless carried out in all out three patients for comparison with the US-phlebography findings. RESULTS: US-phlebography allowed better definition of the presence and extension of deep vein thrombosis in all patients, when compared to conventional color-Doppler US. In the evaluation of suspected acute thrombosis, the comparative efficacy of Doppler-US and US phlebography compared with ascending phlebography as the gold standard, was as follows: sensitivity of 85.7% and 90%, specificity of 71.4 and 100%, accuracy of 80.9 and 95.2%, PPV of 85.7, and 100%, and NPV of 71.4, and 75%, respectively. In the assessment of chronic thrombosis, US and US phlebography achieved a sensitivity of 90% and 100%, a specificity of 75% and 100%, an accuracy of 85.7% and 100%, a PPV of 100, 100%, a NPV of 87.5, 100%, respectively. No complications related to US phlebography were observed. CONCLUSIONS: US-phlebography is a promising tool in the assessment of deep vein thrombosis, being highly accurate and feasible. However, further studies based on larger series are mandatory to confirm our promising results and establish a standardised role for this new technique.

Acute Disease↗

[Bilateral internal jugular vein thrombosis following treatment of laryngeal carcinoma--a case report].

The authors present the case of bilateral internal jugular vein thrombosis, which was diagnosed in a patient after combined therapy (surgery and radiotherapy) because of laryngeal carcinoma. Thrombosis is the frequent complication and the second largest death cause from neoplasms. In review of the literature the cases of bilateral internal jugular vein thrombosis are uncommon. Jugular vein thrombosis has previously been reported in association with deep head and neck infections, sepsis, central vein catherization and the neck injuries. Because of that the presented case of internal jugular vein thrombosis seems to be interesting.

Carcinoma, Squamous Cell↗

Elevated levels of D-dimer and fragment 1+2 upon central venous catheter insertion and factor V Leiden predict subclavian vein thrombosis.

Symptomatic subclavian vein thrombosis is a potential complication in approximately 5-10% patients with indwelling central venous catheters. Having reliable tests that would identify those patients with a high risk of catheter-related thrombosis would be clinically useful by helping to tailor thromboprophylaxis. In this case control study by Jansen et al. (see page 499), patients with a Hickman catheter who were undergoing allogeneic bone marrow transplantation for hematological malignancies were investigated. Baseline levels of D-dimer and fragment 1+2 were found to be significantly higher in patients who developed catheter-related thrombosis and the presence of factor V Leiden genotype was found only in patients with thrombosis. Although these abnormalities were associated with a 5- to 7-fold increased risk of catheter-related thrombosis, the positive predictive values for elevated D-dimer and fragment 1+2 levels were only 80% while the negative predictive values were about 40%. These results support the concept that laboratory evidence of activation of coagulation correlates with clinical thrombotic events, but they are insufficient for recommending routine testing of these markers in patients with central venous catheters. Further studies are required to confirm these findings and to see if similar results are observed in patients with other malignancies.

Antifibrinolytic Agents↗

[Cerebral venous thrombosis and hereditary protein C deficiency].

Protein C together with its plasmatic cofactor protein S and antithrombin III probably represent the most important plasmatic inhibitor in coagulation. Protein C deficiency constitutes a high risk factor for venous thrombosis. Cerebral venous thrombosis is a manifestation which is scarcely referred to in protein C deficiency. The case of a 32 year old patient with protein C deficiency is presented. The patient was admitted for an endocraneal hypertension syndrome. CT and MR demonstrated multiple hemorrhagic cerebral infarctions. Arteriography confirmed vertebral venous thrombosis. Only six cases sufficiently documenting cerebral venous thrombosis due to protein C deficiency were found in the literature. In most cases coadjuvant factors exist predisposing thromboembolic disease. The present clinical case demonstrates the importance of considering protein C deficiency in the diagnosis of cerebral venous thrombosis in young adults.

Adult↗

[Thrombosis of the cerebral veins. X-ray computed tomography and MRI imaging. 11 cases].

11 cases of cerebral venous thrombosis in adults are reported. Main clinical signs are: intracranial hypertension (headache, nausea, papilledema in 7 cases, loss of consciousness in 6 cases, neurological deficit in 6 cases, seizure in 4 cases. 1 patient is dead, who did not receive heparin treatment. Delay before diagnosis is between 2 and 20 days, and is shortened when arteriography or MRI are available and prescribed. At least one (or several) CT examination was performed in 10 patients. Direct signs of thrombosis are uneasily detected without contrast injection, seen here in 4 cases. Empty delta sign is observed in 7 patients, lately in 4 cases, and once only afterwards. Cerebral infarction is visualized in 7 cases over 10. Its features frequently seem evocative for cerebral venous thrombosis: triangularin 4 cases or nodular shape in 3 cases with hemorragic infarct in 7 cases, with bilateral topography in 6 cases, in frontal or central areas in 7 cases. 6 patients had a MRI examination. All cerebral infarctions appeared haemorragical, even at early stages. During subacute period, venous thrombosis is constantly and easily detected by the mean of methemoglobin high signal intensity on T1 weighted images. The prediagnosis delay is short, without necessity of arteriography. MRI should take the place of CT and arteriography in investigation of a clinically suspected cerebral venous thrombosis.

Adult↗

[A case of portal vein thrombosis associated with acute pancreatitis and cholangitis].

Portal vein thrombosis is a rare complication accompanied with acute pancreatitis or cholangitis/cholecystitis. The main pathogenesis of portal vein thrombosis in pancreatitis or cholangitis/cholecystitis are suggested to be venous compression by pseudocyst and an imbalance between the blood coagulation and fibrinolysis. In this case report, we experienced a 63 year old male who developed portal vein thrombosis later in the course of the treatment of acute gallstone pancreatitis with cholangitis/cholecystitis without any symptom or sign. The diagnosis of portal vein thrombosis was given on follow up CT scan and serum protein S activity was decreased to 27% in laboratory study. Immediate anticoagulation therapy with heparin and thrombolytic therapy with urokinase and balloon dilatation were performed. Despite the aggressive treatment, complete reperfusion could not be obtained. With oral warfarin anticoagulation, the patient showed no disease progression and was discharged. We report a case of portal vein thrombosis as a complication of acute pancreatitis and cholangitis/cholecystitis with a review of literatures.

Acute Disease↗

Recurrent venous thrombosis with factor V Leiden mutation.

A patient who presented with recurrent venous thrombosis is reported. Following an episode of spontaneous deep vein thrombosis of the lower limb he was started on oral anticoagulant therapy, which he discontinued. He presented with cerebral venous thrombosis and improved partially with anticoagulant therapy. Evaluation for hypercoagulable states revealed factor V Leiden mutation by polymerized chain reaction method. Long-term anticoagulation has been planned. Evaluation for factor V Leiden mutation is always warranted in patients presenting with spontaneous thrombosis, especially if there is recurrent thrombosis.

Adult↗

Type I congenital plasminogen deficiency is not a risk factor for thrombosis.

The risk of thrombosis in type I congenital plasminogen (PLG) deficiency has been suggested, but is still not confirmed. We studied 40 members of two unrelated families with this disease, and found that 21 were heterozygotes of type I congenital PLG deficiency. Three of them had thrombosis, but the other 18 had no thrombosis. The percentages of family members with no history of thrombosis up to a given age among subjects with type I congenital PLG deficiency and healthy controls were analyzed by the Kaplan-Meier method. No significant difference between the two groups was observed by the generalized Wilcoxon test (p = 0.23). These results suggest that there is no significant correlation between type I congenital PLG deficiency and thrombosis.

Adult↗

Upper body venous thrombosis associated with ovarian stimulation: case report and review of the literature.

Thromboembolic events are a serious complication of assisted conception treatment. Thrombosis may be either arterial or venous but the latter is far more common. This phenomenon is more frequent in the lower limb, but several cases of upper extremity thrombosis have been described in the literature. Although the aetiology of these thromboembolic disorders is not fully understood, the mechanism is thought to be due to a hypercoagulable state associated with haemostasis and thrombophilia. Predisposing factors seem to be hyperoestrogenism, ovarian hyperstimulation syndrome, a hereditary hypercoagulable state and multifoetal pregnancy. We report a case of superior sagittal sinus thrombosis that developed in a patient following successful assisted conception in the absence of evident risk factors. In the current literature, the site of thrombosis, possible predisposing factors, oestrogen levels, number of foetuses, maternal and foetal outcomes, and management of thrombosis were analysed.

Adult↗

Superior sagittal sinus thrombosis and Budd-Chiari syndrome due to paroxysmal nocturnal hemoglobinuria managed with transjugular intrahepatic portosystemic shunt: a case report.

BACKGROUND: Paroxysmal nocturnal hemoglobinuria (PNH), caused by somatic mutation of hematopoietic cells, is associated with complement-mediated hemolysis and a hypercoagulable state. Thrombotic complications in this disease are associated with reduced survival. We report a patient with PNH complicated by intracranial venous thrombosis and Budd-Chiari syndrome, who was managed with transjugular intrahepatic portosystemic shunt. CASE PRESENTATION: A 26-year-old man presented with thrombosis of the superior sagittal and right sigmoid sinuses. Initial investigations did not reveal any underlying cause. Nine months later, he developed hepatic venous thrombosis. At this time, Ham test was positive. Flow cytometry confirmed the diagnosis of PNH. The patient was treated with transjugular intrahepatic portosystemic shunt; one episode of stent blockage one month later was managed successfully with balloon dilatation and restenting. CONCLUSION: PNH should be considered in patients with unexplained venous thrombosis. Thrombosis in these patients needs to be managed with prolonged anticoagulation. For Budd-Chiari syndrome in patients with underlying PNH, transjugular intrahepatic portosystemic shunt may be a good option but caution is needed to prevent stent occlusion.

Adult↗