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PubMedDate not supplied

[Treatment of distal venous thrombosis of the lower extremity with "moderated" doses of heparin].

The effectiveness of a therapeutic protocol, using 15,000 to 22,500 IU/day of heparin by subcutaneous injection, to treat the distal postoperative vein thrombosis on the lower limb, was evaluated. The study was made on 427 patients, which were analyzed by the Fibrinogen I125 marked accumulation test, to give an early diagnostic and follow-up of their thrombosis (thrombus lysis, stabilization or expansion). Treatment made, showed its efficacy preventing from proximal expansion, as well as avoiding pulmonary embolism and postphlebitic syndrome. Its cost is lower than other therapeutic option's costs, and it doesn't extend the hospital stay.

Adult↗

PubMed1995

Deep vein thrombosis: recovery or recurrence?

As many as two thirds of patients with new symptoms after documented DVT have postphlebitic syndrome, not DVT. Noninvasive imaging is central to the differentiation so that unnecessary anticoagulation therapy can be avoided. Recent changes in heparin and warfarin protocols for DVT are also outlined.

Bandages↗

PubMedDate not supplied

[Is photoreflexometry valid as a diagnostic method in the physician's office].

The results of measurements of photoreflexometry (PRM) in 1852 patients in phlebological consultations were broken down statistically. These were patients who had come to consultation of their own free will or who had been sent by their G.P. for an ambulatory phlebological examination. The authors assess the interpretative possibilities of PRM in treatment. They were particularly interested in the question of knowing whether or not PRM is capable of exposing a postphlebitic syndrome. In 9, 1% of these cases, a control phlebography was necessary. In a quarter of these patients, the previous diagnosis of "post-phlebitic syndrome" did not match the result of the phlebography. In each of these cases the deep veins were permeable and it was simply a matter of the incompetence of the deep axes.

Adult↗

PubMed1997

[The value of phlebography, USG-doppler and intraoperative tests in diagnosis of perforating venous insufficiency in the calf].

Accuracy of phlebography, color duplex sonography and intraoperative findings have been compared in a group of 29 patients operated for postphlebitic syndrome. The highest number of perforating veins was identified during the operation, fewer on phlebography and the fewest on color duplex sonography. However in the upper part of the calf both the latter were found to be inaccurate.

Adult↗

PubMed1998

Weber-Christian panniculitis: a review of 30 cases with this diagnosis.

BACKGROUND: More than 60 years ago, Christian described a panniculitis that was later termed Weber-Christian disease. OBJECTIVE: The purpose of this study was to investigate whether this is a specific disease or a nonspecific disease that embraces several specific conditions. METHODS: We studied 30 cases diagnosed as Weber-Christian panniculitis and found it possible to make a more specific diagnosis. RESULTS: In 12 patients, findings were compatible with erythema nodosum. Six patients had phlebitis or postphlebitic syndrome. Factitial panniculitis was diagnosed in five patients, and trauma had a role in the conditions of another three patients. Cytophagic panniculitis, lymphoma, and leukemia were recognized in one patient each. The lesion was lobular in almost all cases, and the presence of lipophagia was noted in 19 biopsy specimens. Granulomatous, neutrophilic, and lymphocytic pathologic changes were present in nine, eight, and eight tissue specimens, respectively. CONCLUSION: The recognition of distinct disease patterns of fat lesions as fat necrosis with pancreatic disease, alpha1-antitrypsin panniculitis, lupus and connective tissue disease panniculitis, involution lipoatrophy, lipomembranous panniculitis, factitial panniculitis syndromes, calcification panniculitis, lipophagic lipoatrophy, and cytophagic panniculitis has lessened the need for a less specific panniculitis category. All these diseases have been reported in the literature as "Weber-Christian disease." Because separate and distinct forms of fat lesions have been described, we believe that the eponym should be abandoned and that more specific diagnoses should be made on the basis of pathogenesis or cause.

Adult↗

PubMed1993

Venous thromboembolic disease: the role of US.

Deep vein thrombosis (DVT) is a ubiquitous process that in the acute setting can lead to pulmonary embolism. Chronically, permanent changes that develop within the venous system following an episode of DVT can produce the postphlebitic syndrome, which is associated with pain, swelling, and ulceration. The postphlebitis syndrome can often mimic acute DVT or coexist with it. The clinical evaluation of DVT is ineffective and necessitates a reliable noninvasive diagnostic technique. Compression ultrasound (US) has proved to be the diagnostic method of choice for detection of extremity clot. Femoral and popliteal veins are routinely evaluated for acute clot, but uncertainty exists concerning the need to evaluate the calf veins similarly. US also can be used to diagnose chronic venous changes, which are indicated by the presence of incompetent valves and retrograde blood flow. Upper-extremity venous thrombosis, often induced by indwelling catheters, can also be diagnosed with US.

Arm↗

PubMed2006

Emerging anticoagulants for the treatment of venous thromboembolism.

Anticoagulant therapy is the cornerstone of treatment of venous thromboembolism (VTE). Such treatment is divided into two stages. Rapid initial anticoagulation is given to minimize the risk of thrombus extension and fatal pulmonary embolism, whereas extended anticoagulation is aimed at preventing recurrent VTE, thereby reducing the risk of postphlebitic syndrome. With currently available drugs, immediate anticoagulation can only be achieved with parenteral agents, such as heparin, low-molecular-weight heparin, or fondaparinux. Extended treatment usually involves the administration of vitamin K antagonists, such as warfarin. Emerging anticoagulants have the potential to streamline VTE treatment. These agents include idraparinux, a long-acting synthetic pentasaccharide that is given subcutaneously on a once-weekly basis, and new oral anticoagulants that target thrombin or factor Xa. This paper i) reviews the pharmacology of these agents, ii) outlines their potential strengths and weaknesses, iii) describes the results of clinical trials with these new drugs, and iv) identifies the evolving role of new anticoagulants in the management of VTE.

Anticoagulants↗

PubMed1998

The natural history of calf vein thrombosis: lysis of thrombi and development of reflux.

PURPOSE: Although the fact is well accepted that deep venous thrombosis (DVT) of the iliac, femoral, and popliteal veins can lead to the post-thrombotic (postphlebitic) syndrome, the significance of isolated calf DVT on the development of late venous sequelae and physiologic calf dysfunction is unknown. The purpose of this study was to review the outcome of 58 limbs with isolated calf DVT and report the clinical, physiologic, and imaging results up to 6 years after the onset of DVT. METHODS: The study consisted of 58 limbs of 54 patients in whom isolated calf vein DVT was diagnosed between 1990 and 1995. Proximal propagation of clot, lysis of thrombi, and development of symptomatic pulmonary emboli were examined. Of the patients, 28 received anticoagulation therapy, and 26 did not, but they had follow-up with serial duplex scans. At late follow-up 1 to 6 years later (median, 3 years), 23 patients were examined for the post-thrombotic syndrome, and all 23 underwent clinical examination, color-flow duplex scanning, and air plethysmography. RESULTS: Proximal propagation of DVT from the calf veins into the popliteal or thigh veins occurred in 2 of 49 cases (4%) within 2 weeks of diagnosis. No patient had clinically overt pulmonary emboli develop regardless of whether anticoagulation therapy was received or not. The most common site for calf DVT was the peroneal vein (71%). Complete lysis of calf thrombi was found in 88% of the cases by 3 months. At 3 years, 95% of the patients were either asymptomatic or mildly symptomatic, and 5% had discoloration of the limb. No ulcers occurred. By air plethysmography, physiologic abnormalities were found in 27% of the cases, which was not significantly different from normal controls. Valvular reflux by duplex scanning of the calf vein segment with DVT was found in 2 of 23 cases (9%). However, reflux in at least one venous segment not involved with DVT was found in 7 of 23 cases (30%), which was higher than, but not statistically different from, normal controls, with reflux occurring in 5 of 26 cases (19%). CONCLUSIONS: Isolated calf vein DVT leads to few early complications (ie, clot propagation, pulmonary emboli) and few adverse sequelae at 3 years. The peroneal vein is most commonly involved and should be a part of the routine screening for DVT. Lysis of clot usually occurs by 3 months. Although valvular reflux rarely is found in the affected calf vein at 3 years, reflux may be found in adjacent uninvolved veins in approximately 30% of the cases. The question of whether this will lead to future sequelae, such as ulceration, will require longer follow-up.

Adult↗

PubMed1985

[Doppler ultrasound and strain gauge plethymography in the diagnosis of the post-phlebitic syndrome].

Certain non-invasive techniques like Doppler CW and strain gauge plethysmography are highly effective ways of evaluating the natural history of postphlebitic syndrome. 40 patients of both sexes, average age 51.5 +/- 6.9 with a history of deep venous thrombosis (28 documented phlebographically) were subjected to Doppler tests with assessment of venous blood pressure and bilateral strain gauge plethysmography. 34 of the 40 suspected PPS cases were confirmed, though not all cases were at the same stage. Persistent deep venous thrombosis was found in five of the extremities and the last one examined revealed a primary varicose syndrome. A comparison of the Doppler and phlebography results showed both to be highly sensitive techniques (100% accuracy). When the contralateral limbs were examined, the Doppler technique revealed 7 cases of PPS and 21 primary varices. In contrast strain gauge plethysmography identified all 28 cases of increased venous capacitance as primary varices, thus confirming the inability of this technique to distinguish between the various varicose conditions. Assuming the presence of a vascular diagnosis laboratory where both techniques are available, strain gauge plethysmography is recommended as the examination of choice. This technique is simple and fast to perform and can provide extensive information whether at rest (filling and emptying volumes and times; venous tone and distensibility, venous blood pressure at rest) or in movement (venous pressure when standing, muscular pumping index). Hence plethysmography can reveal any canalisation present even in the earliest stages though it cannot pinpoint the precise site of the deep obstruction. The longer, more complex Doppler CW procedure should be reserved for secondary investigations. This technique is preferable to plethysmography when a more accurate assessment of the degree, site and extension of the venous recanalisation is needed. Doppler CW also provides information on any valvar sequelae since it records the direction of the blood flow in the presence of a substitution syndrome (increased venous flow in the surface vessels). Finally if used in a rational manner the two techniques can be combined to eliminate contrast medium techniques, which would only be adopted as a preoperative measure.

Adult↗

PubMed1991

Improved management of the Paget-Schroetter syndrome secondary to thoracic outlet compression.

For years, patients with "effort" thrombosis were treated by anticoagulants and conservative exercise; and if recurrent symptoms developed when they returned to work, they were considered for first-rib resection. Recently, use of thrombolytic agents with early surgical decompression of the neurovascular compression has markedly reduced morbidity, such as postphlebitic syndrome and the necessity for thrombectomy. A review of 67 patients seen over 25 years showed that 34 were initially treated with heparin sodium and then Coumadin (crystalline warfarin sodium). Recurrent symptoms developed in 21 after they returned to work and necessitated transaxillary first-rib resection to relieve symptoms. Eight also underwent thrombectomy. Recently, 33 patients were initially treated with thrombolytic agents and heparin, followed promptly by early first-rib resection. The evaluation and efficacy of this therapy have been established by frequent and repetitive venograms and careful follow-up of patients. Most of the patients showed improvement with thrombolytic agents. Remaining stenoses that suggested intravascular thrombosis were usually secondary to external compression of the vein by the clavicle, costoclavicular ligament, rib, or scalenus anterior muscle. Venous thrombectomy was necessary in only 4 patients in whom the clot was not controlled by thrombolytic therapy and operative release of compression. There were no deaths in the series.

Adolescent↗

PubMedDate not supplied

Effects of intermittent pneumatic calf compression in normal and postphlebitic legs.

The changes in common femoral vein flow produced by three different intermittent pneumatic compression devices were recorded with a Doppler velocity detector in 20 normal legs and 20 with postphlebitic syndrome. Mean and peak velocity increases were measured and expressed as a percent of resting baseline values. There was no significant difference in the peak velocity increase produced by the three devices in normals and abnormals; however, there were differences in the mean velocity increases. The devices worked as well on postphlebitic legs as on normal ones. Correct cuff application was more critical than indicated by the manufacturers, suggesting that some of the failures of intermittent pneumatic compression may have resulted from improper cuff placement. The results show that different designs of intermittent pneumatic compression equipment accelerate venous flow in the leg.

Adult↗

PubMedDate not supplied

Skin blood flux and the venoarteriolar response in the perimalleolar area in patients with venous hypertension.

In patients with venous hypertension due to postphlebitic syndrome or varicose veins skin changes, liposclerosis and ulcerations are associated with increased skin blood flux at rest, a decreased venoarteriolar response and increased capillary filtration. Using laser-Doppler flowmetry we studied skin flux and the venoarteriolar response in the perimalleolar region in 100 normal limbs, 100 limb with varicose veins and 100 postphlebitic limbs with edema, skin changes and liposclerosis. The venoarteriolar response was studied with the leg on dependency, the foot being 50 cm below heart level. Flux at rest and on dependency were increased and the venoarteriolar response decreased in both groups of patients at a significantly greater extent in postphlebitic limbs. In conclusion laser-Doppler flowmetry measurements differentiate between normal limbs and those with venous hypertension and between postphlebitic limbs and limbs with venous hypertension due to varicose veins. The increase in skin flux and decrease in venoarteriolar response may be useful to define and quantify the degree of microangiopathy and the effects of treatments in venous hypertension.

Adult↗

PubMed1995

Chronic venous insufficiency.

The consequences of chronic deep venous insufficiency are a major medical concern and result in significant loss of human productivity in addition to a significant compromise of lifestyles. The postphlebitic syndrome of chronic venous stasis and ulceration is a result of chronic venous hypertension and reflects a sequela of events occurring secondary to venous valvular insufficiency and reflux. Diagnostic techniques have advanced considerably; however, the prevention and management of this entity continue to be inadequate. Many new areas are being explored, both from a medical and a surgical perspective, and it is hoped that as clinical investigation proceeds, new conceptual approaches and techniques will arise to combat this difficult medical problem. The literature reviewed in this article reflects a spectrum of research attempting to understand the basic underlying hemodynamic as well as cellular and tissue changes that contribute to the development of postphlebitic signs and symptoms. More investigation is needed to enable us to proceed from the descriptive understanding of this entity to the mechanisms that result in this disease state. Preventive and curative management needs to succeed the current palliative approach to therapy.

Chronic Disease↗

PubMed1998

Late vascular occlusion of central lines in pediatric malignancies.

OBJECTIVE: To determine whether thrombi or vascular occlusion represent a late complication persisting several years after removal of central venous lines (CVLs) in children and adolescents treated for childhood cancer. METHODS: Children whose treatment for malignancy included placement of a CVL that had been removed at least 2 months previously were studied during scheduled follow-up that included contrast-enhanced computed tomography. Spiral volume acquisition was used to obtain 3-mm images from the chest apices through the right hilum, and three-dimensional reconstruction of angiograms was performed. Thrombosis/occlusion was defined as narrowing, obstruction, or filling defect of the deep venous system, with or without the formation of collateral veins. Charts were reviewed to document patient characteristics, previous CVL complications, administration of hyperalimentation, use of urokinase, and family history of venous thrombosis. RESULTS: Twenty-three patients treated for solid tumors and 2 treated for B-cell acute lymphocytic leukemia or lymphoma were studied. Lines had been in place from 0.2 to 36 months (median, 7.4) and were removed at 2.3 to 121.8 months (median, 32.5) before study. Nine patients received hyperalimentation for periods ranging from 2 to 38 weeks (median, 12). Four patients had required urokinase instillations, and one developed superior vena cava syndrome; 4 had a CVL-related infection (two superficial and two Candida line infections). Occlusion was seen on computed tomography angiograms in 3 of the 25 patients (12%; 95% confidence interval: 4.5-31%). One of the patients with occlusion had superior vena cava syndrome; none had a family history of thrombosis, use of a double lumen CVL, or multiple instillations of urokinase. CONCLUSIONS: Persistent asymptomatic vascular occlusion does occur as a late complication of CVL placement for treatment of childhood malignancies, although the frequency appears low among patients treated primarily for solid tumors. Prospective studies of large numbers of patients with a broader spectrum of diagnoses are necessary to define the incidence of and risk factors for this complication and to assess the need for prevention with anticoagulation or other therapy. Pediatricians caring for patients with a history of cancer and CVLs should be aware that these patients may have persistent vascular occlusion that could predispose them to recurrent thrombosis or postphlebitic syndrome.

Adolescent↗

PubMed2006

Incidence, risk factors, and outcomes of catheter-related thrombosis in adult patients with cancer.

PURPOSE: Thrombosis of long-term central venous catheters (CVC) is a serious complication that causes morbidity and interrupts the infusion of chemotherapy, intravenous medication, and blood products. We performed a prospective study to examine the incidence, risk factors, and long-term complications of symptomatic catheter-related thrombosis (CRT) in adults with cancer. PATIENTS AND METHODS: Consecutive patients with cancer, undergoing insertion of a CVC, were enrolled and prospectively followed while their catheter remained in place plus 4 subsequent weeks or a maximum of 52 weeks, whichever came first. Patients with symptomatic CRT were followed for an additional 52 weeks from the date of CRT diagnosis. The end points were symptomatic CRT, symptomatic pulmonary embolism (PE), postphlebitic syndrome, and catheter life span. RESULTS: Over 76,713 patient-days of follow-up, 19 of 444 patients (4.3%) had symptomatic CRT in 19 of 500 catheters (0.3 per 1,000 catheter-days). The median time to CRT was 30 days and the median catheter life span was 88 days. Significant baseline risk factors for CRT were: more than one insertion attempt (odds ratio [OR] = 5.5; 95% CI, 1.2 to 24.6; P = .03); ovarian cancer (OR = 4.8; 95% CI, 1.5 to 15.1; P = .01); and previous CVC insertion (OR = 3.8; 95% CI, 1.4 to 10.4; P = .01). Nine of the 19 CRT patients were treated with anticoagulants alone, eight patients were treated with anticoagulants and catheter removal, while two patients did not receive anticoagulation. None had recurrent CRT or symptomatic PE. Postphlebitic symptoms were infrequent. CONCLUSION: In adults with cancer, the incidence of symptomatic CRT is low and long-term complications are uncommon.

Adolescent↗

PubMed2000

Low-molecular-weight heparin prophylaxis using dalteparin extended out-of-hospital vs in-hospital warfarin/out-of-hospital placebo in hip arthroplasty patients: a double-blind, randomized comparison. North American Fragmin Trial Investigators.

BACKGROUND: No randomized trials have directly evaluated the need for extended out-of-hospital thromboprophylaxis for patients who have hip arthroplasty in the United States or Canada. The uncertainty as to the need for extended prophylaxis in North American patients is complicated by early hospital discharge, resulting in a short thromboprophylaxis interval. METHODS: To resolve this uncertainty, we performed a randomized double-blind trial in 569 patients who underwent hip arthroplasty comparing the use of dalteparin sodium started immediately before surgery or early after surgery and extended out-of-hospital to an overall interval of 35 days with the use of warfarin sodium in-hospital and placebo out-of-hospital. RESULTS: For patients with interpretable venograms in the preoperative, postoperative, and combined dalteparin groups, new proximal vein thrombosis out-of-hospital was observed in 1.3%, 0. 7% (P =.04), and 1.0% (P =.02) of patients, respectively, compared with 4.8% in the in-hospital warfarin/out-of-hospital placebo group. The respective overall cumulative frequencies of all deep vein thrombosis were 30 (17.2%) of 174 patients (P<.001), 38 (22.2%) of 171 (P =.003), and 68 (19.7%) of 345 (P<.001) in the dalteparin groups compared with 69 (36.7%) of 188 for the in-hospital warfarin/out-of-hospital placebo group. For proximal deep vein thrombosis, the respective frequencies were 5 (3.1%) of 162 (P =.02), 3 (2.0%) of 151 (P =.007), and 8 (2.6%) of 313 (P =.002) compared with 14 (9.2%) of 153. No major bleeding occurred during the extended prophylaxis interval. CONCLUSIONS: Extended dalteparin prophylaxis resulted in significantly lower frequencies of deep vein thrombosis compared with in-hospital warfarin therapy. Despite in-hospital thromboprophylaxis, patients having hip arthroplasty in the United States and Canada remain at moderate risk out-of-hospital. The number needed to treat provides a public health focus; only 24 to 28 patients require extended prophylaxis to prevent 1 new out-of-hospital proximal vein thrombosis. Recent studies demonstrate that asymptomatic deep vein thrombi cause the postphlebitic syndrome; thus, extended out-of-hospital prophylaxis will lessen the burden to both the patient and society.

Anticoagulants↗

PubMed1975

Surgical repair of the incompetent femoral vein valve.

Incompetent femoral vein valves are identified by reflux femoral phlebography in selected patients with postphlebitic syndrome. In addition to conventional stripping of varices and subfascial interruption of communicating veins, 14 patients with 17 involved extremities have undergone surgical repair of an incompetent valve in the superficial femoral veins. Pathologic condition of the valve consisted of elongation of the cusp edge. Repair was achieved by a series of tucking sutures shortening the cusp and restoring competence to the valve. Healing of ulcers and relief of swelling occurred in 90% of the patients. This rate was maintained up to seven years. These cases demonstrate the feasibility of surgery on the femoral vein valve. The relative importance of conventional stripping, subfascial communicating vein interruption, and femoral valve repair will have to be established by way of further clinical experience.

Femoral Vein↗

PubMed1982

Status of vein valve transplant after 12 months.

Sequelae of the postphlebitic syndrome can now be treated by direct valve surgery. However, present surgical treatment of stasis ulcer, including removal of the incompetent communicating veins, ulcer excision, and skin grafting, remains essential to patient care. When done alone, perforator interruption and ulcer care are effective but allow a high rate of ulcer recurrence. Experimental studies to restore venous valve function have included autogenous vein valve transplantation, and synthetic valve procedures also have been tried. Clearly, the patency rate of an autogenous vein graft is better than any other procedure. Operations were done in 11 patients using an autogenous vein valve from the upper extremity to restore a normal-functioning venous valve in the lower extremity. Data on preoperative and postoperative measurements and ascending and descending venography indicate hemodynamic improvement of venous function in these extremities.

Adult↗