Deep vein thrombosis in bilateral lower extremities after hip fracture: a retrospective study of 463 patients.
Zhang Bin-Fei,Wei Xing,Huang Hai,Wang Peng-Fei,Liu Ping,Qu Shuang-Wei,Li Jia-Hao,Wang Hu,Cong Yu-Xuan,Zhuang Yan,Zhang Kun
Clinical interventions in aging
OBJECTIVE:To investigate the incidences of deep vein thrombosis (DVT) before and after operation in inpatients with hip fractures in both lower extremities. PATIENTS AND METHODS:We collected the clinical data of 463 patients with lower extremities fractures who presented at Xi'an Honghui Hospital between July 1, 2014, and October 31, 2016 and met all the inclusion criteria. Doppler ultrasonography was used to diagnose DVT. The patients were examined preoperatively and postoperatively and divided into the thrombosis and non-thrombosis group according to the ultrasonographic findings. We divided the DVT cases into central, peripheral, and mixed thromboses. RESULTS:The incidence of preoperative DVT was 34.98%, and the prevalence of DVT on the uninjured side was 13.60%. This composition ratio increased to 57.23% postoperatively, and the prevalence of DVT on the uninjured side was 25.05%. Age (odds ratio [OR], 1.03; 95% CI: 1.01-1.04; =0.002), venous thrombosis at admission (OR, 4.05; 95% CI, 2.30-7.13; =0.000), and the days between the fracture and the operation (OR, 1.10; 95% CI, 1.02-1.20; =0.020) were the independent risk factors of preoperative DVT. Coronary heart disease (OR, 1.85; 95% CI: 1.18-2.89; =0.007), venous thrombosis at admission (OR, 22.35; 95% CI: 6.78-73.60; =0.000), days between fracture and operation (OR, 1.06; 95% CI: 1.01-1.11; =0.021), and blood loss (OR, 1.002; 95% CI: 1.000-1.003; =0.014) were independent risk factors of postoperative DVT. CONCLUSION:The actual incidence of DVT after hip fracture may be underestimated. The incidences of preoperative and postoperative DVTs and the incidence of DVT on the uninjured limb were high.
Chronic CT features in PE patients with co-existing DVT.
Ekici Mehmet,Ekici Aydanur,İleri Şule
The American journal of emergency medicine
OBJECTIVE:Clinical features may be different in patients with PE without co-existing DVT compared to those with PE with co-existing DVT. This prospective study aims to investigate the different clinical features between patients with isolated pulmonary embolism (PE) and those with PE associated with deep venous thrombosis. METHOD:This is a prospective study conducted in 107 consecutive patients diagnosed with acute PE in the emergency department or other departments of Kırıkkale University Hospital. The diagnosis of PE was confirmed by computed tomography pulmonary angiography (CTPA), which was ordered on the basis of symptoms and findings. Bilateral lower extremity compression ultrasound with standard 7.5 MHz linear array probe was applied to all patients. According to compression ultrasound results, the patients were divided into two classes as with and without deep venous thrombosis. Embolism in the main or lobar pulmonary arteries were classified as central, and those found only in segmental or subsegmental arteries were classified as peripheral. Laboratory parameters and Oxygen saturation were assessed on admission. RESULTS:67 of 107 (62.6%) patients with PE were isolated pulmonary embolism, and 40 (37.4%) were PE + DVT. Patients with PE with co-existing DVT have wider pulmonary artery, higher d-dimer and pro BNP level, and lower saturation than those with isolated pulmonary embolism. Central pulmonary embolism is more common in patients with deep vein thrombus than those without it. (87.5% (35/40) vs 32.8% (22/67),p = 0.001). 38.6% of central pulmonary embolism occur without deep vein thrombosis of the lower extremities. Patients with PE with co-existing DVT have 42.5% mosaic perfusion pattern,70% chronic infarct appearance such as linear band, pleural nodüle, %15.0 thickened, small arteries and, %12.5 shrunken complete artery occlusion, suggesting the chronic background. CONCLUSION:PE patients with co-existing DVT are clinically more serious than those who do not have a DVT. An acute picture may be present in the chronic background in a significant proportion of patients with PE with co-existing DVT. In the presence of deep vein thrombosis, pulmonary embolism is usually central, but more than one-third of central pulmonary emboli occur without lower extremity deep vein thrombosis.
Characteristics and risk factors of deep vein thrombosis in hemiplegic, healthy and bilateral limbs of hemiplegic patients: a 10-year retrospective study.
Liang Feng,Chao Min,Li Jue-Bao,Ye Xiang-Ming
Journal of thrombosis and thrombolysis
Deep vein thrombosis (DVT) in hemiplegic patients mainly affects hemiplegic limbs, DVT can also occur only in healthy limbs, and some hemiplegic patients have DVT in both limbs. Characteristics and risk factors of DVT in hemiplegic, healthy, and bilateral limbs are unknown. To describe the proportion, risk factors, extent, and timing of DVT in hemiplegic, healthy and bilateral limbs. A 10-year retrospective review of consecutive patients was performed. DVT affected hemiplegic limbs in 34 (62%), healthy limbs in 11 (20%), and was bilateral in 10 (18%). DVT was more likely to develop in healthy limbs of hemiplegic patients without surgery (odds ratio (OR) 0.022; 95% confidence interval (CI) 0.001-0.922), and without diabetes (OR 0.023, 95% CI 0.001-0.853). Among the veins at the level of which DVT occurred, intermuscular veins represented 20 (45%) in hemiplegic, 5 (37%) in healthy, and 6 (74%) in bilateral limbs. The median time that DVT occurred after hemiplegia onset was 18 days (interquartile range [IQR] 9-79) in hemiplegic, 17 days (IQR 10-56) in healthy, and 21 days (IQR 8-27) in bilateral limbs. Early and effective prevention of DVT after surgery and optimal management of diabetes may reduce the risk of DVT in bilateral limbs. It's important to prevent proximal extension of calf vein DVT. DVT prophylaxis should be started early and continued for at least 3 weeks after hemiplegia onset.
Pulmonary embolism in Europe - Burden of illness in relationship to healthcare resource utilization and return to work.
Willich Stefan N,Chuang Ling-Hsiang,van Hout Ben,Gumbs Pearl,Jimenez David,Kroep Sonja,Bauersachs Rupert,Monreal Manuel,Agnelli Giancarlo,Cohen Alexander
OBJECTIVES:Pulmonary embolism (PE) is associated with a substantial economic burden. However evidence from patients in Europe is scarce. The aim of this study was to report the impacts of PE on healthcare resource utilization (HCRU) and return to work using the PREFER in VTE registry. METHODS:The PREFER in VTE registry was a prospective, observational, multicenter study in seven European countries, aiming to provide data concerning treatment patterns, HCRU, mortality, quality of life and work-loss. Patients with a first-time or recurrent PE were included and followed up at 1, 3, 6 and 12 months. Treatment patterns, re-hospitalization rates, length of hospital stays (LOS), and ambulatory/office visits, as well as proportion of patients returning to work, were assessed. Subgroups by country and with/without active cancer were examined separately. Zero-inflated negative binomial and Cox regression were applied to investigate the relationship between baseline characteristics and LOS and return to work, respectively. RESULTS:Amongst 1399 patients with PE, 53.2% were male and the average age was 62.3 ± 17.1 years old. Overall, patients were treated with combinations of heparin, vitamin K antagonists (VKA) and the non-VKA oral anticoagulants (NOACs) (50.0% treated with the combination of heparin with VKA). Patients with active cancer were primarily treated with heparin (84.9%). NOACs were used more frequently in DACH (Germany, Austria and Switzerland) and France (55.2% and 32.6%) compared to Italy and Spain (4.5% and 6.1%). The VTE-related re-hospitalization rate within 12 months and the average LOS varied substantially between countries, from 26.2% in UK to 12.3% in France, and from 12.9 days in Italy to 3.9 days in France. PE patients were often co-managed by general practitioners in France and DACH (>84%), and less frequently in other countries (<47%). The regression results confirmed the country variation of HCRU. Of the employed patients (n = 385), 60% returned to work at 1 month but 27.8% had not after one year. PE patients with DVT were more likely to return to work. Active cancer was a significant predictor for not returning to work, as well as smoking history. CONCLUSIONS:Medical treatment of PE differed between patients with active cancer and patients without active cancer. VTE-related resource utilization differed markedly between countries. While the reported 'not return to work' was high for patients with PE, this may at least in part reflect the presence of co-morbidities such as cancer.
Pulmonary Embolism and Coexisting Deep Vein Thrombosis: A Detrimental Association?
Cordeanu Elena-Mihaela,Lambach Hélène,Heitz Marie,Di Cesare Julie,Mirea Corina,Faller Alix-Marie,Cavaro Anne-Cécile,Frantz Anne-Sophie,Gaertner Sebastien,Schini-Kerth Valérie,Stephan Dominique
Journal of clinical medicine
BACKGROUND:The prognostic significance of coexisting deep vein thrombosis (DVT) in acute pulmonary embolism (PE) is controversial. This study aimed to provide routine patient care data on the impact of this association on PE severity and 3-month outcomes in a population presenting with symptomatic venous thromboembolism (VTE) from the REMOTEV registry. METHODS AND RESULTS:REMOTEV is a prospective, non-interventional study of patients with acute symptomatic VTE, treated with direct oral anticoagulants (DOACs) or standard anticoagulation (vitamin K antagonists (VKA) or parenteral heparin/fondaparinux alone) for at least 3 months. From 1 November 2013 to 28 February 2018, among 1241 consecutive patients included, 1192 had a follow-up of at least 3 months and, among them, 1037 had PE with (727) or without DVT (310). The median age was 69 (55-80, 25th-75th percentiles). Patients with PE-associated DVT had more severe forms of PE ( < 0.0001) and, when DVT was present, proximal location was significantly correlated to PE severity ( < 0.01). However, no difference in all-cause mortality rate (hazard ratio (HR) 1.36 (CI 95% 0.69-2.92)), nor in the composite criterion of all-cause mortality and recurrence rate (HR 1.56 (CI 95% 0.83-3.10)) was noted at 3 months of follow-up. CONCLUSION:In REMOTEV, coexisting DVT was associated with a higher severity of PE, with no impact on short-term prognosis.
The incidence of pulmonary embolism during deep vein thrombosis.
Nielsen J D
Among life-threatening cardiovascular diseases, pulmonary embolism (PE) is the third most common after myocardial infarction and stroke. PE is a manifestation of venous thromboembolism (VTE). PE shares risk factors with deep vein thrombosis (DVT) and is regarded as a consequence of DVT rather than a separate clinical entity. Risk factors for VTE include major surgery, major trauma, high age, myocardial infarction, chronic heart failure, prolonged immobility, malignancy, thrombophilia and prior VTE. It is, however, important to recognize that these factors are not equally important and not equally common in patients with PE and DVT, respectively. Compared with DVT, PE is more often associated with major surgery, major trauma, high age, myocardial infarction and chronic heart failure, whereas malignancy and thrombophilia primarily are clinical predictors of DVT. In patients with prior VTE the initial clinical manifestation strongly predicts the manifestation of recurrent episodes, i.e. patients with previous PE are more likely to develop recurrent PE than DVT while patients with DVT predominantly are at risk of recurrent DVT.
Anatomic and clinical risk factors for pulmonary embolism in patients with deep venous thrombosis of the lower extremity.
Paik Bomina,Joh Jin Hyun,Park Ho-Chul
Annals of surgical treatment and research
PURPOSE:Iliac vein compression is a known culprit of deep vein thrombosis (DVT). In contrast, the compression may prevent the pulmonary embolism (PE). The aim of this study was to evaluate the anatomic and clinical risk factors of PE in patients with lower extremity DVT. METHODS:PE was evaluated using chest computed tomography in patients with lower extremity DVT. The patients were classified into group I (DVT without PE) and group II (DVT with PE) and analyzed to clarify the anatomic and clinical risk factors associated with PE in patients with DVT. As the anatomic factor, the shortest length between the common iliac artery (CIA) and spinal body (SB) was measured. Statistical analyses utilized the multivariable logistic regression model, and receiver operating characteristic (ROC) curve analysis. RESULTS:We examined 114 patients (age; 62.7 ± 16.9 years, 41.7% men) with DVT with/without PE. The prevalence of concurrent DVT with PE was 52.6%. Blood tests showed no difference between the 2 groups. Of all the assessed patients' characteristics, only infection was significantly and independently associated with PE (P = 0.04). The shortest length between CIA and SB was 6.7 ± 3.5 mm in group I and 11.3 ± 3.7 mm in group II (P < 0.001). ROC curve analysis showed that 7.6 mm was the cut-off value for the anatomic risk of PE. CONCLUSION:Infection was significantly associated with concurrent DVT and PE. The shortest length between CIA and SB (<7.6 mm) may prevent PE in patients with DVT.
Silent pulmonary embolism in patients with proximal deep vein thrombosis in the lower limbs.
Tzoran I,Saharov G,Brenner B,Delsart D,Román P,Visoná A,Jiménez D,Monreal M,
Journal of thrombosis and haemostasis : JTH
BACKGROUND:One in every three patients with deep vein thrombosis (DVT) in the lower limbs may have silent pulmonary embolism (PE), but its clinical relevance has not been thoroughly studied. METHODS:We used the RIETE Registry data to study patients with proximal DVT and no PE symptoms, but with a systematic search for PE. We compared the outcome of DVT patients with silent PE and those with no PE. RESULTS:Of 2375 patients with DVT, 842 (35%) had silent PE and 1533 had no PE. During the first 15 days of anticoagulation, patients presenting with silent PE had a higher incidence of symptomatic PE events than those with no PE (0.95% vs. 0.13%; P = 0.015), with a similar incidence of major bleeding (0.95% vs. 1.63%; P = 0.09). In patients with silent PE, the incidence of PE events during the first 15 days was equal to the incidence of major bleeding (eight events each), but in those with no PE the incidence of PE events was eight times lower (3 vs. 25 bleeding events). Multivariate analysis confirmed that DVT patients with silent PE had a higher incidence of symptomatic PE events during the first 15 days than those with no PE (odds ratio, 4.80; 95% CI, 1.27-18.1), with no differences in bleeding. CONCLUSIONS:DVT patients with silent PE at baseline had an increased incidence of symptomatic PE events during the first 15 days of anticoagulant therapy. This effect disappeared after 3 months of anticoagulation.
Symptomatic in-hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis: a systematic review.
Januel Jean-Marie,Chen Guanmin,Ruffieux Christiane,Quan Hude,Douketis James D,Crowther Mark A,Colin Cyrille,Ghali William A,Burnand Bernard,
CONTEXT:Symptomatic venous thromboembolism (VTE) after total or partial knee arthroplasty (TPKA) and after total or partial hip arthroplasty (TPHA) are proposed patient safety indicators, but its incidence prior to discharge is not defined. OBJECTIVE:To establish a literature-based estimate of symptomatic VTE event rates prior to hospital discharge in patients undergoing TPHA or TPKA. DATA SOURCES:Search of MEDLINE, EMBASE, and the Cochrane Library (1996 to 2011), supplemented by relevant articles. STUDY SELECTION:Reports of incidence of symptomatic postoperative pulmonary embolism or deep vein thrombosis (DVT) before hospital discharge in patients who received VTE prophylaxis with either a low-molecular-weight heparin or a subcutaneous factor Xa inhibitor or oral direct inhibitor of factors Xa or IIa. DATA EXTRACTION AND SYNTHESIS:Meta-analysis of randomized clinical trials and observational studies that reported rates of postoperative symptomatic VTE in patients who received recommended VTE prophylaxis after undergoing TPHA or TPKA. Data were independently extracted by 2 analysts, and pooled incidence rates of VTE, DVT, and pulmonary embolism were estimated using random-effects models. RESULTS:The analysis included 44,844 cases provided by 47 studies. The pooled rates of symptomatic postoperative VTE before hospital discharge were 1.09% (95% CI, 0.85%-1.33%) for patients undergoing TPKA and 0.53% (95% CI, 0.35%-0.70%) for those undergoing TPHA. The pooled rates of symptomatic DVT were 0.63% (95% CI, 0.47%-0.78%) for knee arthroplasty and 0.26% (95% CI, 0.14%-0.37%) for hip arthroplasty. The pooled rates for pulmonary embolism were 0.27% (95% CI, 0.16%-0.38%) for knee arthroplasty and 0.14% (95% CI, 0.07%-0.21%) for hip arthroplasty. There was significant heterogeneity for the pooled incidence rates of symptomatic postoperative VTE in TPKA studies but less heterogeneity for DVT and pulmonary embolism in TPKA studies and for VTE, DVT, and pulmonary embolism in TPHA studies. CONCLUSION:Using current VTE prophylaxis, approximately 1 in 100 patients undergoing TPKA and approximately 1 in 200 patients undergoing TPHA develops symptomatic VTE prior to hospital discharge.
Unprovoked proximal venous thrombosis is associated with an increased risk of asymptomatic pulmonary embolism.
Boc Anja,Vene Nina,Stalc Monika,Košmelj Katarina,Mavri Alenka
INTRODUCTION:Pulmonary embolism (PE) is common in patients with deep venous thrombosis (DVT). The outcome of DVT with concomitant symptomatic PE is worse than the outcome of isolated DVT. The risk factors for DVT and simultaneous asymptomatic PE have not been systematically studied yet. AIM:To evaluate the frequency and risk factors for asymptomatic PE in patients with DVT. PATIENTS/METHODS:In 155 consecutive patients with a first episode of DVT and no PE symptoms, a ventilation-perfusion lung scan was performed. Body mass index (BMI) and waist-to-hip ratio (WHR) were calculated and concentrations of D-dimer, high-sensitivity CRP (hsCRP), tissue plasminogen activator (t-PA) and troponin were measured. Laboratory tests for thrombophilia were performed. RESULTS:Asymptomatic PE was present in 36% of patients. No differences in gender, age, BMI and WHR were found between the patients with and without PE. PE was more common in patients with proximal DVT than in those with distal DVT (42% vs. 17%, p<0.01), and in patients with unprovoked DVT compared to patients with provoked DVT (51% vs. 28%, p<0.01). The risk of silent PE was the highest in patients with unprovoked proximal DVT (OR, 6.9; 95% CI, 2.3-21.0). Patients with asymptomatic PE had significantly higher values of D-dimer, hsCRP, t-PA and troponin than patients with isolated DVT. CONCLUSIONS:Asymptomatic PE affected more than one third of patients with a first DVT. Unprovoked proximal DVT is the most important risk factor for the occurrence of silent PE.
Analysis of National Trends in Admissions for Pulmonary Embolism.
Smith Sean B,Geske Jeffrey B,Kathuria Parul,Cuttica Michael,Schimmel Daniel R,Courtney D Mark,Waterer Grant W,Wunderink Richard G
BACKGROUND:Pulmonary embolism (PE) remains a significant cause of hospital admission and health-care costs. Estimates of PE incidence came from the 1990s, and data are limited to describe trends in hospital admissions for PE over the past decade. METHODS:We analyzed Nationwide Inpatient Sample data from 1993 to 2012 to identify patients admitted with PE. We included admissions with International Classification of Diseases, 9th revision, codes listing PE as the principal diagnosis as well as admissions with PE listed secondary to principal diagnoses of respiratory failure or DVT. Massive PE was defined by mechanical ventilation, vasopressors, or nonseptic shock. Outcomes included hospital lengths of stay, adjusted charges, and all-cause hospital mortality. Linear regression was used to analyze changes over time. RESULTS:Admissions for PE increased from 23 per 100,000 in 1993 to 65 per 100,000 in 2012 (P < .001). The percent of admissions meeting criteria for massive PE decreased (5.3% to 4.4%, P = .002), but the absolute number of admissions for massive PE increased (from 1.5 to 2.8 per 100,000, P < .001). Median length of stay decreased from 8 (interquartile range [IQR], 6-11) to 4 (IQR, 3-6) days (P < .001). Adjusted hospital charges increased from $16,475 (IQR, $10,748-$26,211) in 1993 to $25,728 (IQR, $15,505-$44,493) in 2012 (P < .001). All-cause hospital mortality decreased from 7.1% to 3.2% (P < .001), but population-adjusted deaths during admission for PE increased from 1.6 to 2.1 per 100,000 (P < .001). CONCLUSIONS:Total admissions and hospital charges for PE have increased over the past two decades. However, the population-adjusted admission rate has increased disproportionately to the incidence of patients with severe PE. We hypothesize that these findings reflect a concerning national movement toward more admissions of less severe PE.
Impact of Asymptomatic Pulmonary Embolism on the Long-Term Prognosis of Patients with Deep Venous Thrombosis.
Boc Anja,Vene Nina,Košmelj Katarina,Mavri Alenka
Seminars in thrombosis and hemostasis
Asymptomatic pulmonary embolism (PE) is present in at least one-third of patients with deep venous thrombosis (DVT). However, knowledge about its influence on the prognosis of patients is limited. The aim of this study was to assess the prognostic impact of asymptomatic PE in patients with DVT and to explore risk factors for recurrent venous thromboembolic events. A total of 200 consecutive patients with the first episode of objectively confirmed DVT without symptoms of PE were included. All patients underwent ventilation-perfusion scintigraphy within 48 hours of DVT confirmation. Patients with inconclusive scans further underwent computed tomography pulmonary angiography. At the time of inclusion and 4 weeks after discontinuation of anticoagulation, the levels of biomarkers of hemostasis and inflammation were assessed. Patients were followed up for a mean period of 4.2 ± 0.6 years. Recurrent episodes of venous thromboembolisms were recorded. Consistent with the literature, asymptomatic PE was present in 33.5% of the patients. During follow-up, 27 recurrent venous thromboembolisms were recorded, 20 presenting as DVT and 7 as symptomatic PE. Asymptomatic PE wasn't significantly associated with the rate of recurrence ( = 0.676). Recurrent events were associated with unprovoked versus provoked DVT (hazard ratio [HR]: 5.01; 95% confidence interval [CI]: 2.25-11.17; < 0.001) and with increased versus normal D-dimer values, measured 4 weeks after discontinuation of anticoagulation (HR: 6.47; 95% CI: 2.96-14.17; < 0.001).
Daily hospitalization costs in patients with deep vein thrombosis or pulmonary embolism treated with anticoagulant therapy.
Dasta Joseph F,Pilon Dominic,Mody Samir H,Lopatto Jessica,Laliberté François,Germain Guillaume,Bookhart Brahim K,Lefebvre Patrick,Nutescu Edith A
BACKGROUND:Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), affects about 900,000 persons in the United States each year. OBJECTIVES:To quantify the progression of daily hospitalization costs among DVT and PE patients. PATIENTS/METHODS:A retrospective claims analysis was conducted from 01/01/2009 to 03/01/2013 using the Premier Perspective Comparative Hospital Database. Patients≥ 18years of age with an admitting/primary diagnosis of DVT or PE and receiving anticoagulant therapy were identified. Treatment patterns, mean daily costs, and total hospitalization costs were reported for the DVT and PE populations. Comparisons of mean daily costs with those of the previous day were presented to identify statistical cost differences between hospitalization days. RESULTS:A total of 28,953 and 35,550 patients were identified with a diagnosis of DVT and PE, respectively. The daily costs were at their highest during the first three days for DVT patients at $2,321, $1,875, and $1,558, respectively. Similar results were found for PE patients with costs at their highest in the first three days, at $2,981, $2,034, and $1,564, respectively. Among the DVT and PE populations, mean daily costs were $1,594 and $1,735, respectively, and daily hospitalization costs became stable on the third day of the hospitalization (standardized differences<10%). CONCLUSIONS:Daily hospitalization costs of patients with an admitting/primary diagnosis of DVT or PE were high in the first days and became stable on the third day. It was further suggested that any change in the LOS could significantly affect hospitalization costs.
Association between Laterality and Location of Deep Vein Thrombosis of Lower Extremity and Pulmonary Embolism.
Vascular specialist international
PURPOSE:The aim of this study was to investigate the relationship between the anatomical location of thrombi in the lower extremities and the development of pulmonary embolism (PE). MATERIALS AND METHODS:We collected and analyzed the data of patients diagnosed with deep vein thrombosis (DVT) of the lower extremities between 2006 and 2015, and included those whose computed tomography (CT) data were available for PE identification. We evaluated the relationship between the laterality and the proximal/distal location of the thrombi in lower extremites and the location of PE. RESULTS:CT images were available for 388/452 patients with DVT. After excluding 32 cases with bilateral involvement, 356 cases were included for analysis in this study. The ratio of DVT in the left:right leg was 232:124. PEs developed in 121 (52.2%) patients with left-sided DVT and in 78 (62.9%) with right-sided DVT (P=0.052). PEs in the main pulmonary arteries developed in 36 (15.5%) patients with left leg DVT and in 30 (24.2%) with right leg DVT (P=0.045). The most frequent site of thrombosis associated with the development of PE was the left iliac vein (59/199, 29.6%). According to the anatomical segment of the leg affected by DVT, patients with DVT in the right femoral vein (50/71, 70.4%; P=0.016) had the highest rate of occurrence of PE. CONCLUSION:PE develops more frequently in patients with right-sided DVT than in those with left-sided DVT. Therefore, careful observation for the possible development of PE is recommended in cases with right-sided DVT of the lower extremity.
Inpatient resource use and cost burden of deep vein thrombosis and pulmonary embolism in the United States.
LaMori Joyce C,Shoheiber Omar,Mody Samir H,Bookhart Brahim K
PURPOSE:Venous thromboembolism (VTE), which comprises deep vein thrombosis (DVT) and pulmonary embolism (PE), is associated with significant morbidity and mortality. VTE frequently leads to hospitalization and represents a considerable economic burden to the US health care system. However, little information exists on the duration of hospitalization and associated charges among patients with an admitting or primary diagnosis of DVT or PE. This study assessed the charges associated with hospitalization length of stay in patients with DVT or PE discharged from US hospitals in 2011. METHODS:Using data from the Nationwide Inpatient Sample of the Healthcare Utilization Project database, this analysis examined hospital length of stay and associated charges in patients with DVT or PE discharged from US hospitals in 2011. Both initial and subsequent hospitalizations were analyzed. FINDINGS:DVT was responsible for fewer hospitalizations than PE. In 2011, among 330,044 patients with VTE discharged from US hospitals, 143,417 had DVT and 186,627 had PE. Mean length of stay for patients with DVT was 4.7 days (median, 3.9 days) compared with 5.1 days (median, 4.5 days) for patients with PE. For initial hospitalizations, the mean (SE) charge amounted to $30,051 ($246) for DVT compared with $37,006 ($214) for PE. Older patients with PE incurred greater hospital charges than younger ones, and for both DVT and PE patients, women incurred greater charges than men. Of 31,463 patients admitted to the hospital with PE, 4.0% had a subsequent admission, which was more costly than the initial admission. Many patients with both DVT and PE were discharged to specialist nursing facilities, indicating continuing posthospitalization charges. IMPLICATIONS:Hospital stays for DVT and PE represent a substantial cost burden to the US health care system. Health care systems have the potential to reduce the clinical and economic burden of VTE by ensuring that evidence-based, guideline-recommended anticoagulation therapy is adhered to by patients with an initial VTE. Appropriate anticoagulant therapy and continuity of care in these patients may reduce the incidence and frequency of hospital readmissions and VTE-related morbidity and mortality and have a potential effect on health care resources.
Survival and recurrent venous thromboembolism in patients with first proximal or isolated distal deep vein thrombosis and no pulmonary embolism.
Barco S,Corti M,Trinchero A,Picchi C,Ambaglio C,Konstantinides S V,Dentali F,Barone M
Journal of thrombosis and haemostasis : JTH
Essentials The long-term risk of recurrence and death after distal deep vein thrombosis (DVT) is uncertain. We included subjects with first proximal or isolated distal DVT (IDDVT) and no pulmonary embolism. The risk of symptomatic and asymptomatic recurrence is lower after IDDVT (vs. proximal). IDDVT may be associated with a lower long-term risk of death, especially after unprovoked DVT. SUMMARY:Background A few studies have focused on the risk of recurrence after first acute isolated distal deep vein thrombosis (IDDVT) compared with proximal DVT (PDVT), whereas the incremental risk of death has never been explored beyond the first 3 years after acute event. Methods Our single-center cohort study included patients with first symptomatic acute PDVT or IDDVT. Patients were excluded if they had concomitant pulmonary embolism (PE) or prior venous thromboembolism. The primary outcomes were symptomatic objectively diagnosed recurrent PDVT or PE and all-cause death. Results In total, 4759 records were screened and 831 subjects included: 202 had symptomatic IDDVT and 629 had PDVT. The median age was 66 years and 50.5% were women. A total of 125 patients had recurrent PDVT or PE during 3175 patient-years of follow-up: 109 events occurred after PDVT (17.3%) and 16 after IDDVT (7.9%). Annual recurrence rates were 4.5% (95% confidence interval [CI], 3.7-5.4%) and 2.0% (95% CI, 1.1-3.2%), respectively, for an adjusted hazard ratio (aHR) for IDDVT patients of 0.32 (95% CI, 0.19-0.55). Death occurred in 263 patients (31.6% [95% CI, 28.6-34.9%]) during 5469 patient-years of follow-up for an overall annual incidence rate of 4.8% (95% CI, 4.2-5.4%). The mortality rate was 33.5% (n = 211) in PDVT patients and 25.7% (n = 52) in IDDVT patients. The long-term hazard of death appeared lower for IDDVT patients (aHR, 0.75 [95% CI, 0.55-1.02]), especially after unprovoked events (aHR, 0.58 [95% CI, 0.26-1.31]). Conclusions Compared with PDVT, IDDVT patients were at a lower risk of recurrent VTE. The risk of death appeared lower after IDDVT during a median follow-up of 7.6 years.
Late consequences of venous thromboembolism: Measuring quality of life after deep vein thrombosis and pulmonary embolism.
Ghanima Waleed,Wik Hilde Skuterud,Tavoly Mazdak,Enden Tone,Jelsness-Jørgensen Lars-Petter
The identification of specific post-thrombotic complications as well as an increased appreciation of the importance of patient-reported outcome measures have triggered an interest in studying health-related quality of life (HRQoL) in patients with a history of venous thromboembolism (VTE). In order to enable a comprehensive assessment of HRQoL in clinical trials it is recommended that both generic and disease-specific questionnaires be used. SF-36 and EQ-5D are the most widely used generic questionnaires in VTE studies, whereas several disease-specific questionnaires have been developed to evaluate HRQoL following deep vein thrombosis (DVT) and in chronic venous disease (CVD). The most widely used of these is the VEINES-QOL/Sym, which was developed for CVD. VT-QOL and DVTQOL are both questionnaires developed to evaluate HRQoL after DVT, while PEmb-QoL is currently the only available disease-specific questionnaire developed specifically for pulmonary embolism (PE). Although studies show inconsistent results, patients who sustain DVT seem in general to report similar HRQoL compared to the general population. However, patients who develop PTS after DVT report poorer HRQoL using both generic and disease-specific questionnaires. HRQoL appears to be impaired in patients who sustain PE compared to the general population. In these patients, persistent dyspnea after PE has been shown to be a predictor of reduced HRQoL. Further work is needed to develop practical, patient-derived, valid, reliable and responsive disease-specific HRQoL instruments covering the specific aspects of these diseases.
Pulmonary embolism and deep vein thrombosis-comorbidities and temporary provoking factors in a register-based study of 1.48 million people.
Research and practice in thrombosis and haemostasis
Background:Knowledge on differences in patients who present with deep vein thrombosis (DVT) and those with pulmonary embolism (PE) is incomplete. Objective:To determine comorbidities and temporary provoking factors in patients with a first-time PE or DVT. Methods:This was a nationwide Swedish registry-based, retrospective, case-control study including 298 172 patients with first-time venous thromboembolism (VTE) and 1 185 079 controls matched for age, sex, and county of residence, free of VTE at the time of matching. Results:Patients with PE were older than those with DVT (mean age, 69 vs 66 years) and included slightly more women (PE, 53.4% vs DVT, 52.1%). After multivariable adjustment for comorbidities (within 7 years) and temporary provoking factors (within 3 months), heart failure (PE: adjusted odds ratio [aOR], 2.64 [99% confidence interval [CI], 2.55-2.73]; DVT: aOR, 1.66 [99% CI, 1.60-1.72]), ischemic heart disease (PE: aOR, 1.51 [99% CI, 1.47-1.56]; DVT: aOR, 1.01 [99% CI, 0.98-1.04]), and chronic obstructive pulmonary disease (PE: aOR, 2.51 [99% CI, 2.40-2.63]; DVT, 1.54 [99% CI, 1.47-1.62]) were among diseases that showed higher odds ratios in patients with PE than in those with DVT, compared with controls. Comorbidities registered within 6 months were associated with higher aORs than those within 7 years. The highest population attributable risks for PE were for cancer (13.0%) and heart failure (11.7%). Conclusion:Cardiopulmonary diseases, particularly with recent onset, imply a higher risk for PE, whereas orthopedic surgery and lower-extremity fractures carry a higher risk of DVT.
Risk of Pulmonary Embolism After Cerebral Venous Thrombosis.
Liberman Ava L,Merkler Alexander E,Gialdini Gino,Messé Steven R,Lerario Michael P,Murthy Santosh B,Kamel Hooman,Navi Babak B
BACKGROUND AND PURPOSE:Cerebral vein thrombosis (CVT) is a type of venous thromboembolism. Whether the risk of pulmonary embolism (PE) after CVT is similar to the risk after deep venous thrombosis (DVT) is unknown. METHODS:We performed a retrospective cohort study using administrative data from all emergency department visits and hospitalizations in California, New York, and Florida from 2005 to 2013. We identified patients with CVT or DVT and the outcome of PE using previously validated codes. Kaplan-Meier survival statistics and Cox proportional hazards models were used to compare the risk of PE after CVT versus PE after DVT. RESULTS:We identified 4754 patients with CVT and 241 276 with DVT. During a mean follow-up of 3.4 (±2.4) years, 138 patients with CVT and 23 063 with DVT developed PE. CVT patients were younger, more often female, and had fewer risk factors for thromboembolism than patients with DVT. During the index hospitalization, the rate of PE was 1.4% (95% confidence interval [CI], 1.1%-1.8%) in patients with CVT and 6.6% (95% CI, 6.5%-6.7%) in patients with DVT. By 5 years, the cumulative rate of PE after CVT was 3.4% (95% CI, 2.9%-4.0%) compared with 10.9% (95% CI, 10.8%-11.0%; <0.001) after DVT. CVT was associated with a lower adjusted hazard of PE than DVT (hazard ratio, 0.26; 95% CI, 0.22-0.31). CONCLUSION:The risk of PE after CVT was significantly lower than the risk after DVT. Among patients with CVT, the greatest risk for PE was during the index hospitalization.
Left iliac vein involvement is a protective factor against symptomatic pulmonary embolism in lower left extremity deep vein thrombosis.
Journal of vascular surgery. Venous and lymphatic disorders
OBJECTIVE:Left iliac vein compression is associated with left iliac vein thrombosis (IVT), potentially limiting the migration of the thrombus from this stenotic segment to the pulmonary arteries. We sought to investigate the differences in clinical characteristics and risk factors of symptomatic pulmonary embolism (SPE) in patients with deep vein thrombosis (DVT) in different limbs and anatomical locations. METHODS:A retrospective analysis was conducted of 1476 patients with acute unilateral lower extremity DVT. Differences of clinical characteristics and risk factors between left-sided and right-sided DVT, IVT, and non-IVT, cases with SPE and cases without SPE were compared. Risk factors for SPE were investigated using logistic regression analysis. RESULTS:SPE was more common in patients with right-sided DVT than patients with left-sided DVT (13.8% vs 7.0%; P < .001). SPE incidence in left IVT (5.4%) was lower than that in left non-IVT, right IVT, and right non-IVT (12.8%, 10.1%, 16.6%, respectively; P < .001). There was no difference in SPE incidence among patients with left non-IVT, right IVT and right non-IVT (P > .05). In patients with left-sided DVT, male sex was associated with an increased odds of SPE (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.10-2.85; P = .02). IVT, surgery, and immobilization were associated with a decreased odds of SPE (OR, 0.46 [95% CI, 0.28-0.76; P < .01]; OR, 0.55 [95% CI, 0.32-0.95; P = .03]; and OR, 0.53 [95% CI, 0.32-0.86; P = .01]). In patients with right-sided DVT, provoked DVT was associated with a decreased odds of SPE (OR, 0.50; 95% CI, 0.27-0.93; P = .03). CONCLUSIONS:Left IVT is associated with a lower SPE incidence than right-sided DVT. Left IVT and may be a relative protective factor against SPE.
Prevalence of Deep Vein Thrombosis in Hospitalized Patients With Suspected Pulmonary Embolism Ruled Out by Multislice CT Angiography.
Vazquez Fernando Javier,Posadas-Martinez Maria Lourdes,Boietti Bruno,Giunta Diego,Gandara Esteban
Clinical and applied thrombosis/hemostasis : official journal of the International Academy of Clinical and Applied Thrombosis/Hemostasis
Current evidence suggests that for outpatients with suspected pulmonary embolism (PE), multislice computed tomographic angiography (CTPA) is sufficient to rule out PE. However, the accuracy of CTPA alone has not been established for hospitalized patients. Our goal was to determine the prevalence of deep vein thrombosis (DVT) in hospitalized patients who had PE ruled out by CTPA. We conducted a prospective cohort study of patients who developed symptoms indicative of PE, after being admitted to the hospital for any reason other than PE and were evaluated with multislice CTPA. The main outcome was proximal DVT. Between November 2011 and December 2014, 191 hospitalized patients were screened. A total of 99 patients satisfied our inclusion criteria. The average length of hospitalization for this group was 14 days (range: 2-127 days). While hospitalized, 54 (28%) patients underwent a major surgical procedure and 80 (79%) were receiving thromboprophylaxis. Of the 99 patients included, 7 (7.07%; 95% confidence intervals [CIs]: 3.4-13.8) were diagnosed with a proximal DVT. The likelihood of developing a proximal DVT was higher for those with subtle and nonspontaneously reported symptoms of DVT, odds ratio [OR] was 50.93 (95% CI: 5.35-2572) and for those classified as PE likely OR was 37.54 (95% CI: 4.05-186.1). Given the prevalence of DVT in hospitalized patients with suspected PE ruled out by a negative multislice CTPA, our study suggests that compression ultrasonography would, in fact, be justified for patients with these characteristics.
Prevalence of deep vein thrombosis and pulmonary embolism in patients with superficial vein thrombosis: a systematic review and meta-analysis.
Di Minno M N D,Ambrosino P,Ambrosini F,Tremoli E,Di Minno G,Dentali F
Journal of thrombosis and haemostasis : JTH
UNLABELLED:Essentials The association of superficial vein thrombosis (SVT) with venous thromboembolism (VTE) is variable. We performed a meta-analysis to assess the prevalence of concomitant VTE in patients with SVT. Deep vein thrombosis was found in 18.1%, and pulmonary embolism in 6.9%, of SVT patients. Screening for VTE may be worthy in some SVT patients to plan adequate anticoagulant treatment. SUMMARY:Background Some studies have suggested that patients with superficial vein thrombosis (SVT) have a non-negligible risk of concomitant deep vein thrombosis (DVT) or pulmonary embolism (PE) at the time of SVT diagnosis. Unfortunately, the available data on this association are widely variable. Objectives To perform a systematic review and meta-analysis of the literature in order to evaluate the prevalence of concomitant DVT/PE in patients with SVT of the lower limbs. Methods Studies reporting on the presence of DVT/PE in SVT patients were systematically searched for in the PubMed, Web of Science, Scopus and EMBASE databases. The weighted mean prevalence (WMP) of DVT and PE was calculated by use of the random effect model. Results Twenty-one studies (4358 patients) evaluated the prevalence of DVT and 11 studies (2484 patients) evaluated the prevalence of PE in patients with SVT. The WMP of DVT at SVT diagnosis was 18.1% (95%CI: 13.9%, 23.3%) and the WMP of PE was 6.9% (95%CI: 3.9%, 11.8%). Heterogeneity among the studies was substantial. Selection of studies including outpatients only gave similar results (WMP of DVT, 18.2%, 95% CI 12.2-26.3%; and WMP of PE, 8.2%, 95% CI 3.3-18.9%). Younger age, female gender, recent trauma and pregnancy were inversely associated with the presence of DVT/PE in SVT patients. Conclusions The results of our large meta-analysis suggest that the prevalence of DVT and PE in patients presenting with SVT is not negligible. Screening for a major thromboembolic event may be worthwhile in some SVT patients, in order to allow adequate anticoagulant treatment to be planned. Other high-quality studies are warranted to confirm our findings.
Prevalence and Predictor of Pulmonary Embolism in a Cohort of Chinese Patients with Acute Proximal Deep Vein Thrombosis.
Li Hai-Lei,Chan Yiu Che,Li Ning,Cui Dongzhe,Cheng Stephen W
Annals of vascular surgery
BACKGROUND:The aim of this study is to investigate the incidence of pulmonary embolism (PE) in a cohort of Chinese patients with acute (<14 days) proximal (above-knee) deep vein thrombosis (DVT) in the lower limbs, and to evaluate whether the location of thrombosis is associated with the existence of PE. METHODS:A retrospective review of patients diagnosed with acute proximal DVT from January 2014 to June 2018 at a single center was performed. Helical computed tomography angiography was performed to screen PE within 48 hr after admission. Multiple factors associated with PE were compared between the PE group and the non-PE group. RESULTS:A total of 100 patients with acute proximal DVT were screened for PE. The mean age was 56.9 ± 18.1 (range 21-88) years, and 55% were male. The most common risk factors of DVT were immobilization (38%), malignancy (27%), and trauma or surgery (21%). Majority of the patients' thrombosis was located at the left leg (66%) and 8 patients had bilateral lower limb DVT. Femoral vein was involved in 52 patients (52%), while iliofemoral thrombosis was identified in 48 patients (48%). PE was identified in 58 patients (58%), including 3 massive and 55 nonmassive PE. There was no statistical difference between the PE group and the non-PE group in terms of age, sex, and risk factors. The D-dimer level was associated with the existence of PE (P = 0.038). Patients with iliofemoral thrombosis had a similar incidence of PE compared with those with femoral thrombosis alone (P = 1.000). CONCLUSIONS:PE occurred in more than half of patients with acute proximal DVT, despite the fact that most of them were asymptomatic. In this study, existence of PE did not correlate with pelvic thrombosis. Increasing D-dimer level was statistically associated with the presence of PE.
Risk factors of pulmonary embolism in the elderly patients: a retrospective study.
Aging clinical and experimental research
AIM:We aimed to summarize the clinical feature and risk factors of patients suffering from pulmonary embolism (PE) in the elderly patients, and explore the change in D-dimer after anti-coagulant therapy. METHODS:A total of 426 patients with PE admitted from August 2012 to January 2019 in the Cangzhou Central Hospital were analyzed in this retrospective study. A comparison of clinical features and risk factors was conducted between the elderly group and non-elderly groups. Blood levels of D-dimer, C-reactive protein (CRP), tumor necrosis factor-α and interferon-γ were measured before and 3 days after anti-coagulant therapy in two groups. RESULTS:The most important risk factor for the elderly patients was stroke, while for non-elderly patients was deep vein thrombosis (DVT). After anti-coagulant therapy, the decreasing level of D-dimer and CRP showed statistically significant differences between the two groups. Between the elderly and non-elderly groups, the main clinical manifestations were similar. The risk factors of elderly patients were chronic obstructive pulmonary disease, malignant tumor, DVT and stroke. After anti-coagulant therapy, the content of D-dimer was lower than 3 days ago. CONCLUSION:Blood levels of D-dimer and CRP may be potent screening markers for PE especially among elderly patients.
Risk factors for presence and severity of pulmonary embolism in patients with deep venous thrombosis.
Huynh Nancy,Fares Wassim H,Brownson Kirstyn,Brahmandam Anand,Lee Alfred I,Dardik Alan,Sarac Timur,Ochoa Chaar Cassius Iyad
Journal of vascular surgery. Venous and lymphatic disorders
OBJECTIVE:The Caprini model estimates patients' risk for venous thromboembolism by 30 different factors. Hemodynamically significant pulmonary embolism (PE), defined as high-risk (massive) or intermediate-risk (submassive) PE, has high morbidity and mortality rates. This study tests whether the Caprini model and deep venous thrombosis (DVT) characteristics correlate with the prevalence of PE and hemodynamically significant PE in patients with DVT. METHODS:A retrospective review of patients diagnosed with DVT between January 2013 and August 2014 in a tertiary care center was performed. Multivariable analysis was used to determine predictors of PE and hemodynamically significant PE. RESULTS:Of 838 consecutive patients with DVT, 217 (25.9%) had concomitant PE at presentation, of whom 135 had hemodynamically significant PE (101 submassive PE, 34 massive PE). The mean age was 65 years, and 51.0% were women. There was no significant relation between age or gender and the occurrence of PE or hemodynamically significant PE. Patients with PE were less likely to have undergone recent surgery (18.4% vs 30.3%; P = .001), to have sepsis (4.6% vs 11.8%; P = .002), and to have higher Caprini scores (6.1 vs 6.5; P = .047). Patients with DVT were less likely to have hemodynamically significant PE after recent surgery (13.3% vs 27.2%; P = .011) but more likely to have hemodynamically significant PE with proximal DVT (80.7% vs 64.2%). There was no association between Caprini score and hemodynamically significant PE (6.3 vs 5.7; P = .171). CONCLUSIONS:The Caprini model has a poor association with PE or hemodynamically significant PE in patients with DVT. Among all patients with DVT, a concomitant diagnosis of PE or hemodynamically significant PE is less common in those with sepsis or undergoing recent surgery but more common in those with proximal DVT.
Refinement of a modified simplified Pulmonary Embolism Severity Index for elderly patients with acute pulmonary embolism.
Morillo Raquel,Jiménez David,Bikdeli Behnood,Rodríguez Carmen,Tenes Andrés,Yamashita Yugo,Morimoto Takeshi,Kimura Takeshi,Vidal Gemma,Ruiz-Giménez Nuria,Espitia Olivier,Monreal Manuel,
International journal of cardiology
OBJECTIVE:To evaluate the utility of a modified (i.e., without the variable "Age >80 years") simplified Pulmonary Embolism Severity Index (sPESI) in elderly patients with acute symptomatic pulmonary embolism (PE), and to derive and validate a refined version of the sPESI for identification of elderly patients at low risk of adverse events. METHODS:The study included normotensive patients aged >80 years with acute PE enrolled in the RIETE registry. We used multivariable logistic regression analysis to create a new risk score to predict 30-day all-cause mortality. We externally validated the new risk score in elderly patients from the COMMAND VTE registry. RESULTS:Multivariable logistic regression identified four predictors for mortality: high-risk sPESI, immobilization, coexisting deep vein thrombosis (DVT), and plasma creatinine >2 mg/dL. In the RIETE derivation cohort, the new model classified fewer patients as low risk (4.0% [401/10,106]) compared to the modified sPESI (35% [3522/10,106]). Low-risk patients based on the new model had a lower 30-day mortality than those based on the modified sPESI (1.2% [95% CI, 0.4-2.9%] versus 4.7% [95% CI, 4.0-5.4%]). In the COMMAND VTE validation cohort, 1.5% (3/206) of patients were classified as having low risk of death according to the new model, and the overall 30-day mortality of this group was 0% (95% CI, 0-71%), compared to 5.9% (95% CI, 3.1-10.1%) in the high-risk group. CONCLUSIONS:For predicting short-term mortality among elderly patients with acute PE, this study suggests that the new model has a substantially higher sensitivity than the modified sPESI. A minority of these patients might benefit from safe outpatient therapy of their disease.
Assessment of coexisting deep vein thrombosis for risk stratification of acute pulmonary embolism.
Quezada Carlos Andrés,Bikdeli Behnood,Barrios Deisy,Morillo Raquel,Nieto Rosa,Chiluiza Diana,Barbero Esther,Guerassimova Ina,García Aldara,Yusen Roger D,Jiménez David, ,
BACKGROUND:In patients with acute pulmonary embolism (PE), studies have shown an association between coexisting deep vein thrombosis (DVT) and short-term prognosis. It is not known whether complete compression ultrasound testing (CCUS) improves the risk stratification of their disease beyond the recommended prognostic models. METHODS:We included patients with normotensive acute symptomatic PE and prognosticated them with the European Society of Cardiology (ESC) risk model for PE. Subsequently, we determined the prognostic significance of coexisting DVT in patients with various ESC risk categories. The primary endpoint was a complicated course after the diagnosis of PE, defined as death from any cause, haemodynamic collapse, or adjudicated recurrent PE. RESULTS:According to the ESC model, 37% of patients were low-risk, 56% were intermediate-low risk, and 6.7% were intermediate-high risk. CCUS demonstrated coexisting DVT in 375 (44%) patients. Among the 313 patients with low-risk PE, coexisting DVT (46%) did not show a significant increased risk of complicated course (2.8%; 95% confidence interval [CI], 0.8%-7.0%), compared with those without DVT (0.6%; 95% CI, 0%-3.2%), (P = 0.18). Of the 478 patients with intermediate-low risk PE, a complicated course was 14% and 6.8% for those with and without DVT, respectively (P = 0.01). Of the 57 patients that had intermediate-high risk PE, a complicated course occurred in 17% and 18% for those with and without DVT, respectively (P = 1.0). CONCLUSIONS:In normotensive patients with PE, testing for coexisting DVT might improve risk stratification of patients at intermediate-low risk for short-term complications.
Efficacy and Safety of Mechanical IVC Filtration for Preventing Pulmonary Embolism in High-Risk Orthopedic Patients Undergoing Total Hip or Knee Arthroplasty.
Ahmed Osman,Kim Ye Joon,Patel Mikin V,Luu Hue H,Scott Bryan,Cohen Kenneth
The Journal of arthroplasty
BACKGROUND:To determine the efficacy and safety of inferior vena cava (IVC) filters in preventing pulmonary embolism (PE) in high-risk patients undergoing hip or knee arthroplasty. METHODS:2857 hip or knee arthroplasty procedures between January 2013 and December 2018 were retrospectively reviewed. Patients with a preoperative history of venous thromboembolism (VTE), either PE or deep venous thrombosis (DVT), were categorized as high-risk patients. The incidence of overall VTE, PE, and DVT were compared between patients with filters and those without. The subgroup analysis was also performed by patient risk, and filter status and the incidence of VTE, PE, and DVT were compared. Variables such as filter placement, history of hypercoagulability etcetra were evaluated as risk factors for the development of postoperative VTE. RESULTS:In the high-risk group, the use of IVC filters was significantly associated with a lower incidence of pulmonary embolism (0.8% vs 5.5%, P = .028). When compared with the low-risk group, the high-risk group had significantly higher incidence of PE (3.8% vs 2.0%, P = .038), DVT (11.6% vs 5.3%, P < .001), and overall VTE (15.0% vs 6.8%, P < .001). The history of VTE was associated with postoperative VTE (P < .001), PE (P = .042), and DVT (P < .001). There was no significant correlation between filter placement and postoperative VTE, DVT, or PE in the low-risk group. Filter retrieval was successful in 100% (96/96) of attempted patients with no complications. CONCLUSION:The use of IVC filters is significantly associated with a lower incidence in pulmonary embolism in high-risk arthroplasty patients. High-risk patients demonstrated an incidence of postoperative VTE over two times greater than other patients. Prophylactic placement of IVC filters in hip/knee arthroplasty is safe.
Profile of Patients with Isolated Distal Deep Vein Thrombosis versus Proximal Deep Vein Thrombosis or Pulmonary Embolism: RE-COVERY DVT/PE Study.
Seminars in thrombosis and hemostasis
Isolated distal deep vein thrombosis (IDDVT) is presumed to be more benign than proximal DVT (PDVT) or pulmonary embolism (PE), suggesting a need for different management approaches. This subgroup analysis of the RE-COVERY DVT/PE global, observational study investigated patient characteristics, hospitalization details, and anticoagulant therapy in patients with IDDVT in real-world settings in 34 countries enrolled from January 2016 to May 2017. Data were analyzed descriptively according to the type and location of the index venous thromboembolism (VTE): IDDVT, PDVT ± distal DVT (DDVT), and PE ± DVT. Of the 6,095 eligible patients, 323 with DVT located outside the lower limb and no PE were excluded. Of the remaining 5,772 patients, 17.6% had IDDVT, 39.9% had PDVT ± DDVT, and 42.5% had PE ± DVT. IDDVT patients were younger and had fewer risk factors for VTE than the other groups. Other comorbidities were less frequent in the IDDVT group, except for varicose veins, superficial thrombophlebitis, and venous insufficiency. IDDVT patients were less likely to be diagnosed in an emergency department (22.3 vs. 29.7% for PDVT ± DDVT and 45.4% for PE ± DVT) or hospitalized for VTE (29.2 vs. 48.5% for PDVT ± DDVT and 75.0% for PE ± DVT). At hospital discharge or 14 days after diagnosis (whichever was later), non-vitamin K antagonist oral anticoagulants were the most commonly used anticoagulants (55.6% for IDDVT, 54.7% for PDVT ± DDVT, and 52.8% for PE ± DVT). Although differences in patient characteristics, risk factors, and clinical management were identified, anticoagulant treatment of IDDVT was almost equal to that of PDVT or PE. Prospective studies should investigate whether, in a global perspective, this is an appropriate use of anticoagulants.
Clinical characteristics and outcomes of patients with isolated pulmonary embolism.
Lee Yong Hoon,Cha Seung-Ick,Shin Kyung Min,Lim Jae Kwang,Lee Won Kee,Park Ji-Eun,Choi Sun Ha,Seo Hyewon,Yoo Seung-Soo,Lee Shin-Yup,Lee Jaehee,Kim Chang-Ho,Park Jae-Yong
Blood coagulation & fibrinolysis : an international journal in haemostasis and thrombosis
The clinical relevance of concomitant deep vein thrombosis (DVT) in patients with pulmonary embolism remains controversial. The aim of the present study was to assess clinical characteristics of patients with isolated pulmonary embolism, thereby investigating isolated pulmonary embolism related clinical factors. Patients hospitalized for pulmonary embolism who underwent DVT workup within 3 days of pulmonary embolism diagnosis were retrospectively classified into two groups: patients with isolated pulmonary embolism and patients with DVT-associated pulmonary embolism (DVT-PE). The clinical, laboratorial and radiological parameters were compared between the two groups. Of 1012 patients, 322 (31.8%) presented with isolated pulmonary embolism, and 690 (68.2%) presented with DVT-PE. In a multivariate analysis, female sex was an independent factor for predicting isolated pulmonary embolism [odds ratio (OR) 1.69, 95% confidence interval (CI) 1.26-2.26, P < 0.001], whereas cancer (OR 0.64, 95% CI 0.43-0.96, P = 0.031), leg pain or swelling (OR 0.08, 95% CI 0.04-0.18, P < 0.001), and central pulmonary embolism (OR 0.44, 95% CI 0.32-0.59, P < 0.001) were negatively associated with isolated pulmonary embolism. There were no significant differences between the two groups with regard to risk stratification and short-term prognosis of pulmonary embolism, including adverse outcomes and pulmonary embolism related in-hospital mortality. Of pulmonary embolism patients who underwent imaging tests for DVT, approximately 32% presented with isolated pulmonary embolism. Isolated pulmonary embolism was positively associated with female sex, whereas it was negatively associated with cancer, leg pain or swelling, and central pulmonary embolism. The presence or absence of concomitant DVT did not influence the severity and short-term prognosis of pulmonary embolism.
Clinical outcomes of patients with pulmonary embolism versus deep vein thrombosis: From the COMMAND VTE Registry.
Yamashita Yugo,Murata Koichiro,Morimoto Takeshi,Amano Hidewo,Takase Toru,Hiramori Seiichi,Kim Kitae,Oi Maki,Akao Masaharu,Kobayashi Yohei,Toyofuku Mamoru,Izumi Toshiaki,Tada Tomohisa,Chen Po-Min,Tsuyuki Yoshiaki,Saga Syunsuke,Nishimoto Yuji,Sasa Tomoki,Sakamoto Jiro,Kinoshita Minako,Togi Kiyonori,Mabuchi Hiroshi,Takabayashi Kensuke,Yoshikawa Yusuke,Shiomi Hiroki,Kato Takao,Makiyama Takeru,Ono Koh,Nawada Ryuzo,Onodera Tomoya,Kimura Takeshi,
INTRODUCTION:Pulmonary embolism (PE) and deep vein thrombosis (DVT) can be considered as one clinical entity, venous thromboembolism (VTE). However, the potential differences between PE and DVT might have to be taken into consideration for the decision-making of the optimal treatment strategies. MATERIALS AND METHODS:The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic VTE. The current study population consisted of 1715 PE patients with or without DVT and 1312 DVT only patients. RESULTS:The adjusted risk for recurrent VTE was not significantly different between the PE and DVT only groups (HR 1.22, 95%CI 0.93-1.60, P = 0.15). PE patients developed recurrent VTE events more often as PE than as DVT only (62% and 38%). The adjusted excess mortality risk of PE patients relative to DVT only patients was significant (HR 1.29, 95%CI 1.11-1.50, P < 0.001), with markedly higher cumulative 30-day incidence of all-cause death in PE patients (6.4% and 1.4%, P < 0.001). The most frequent cause of deaths was cancer death in both groups, and second most frequent cause of deaths in PE patients was fatal PE, most of which developed within 30 days. CONCLUSIONS:The risk for recurrent VTE was not significantly different between PE and DVT, although PE was more likely to develop recurrent VTE as PE. The mortality risk of PE seemed to be higher than that of DVT, which was more remarkable in the short term due to PE death, and less remarkable in the long term due to cancer death.
Patients with isolated pulmonary embolism in comparison to those with deep venous thrombosis. Differences in characteristics and clinical evolution.
Palareti Gualtiero,Antonucci Emilia,Dentali Francesco,Mastroiacovo Daniela,Mumoli Nicola,Pengo Vittorio,Poli Daniela,Testa Sophie,Pujatti Pietro Luigi,Menditto Vincenzo Giannicola,Imberti Davide,Fontanella Andrea
European journal of internal medicine
BACKGROUND:Patients with acute pulmonary embolism (PE) often have leg deep vein thrombosis (DVT); sometimes, however, a DVT is not detected (isolated PE, I-PE). We aimed at assessing the proportion of patients with I-PE, and their characteristics and clinical evolution compared to those with DVT with/without PE (DVT/PE). METHODS:Among 3573 patients included in the START2-Register for a venous thromboembolic event, 2880 (80.6%) had DVT/PE, the remaining I-PE (19.4%). RESULTS:Patients with I-PE were older [(≥75 years, OR 1.4 (95%CI 1.13-1.69)], and more frequently females [OR 1.4 (1.19-1.67)]. Young females (aged ≤ 50 years) with an index event occurring during hormonal contraception (HC), were more prevalent in I-PE [OR 1.96 (1.26-3.03)]. At multivariate analysis, age > 75 years, female sex, heart failure, cancer and use of HC were risk factors significantly associated with I-PE, whereas thrombophilic alterations were associated with DVT/PE. During a follow-up of 4504 years (during anticoagulation), the rate of bleeding events was 1.1% patient/years and 1.0% patient/years in I-PE and DVT/PE, respectively. Venous thromboembolic events were equally prevalent in DVT/PE or I-PE (1.94% vs 0.86%, ns), whereas arterial complications were more prevalent in the latter group (1.01% vs 0.28%, p = 0.008). CONCLUSION:I-PE and DVT/PE have important differences. Older age, female sex, heart failure and cancer, were risk factors for I-PE; thrombophilic alterations were associated with DVT/PE. HC use was more frequent in the I-PE group. The prevalence of arterial complications was higher in patients with I-PE. Further studies, specifically designed on this issue, are warranted.
May-Thurner syndrome and the risk of pulmonary embolism in patients with acute deep venous thrombosis.
Jin Song,Sun Ziqiang,Li Xiaoqin,Jian Tao,Jin Xing,Li Sheng,Wang Guodong,Ma Chong,Cui Kai,Xu Peng
Journal of vascular surgery. Venous and lymphatic disorders
OBJECTIVE:Pulmonary embolism (PE) is the most common complication of deep venous thrombosis (DVT). May-Thurner syndrome (MTS) is known to increase the risk of DVT, but an association between MTS and PE has not been established. This study investigated an association between MTS and the risk of PE in patients with acute lower extremity DVT. METHODS:Between June 2014 and September 2016, there were 112 patients with DVT at our hospital who underwent venous angiography and computed tomography pulmonary angiography. Data related to the patients' demographics, risk factors, disease onset time, side of DVT, D-dimer level, Doppler ultrasound, venous angiography, and computed tomography pulmonary angiography were collected. Associations between MTS and PE were analyzed. RESULTS:The 112 DVT patients included 79 with MTS. The rate of DVT in the left lower extremity was higher in the MTS group (98.7%) than in the non-MTS group (48.5%; P < .001). PE was less common in the MTS group (50.6%) than in the non-MTS group (78.8%; P = .006). The multinomial logistic analysis revealed a significant negative correlation between MTS and PE. The correlation remained after applying adjustment models I, II, and III. Model I adjusted for risk factors, DVT side, and D-dimer tertile (odds ratio [OR], 0.17; 95% confidence interval [CI], 0.04-0.68; P = .0125); model II adjusted for sex, age, risk factors, onset time, DVT side, D-dimer level, and D-dimer tertile (OR, 0.15; 95% CI, 0.03-0.71; P = .0162); and model III adjusted for sex, age, risk factors, onset time, DVT side, D-dimer level, D-dimer tertile, iliofemoral DVT, mixed (both iliofemoral and femoropopliteal) DVT, and femoropopliteal DVT (OR, 0.35; 95% CI, 0.06-2.08; P = .2501). CONCLUSIONS:DVT patients with concomitant MTS have a decreased risk of PE compared with those without MTS. This finding extends previous reports of increased PE risk after DVT and calls for better understanding of shared risk factors and underlying mechanisms.
Deep vein thrombosis and pulmonary embolism.
Di Nisio Marcello,van Es Nick,Büller Harry R
Lancet (London, England)
Deep vein thrombosis and pulmonary embolism, collectively referred to as venous thromboembolism, constitute a major global burden of disease. The diagnostic work-up of suspected deep vein thrombosis or pulmonary embolism includes the sequential application of a clinical decision rule and D-dimer testing. Imaging and anticoagulation can be safely withheld in patients who are unlikely to have venous thromboembolism and have a normal D-dimer. All other patients should undergo ultrasonography in case of suspected deep vein thrombosis and CT in case of suspected pulmonary embolism. Direct oral anticoagulants are first-line treatment options for venous thromboembolism because they are associated with a lower risk of bleeding than vitamin K antagonists and are easier to use. Use of thrombolysis should be limited to pulmonary embolism associated with haemodynamic instability. Anticoagulant treatment should be continued for at least 3 months to prevent early recurrences. When venous thromboembolism is unprovoked or secondary to persistent risk factors, extended treatment beyond this period should be considered when the risk of recurrence outweighs the risk of major bleeding.
Impact of concomitant deep or superficial venous thrombosis of the legs on survival of patients with pulmonary embolism.
Keller Karsten,Hobohm Lukas,Münzel Thomas,Ostad Mir A
International journal of cardiology
BACKGROUND:Pulmonary embolism (PE) is a frequent cause of death and morbidity. A few studies suggest that clot burden in pulmonary artery bed is related to PE patients' survival, but the impact of concomitant deep venous thrombosis and/or thrombophlebitis (DVT) on short-term survival of PE patients remains unclear. Thus, we aimed to investigate the impact of DVT on adverse outcomes in PE patients. METHODS:Patients of the nationwide inpatient sample with PE (ICD-code I26) were stratified for DVT (ICD-code I80) and compared for patient characteristics, risk stratification markers, treatments and outcomes. Impact of concomitant DVT on adverse in-hospital outcomes was tested. RESULTS:Overall, 346,586 PE patients (53.3% females) were included in this analysis. Among these, in 126,477 (36.5%) DVT was coded. PE patients with DVT were younger, less often of female sex and VTE risk-factors (surgery, cancer) as well as cardiovascular and pulmonary diseases were less prevalent compared with isolated PE. PE patients with DVT showed a significant better survival (5.4% vs. 20.2%, P < .001) and lower adverse in-hospital event rate (9.7% vs. 27.4%, P < .001) compared to patients with isolated PE. Lower risk for in-hospital mortality (OR 0.238 [95%CI 0.232-0.245], P < .001) and adverse in-hospital events (OR 0.302 [95%CI 0.295-0.309], P < .001) were respectively independent of age, gender, comorbidities and reperfusion-treatments. CONCLUSIONS:Concomitant DVT affects survival of PE patients. Patients with an isolated PE had higher rate of in-hospital mortality and adverse in-hospital events. Our data suggest, that peripheral thrombus burden in PE with concomitant DVT might be less harmful in comparison to isolated PE with a probably larger thrombus burden.
Impact of no, distal, and proximal deep vein thrombosis on clinical outcomes in patients with acute pulmonary embolism: From the COMMAND VTE registry.
Nishiwaki Shushi,Morita Yusuke,Yamashita Yugo,Morimoto Takeshi,Amano Hidewo,Takase Toru,Hiramori Seiichi,Kim Kitae,Oi Maki,Akao Masaharu,Kobayashi Yohei,Toyofuku Mamoru,Izumi Toshiaki,Tada Tomohisa,Chen Po-Min,Murata Koichiro,Tsuyuki Yoshiaki,Saga Syunsuke,Sasa Tomoki,Sakamoto Jiro,Kinoshita Minako,Togi Kiyonori,Mabuchi Hiroshi,Takabayashi Kensuke,Shiomi Hiroki,Kato Takao,Makiyama Takeru,Ono Koh,Inoko Moriaki,Kimura Takeshi,
Journal of cardiology
BACKGROUND:The majority of acute pulmonary embolism (PE) is caused by thrombus developed from leg veins. However, impact of concomitant deep venous thrombosis (DVT) on clinical outcomes has not been fully evaluated in patients with acute PE. METHODS:The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic venous thromboembolism (VTE) in Japan. The current study population consisted of 655 acute PE patients who underwent lower extremities ultrasound examination at diagnosis for the assessment of concomitant DVT status. RESULTS:There were 424 patients with proximal DVT (64.7%), 162 patients with distal DVT (24.7%), and 69 patients with no DVT (10.5%). The cumulative 90-day incidence of all-cause death was higher in proximal DVT patients than in distal DVT and no DVT patients (7.9%, 2.5%, and 1.4%, p = 0.01). Regarding the causes of death, the cumulative 90-day incidence of PE-related death was low, and not significantly different across the 3 groups (1.4%, 0.6%, and 1.7%, p = 0.62). The most frequent cause of death was cancer in proximal and distal DVT patients. There were no significant differences in 90-day rates of recurrent VTE and major bleeding, regardless of the status of concomitant DVT (2.9%, 3.2%, and 2.2%, p = 0.79, and 1.5%, 4.4%, and 4.9%, p = 0.46, respectively). CONCLUSIONS:Acute PE with proximal DVT at diagnosis was associated with a higher risk for short-term mortality than in patients without DVT, while the risk for short-term mortality was not significantly different between distal DVT patients and patients without DVT.
Pulmonary embolism and deep vein thrombosis: Similar but different.
Wenger Nicolas,Sebastian Tim,Engelberger Rolf Peter,Kucher Nils,Spirk David
INTRODUCTION:Pulmonary embolism (PE) and deep vein thrombosis (DVT), the two clinical manifestations of venous thromboembolism (VTE), constitute a major global burden of cardiovascular disease. They are often referred to as one disease but several patient characteristics, risk factors, real-world treatment, and clinical outcomes may differ substantially between PE and DVT alone. MATERIALS AND METHODS:We conducted a narrative review of the state-of-the-art literature on the topic of PE and DVT alone using PubMed, Google scholar, and MEDLINE databases and the most established international consensus statement guidelines for the management of VTE, focusing on the recommendations for diagnosis and treatment but also including epidemiological and clinical characteristics of VTE, highlighting similarities and differences between PE and DVT alone. RESULTS:Several patient characteristics, risk factors, clinical manifestations, and outcomes differ substantially between PE versus DVT alone. Nevertheless, recommendations for both diagnosis and treatment are strikingly similar in the current guidelines for the management of DVT and PE, except for the indication for advanced reperfusion therapies. CONCLUSIONS:The differences in risk factors, clinical manifestations, and clinical outcomes between patients with PE versus DVT alone are only marginally addressed in the current consensus guidelines. More data is needed allowing proposal of evidence-based adjustments in the diagnostic and therapeutic strategies for these two manifestations of VTE. Tailored risk stratification and individualized management strategies for patients with PE and DVT alone may lead to a better prognosis, less recurrence and complications, and possibly to a gain of quality-adjusted life years in patients with VTE.
Association between air temperature, air pollution and hospital admissions for pulmonary embolism and venous thrombosis in Italy.
Di Blasi Chiara,Renzi Matteo,Michelozzi Paola,De' Donato Francesca,Scortichini Matteo,Davoli Marina,Forastiere Francesco,Mannucci Pier Mannuccio,Stafoggia Massimo
European journal of internal medicine
BACKGROUND:Previous studies reported a link between short-term exposure to environmental stressors (air pollution and air temperature) and atherothrombotic cardiovascular diseases. However, only few of them reported consistent associations with venous thromboembolism (VTE). Our aim was to estimate the association between daily air temperature and particulate matter (PM) air pollution with hospital admissions for pulmonary embolism (PE) and venous thrombosis (VT) at national level in Italy. METHODS:We collected daily hospital PE and VT admissions from the Italian Ministry of Health during 2006-2015 in all the 8,084 municipalities of Italy, and we merged them with air temperature and daily PM10 concentrations estimated by satellite-based spatiotemporal models. First, we applied multivariate Poisson regression models at province level. Then, we obtained national overall effects by random-effects meta-analysis. RESULTS:This analysis was conducted on 219,952 PE and 275,506 VT hospitalizations. Meta-analytical results showed weak associations between the two exposures and the study outcomes in the full year analysis. During autumn and winter, PE hospital admissions increased by 1.07% (95% confidence intervals [CI]: 0.21%; 1.92%) and 0.96% (95% CI: 0.07%; 1.83%) respectively, per 1 °C decrement of air temperature in the previous 10 days (lag 0-10). In summer we observed adverse effects at high temperatures, with a 1% (95% CI: 0.10%; 1.91%) increasing risk per 1 °C increment. We found no association between VT and cold temperatures. CONCLUSION:Results show a significant effect of air temperature on PE hospitalizations in the cold seasons and summer. No effect of particulate matter was detected.
Prominent seasonal variation in pulmonary embolism than deep vein thrombosis incidence: a Korean venous thrombosis epidemiology study.
Hong Junshik,Lee Ju Hyun,Lee Ji Yun,Lee Jeong-Ok,Choi Won-Il,Ahn Soyeon,Lim Youn-Hee,Bang Soo-Mee,Oh Doyeun
The Korean journal of internal medicine
BACKGROUND/AIMS:Seasonal variation is an environmental factor proposed to affect the incidence of venous thromboembolism (VTE). However, VTE seasonal variation is not well studied in Asian populations, which have different genetic determinants of VTE compared to Westerners. The present study aimed at investigating seasonal variation of VTE occurrence and the effect of various demographic factors (i.e., age, sex, and co-morbidities) on variation. METHODS:VTE seasonal variation was evaluated in 59,626 index cases (from January 2009 to December 2013) in the Korean Health Insurance Review and Assessment Service database. We quantified and compared VTE occurrence across four seasons, and additionally assessed monthly through a chronobiological analysis. RESULTS:VTE incidence varied both seasonally and monthly, with new cases peaking in the winter (January and February) and the lowest incidence in the summer (August and September). After adjusting for sex, age, type of VTE, and combined cancer diagnosis, winter remained a significant independent factor driving VTE incidence. Additionally, seasonal variation was prominent in patients aged 60 years or older and in patients with pulmonary embolism, but not so prominent in patients of aged less than 60 years and patients with deep vein thrombosis. CONCLUSION:Seasonal variation was a weak but independent contributor to VTE incidence in a Korean population diagnosed from 2009 to 2013, especially in those individuals with old age or suffering from a pulmonary embolism.
Bilateral Deep Vein Thrombosis and Pulmonary Embolism Due to Right Common Iliac Artery Aneurysm with a Contained Rupture.
Malli Foteini,Dimeas Ilias E,Sinis Sotirios I,Karetsi Eleni,Nana Petroula,Kouvelos George,Gourgoulianis Konstantinos I
Medicina (Kaunas, Lithuania)
Venous thromboembolism (comprising deep venous thrombosis and/or pulmonary embolism) is a common disease, often of multifactorial cause. Focal iliac artery aneurysms are relatively rare, and only a few reports exist in the literature describing patients with venous thromboembolism resulting from venous floe disruption due to iliac artery aneurysm. Thus, we report a case of a 65-year-old male presenting with pulmonary embolism and bilateral deep vein thrombosis associated with a contained rupture of the right common iliac artery aneurysm.
Clinical presentation of isolated calf deep vein thrombosis in inpatients and prevalence of associated pulmonary embolism.
Journal of vascular surgery. Venous and lymphatic disorders
OBJECTIVE:Controversy exists regarding the clinical significance and optimal treatment of isolated calf deep vein thrombosis (DVT). In the present study, the clinical presentation of isolated calf DVT and the association of isolated calf DVT with pulmonary embolism (PE) in hospitalized patients were investigated. METHODS:A total of 1435 hospitalized patients had undergone whole leg duplex ultrasound between January 2018 and June 2020. Isolated calf vein DVT was diagnosed in 135 of these 1435 patients. RESULTS:The soleal vein was the most frequently involved (52.6%). Thrombus was detected only in the axial veins in 57 patients (42.2%), muscular veins in 46 patients (34.4%), and both axial and muscular veins in 32 patients (23.7%). Of the 135 patients, 44 (32.6%) had undergone recent orthopedic surgery, 31 (23.0%) had active cancer, and 22 (16.3%) had a history of recent stroke. The reasons for duplex ultrasound examination were leg edema and/or pain for 57 patients (42.2%), the diagnosis of PE for 33 (24.4%), and an elevated D-dimer level for 27 patients (20.0%). For 16 patients (11.9%), DVT had been diagnosed as an incidental finding on imaging studies performed for other purposes. Of the 135 patients, 96 (71.1%) had received anticoagulation therapy. Concurrent PE was diagnosed in 45 patients (33.3%), 14 of whom had had lesions in the main pulmonary artery. Of the 45 patients with concurrent PE, 35 had not experienced leg edema and/or pain. Recurrent venous thromboembolism was observed in four patients (3.0%) at a mean follow-up of 15.5 ± 12.7 months. CONCLUSIONS:In the present study, isolated calf DVT was associated with a high prevalence of PE in the hospitalized patients. Patients with isolated calf DVT, even without leg edema and/or pain, could have concurrent PE. Anticoagulation therapy should be considered for inpatients with isolated calf DVT. The muscular veins were frequently involved and, thus, should be thoroughly evaluated with imaging studies.
Common Reasons for Malpractice Lawsuits Involving Pulmonary Embolism and Deep Vein Thrombosis.
Wilson Eelin,Phair John,Carnevale Matthew,Koleilat Issam
The Journal of surgical research
BACKGROUND:Pulmonary embolism and deep vein thrombosis are common clinical entities, and the related malpractice suits affect all medical subspecialties. Claims from malpractice litigation were analyzed to understand the demographics of these lawsuits and the common reasons for pursuing litigation. METHODS:Cases entered into the Westlaw database from March 5, 1987, to May 31, 2018, were reviewed. Search terms included "pulmonary embolism" and "deep vein thrombosis." RESULTS:A total of 277 cases were identified. The most frequently identified defendant was an internist (including family practitioner; 33%), followed by an emergency physician (18%), an orthopedic surgeon (16%), and an obstetrician/gynecologist (9%). The most common etiology for pulmonary embolism was prior surgery (41%). The most common allegation was "failure to diagnose and treat" in 62%. Other negligence included the failure to administer prophylactic anticoagulation while in the hospital (18%), failure to prescribe anticoagulation on discharge (8%), failure to administer anticoagulation after diagnosis (8%), and premature discontinuation of anticoagulation (2%). The most frequently claimed injury was death in 222 cases (80%). Verdicts were found for the defendant in 57% of cases and for the plaintiff in 27% and settled in 16%. CONCLUSIONS:The most frequently cited negligent act was the failure to give prophylactic anticoagulation, even after discharge. The trends noted in this study may potentially be addressed and therefore prevented by systems-based practice changes. The most common allegation, "failure to diagnose and treat," suggests that first-contact doctors such as emergency physicians and primary care practitioners must maintain a high index of suspicion for deep vein thrombosis/pulmonary embolism.
Treatment and Outcomes of Acute Pulmonary Embolism and Deep Venous Thrombosis: The CVRN VTE Study.
Fang Margaret C,Fan Dongjie,Sung Sue Hee,Witt Daniel M,Schmelzer John R,Williams Marc S,Yale Steven H,Baumgartner Christine,Go Alan S
The American journal of medicine
BACKGROUND:Few studies describe both inpatient and outpatient treatment and outcomes of patients with acute venous thromboembolism in the United States. METHODS:A multi-institutional cohort of patients diagnosed with confirmed pulmonary embolism or deep venous thrombosis during the years 2004 through 2010 was established from 4 large, US-based integrated health care delivery systems. Computerized databases were accessed and medical records reviewed to collect information on patient demographics, clinical risk factors, initial antithrombotic treatment, and vital status. Multivariable Cox regression models were used to estimate the risk of death at 90 days. RESULTS:The cohort comprised 5497 adults with acute venous thromboembolism. Pulmonary embolism was predominantly managed in the hospital setting (95.0%), while 54.5% of patients with lower extremity thrombosis were treated as outpatients. Anticoagulant treatment differed according to thromboembolism type: 2688 patients (92.8%) with pulmonary embolism and 1625 patients (86.9%) with lower extremity thrombosis were discharged on anticoagulants, compared with 286 patients (80.1%) with upper extremity thrombosis and 69 (54.8%) patients with other thrombosis. While 4.5% of patients died during the index episode, 15.4% died within 90 days. Pulmonary embolism was associated with a higher 90-day death risk than lower extremity thrombosis (adjusted hazard ratio 1.23; 95% confidence interval, 1.04-1.47), as was not being discharged on anticoagulants (adjusted hazard ratio 5.56; 95% confidence interval, 4.76-6.67). CONCLUSIONS:In this multicenter, community-based study of patients with acute venous thromboembolism, anticoagulant treatment and outcomes varied by thromboembolism type. Although case fatality during the acute episode was relatively low, 15.4% of people with thromboembolism died within 90 days of the index diagnosis.
Popliteal cysts are not a risk factor for lower extremity deep vein thrombosis.
Journal of thrombosis and thrombolysis
BACKGROUND:Popliteal cysts (PC) result from distension of the gastrocnemio-semimembranosous bursa. Published reports indicate coincident PC and deep vein thrombosis (DVT). Whether the presence of PC increase the risk of deep vein thrombosis (DVT) remains unclear. METHODS:Lower extremity venous Duplex ultrasound (DUS) reports were evaluated across the Mayo Clinic Enterprise (Rochester, Minnesota, Jacksonville, Florida, Scottsdale, Arizona, and the Mayo Clinic Health System) in patients ≥ 18 years of age. Natural language processing (NLP) algorithms were created and validated to identify acute lower extremity DVT and PC from these reports. To determine whether there is a link between PC and lower extremity DVT, the frequency of PC among cases (ultrasounds with acute DVT) were compared to controls (ultrasounds without acute DVT). RESULTS:A total of 357,703 lower extremities venous DUS were performed in 237,052 patients (mean age 63.3 ± 16.6, 54.4% were female) between 1992 and 2021. Acute DVT was identified in 32,572 (9.1%) DUS, and PC in 32,448 (9.1%). PC were seen in a lower frequency (8.0%) of ultrasounds with acute DVT than those without (9.2%) acute DVT (OR: 0.85, 95% CI: 0.82 to 0.89, p < 0.001). In a multivariate logistic regression model after adjusting for age, sex, and race, PCs were not positively associated with acute DVT (adjusted OR: 0.84, 95% CI: 0.81 to 0.88). CONCLUSIONS:PC are an incidental finding or an alternative diagnosis on lower extremity venous DUS, a finding that increases significantly with age. PC were not a risk factor in the development of lower extremity DVT.
Preoperative incidence and locations of deep venous thrombosis (DVT) of lower extremity following ankle fractures.
Luo Zixuan,Chen Wei,Li Yansen,Wang Xiaomeng,Zhang Weili,Zhu Yanbin,Zhang Fengqi
This retrospective study aimed to investigate the preoperative incidence and locations of deep venous thrombosis (DVT) in patients undergoing surgeries for ankle fractures and identify the associated risk factors. From January 2016 to June 2019, 1,532 patients undergoing surgery of ankle fractures were included. Their inpatient medical records were inquired for data collection, including demographics, comorbidities, injury-related data and preoperative laboratory biomarkers. DVT of bilateral lower extremities was diagnosed by routine preoperative Doppler examination. Univariate analyses and multivariate logistic regression analyses were used to identify the independent risk factors. Totally, 98 patients had a preoperative DVT, indicating an incidence rate of 6.4%. A total of 164 clots for 6 veins were found, representing an average of 1.7 for each patient. The detailed DVTs involving veins were as follows: 2 in femoral common vein, 7 in superficial femoral vein, 2 in deep femoral vein, 16 in popliteal vein, 49 in posterior tibial vein, and 88 in peroneal vein. In the multivariate model, 5 risk factors were identified to be associated with DVT, including age (10-year increase), gender, lower ALB level, reduced LYM count and elevated D-dimer level. There was a tendency for diabetes mellitus to increase the risk of DVT, although there was no statistical significance (p = 0.063). These epidemiologic data on DVT may help counsel patients about the risk of DVT, individualized risk assessment and accordingly the risk stratification.
Fibrinolysis Index as a new predictor of deep vein thrombosis after traumatic lower extremity fractures.
Zhang Wenjie,Su Yu,Liu Lei,Zhao Huiru,Wen Meng,Zhao Yujing,Lu Shan,Chen Yuying,Cao Xiangyu,Wu Jun
Clinica chimica acta; international journal of clinical chemistry
BACKGROUND:Deep vein thrombosis (DVT) is a common complication in patients with traumatic injury. The purpose of this study was to develop a potential predictor of DVT. METHODS:This case-control study enrolled adult trauma patients and healthy volunteers. Patients underwent angiography before surgery to diagnose DVT. Patients with or without DVT were matched by gender, age and fracture sites. Laboratory parameters included lysis potential (LP), lysis time (LT), blood cell counts, conventional coagulation tests, tissue plasminogen activator inhibitor complex (tPAIC) and others. RESULTS:41 of 319 patients with DVT were matched with 41 patients without DVT and 80 healthy volunteers were controls. LP and LT were significantly decreased in patients with DVT than without (P = 0.043 and P = 0.014, respectively). The level of tPAIC in the DVT group was significantly higher than in patients without DVT (P = 0.042). We defined the Fibrinolysis Index as (-10.707) × LP + (-0.607) × LT (min) + 0.012 × fibrinogen (mg/dl) + 0.299 × tPAIC (ng/ml) + 9.917, and found that the area under the receiver operating characteristic curve for the Fibrinolysis Index was 0.802, making it a novel indicator. CONCLUSION:The Fibrinolysis Index represents a new discriminator for predicting DVT after traumatic lower extremity fractures.
Ilio-Femoral Deep Vein Thrombosis Secondary to May-Thurner Syndrome With Ipsilateral Lower Limb Arterio-Venous Graft In-Situ.
Betzler Brjan Kaiji,Zhang Li,Chan Kai Siang,Yong Enming,Huang Ivan Kuang Hsin,Lo Zhiwen Joseph
Vascular and endovascular surgery
Ilio-femoral deep vein thrombosis (DVT) is rare in patients with lower limb arterio-venous grafts due to a state of high blood flow. May-Thurner syndrome (MTS) is an anomaly where the left common iliac vein is compressed by the right common iliac artery. We present a rare case of ilio-femoral deep vein thrombosis in a patient with May-Thurner Syndrome and an underlying arteriovenous graft in-situ who presented with acute lower limb swelling. The patient underwent catheter-directed thrombolysis, pharmaco-mechanical thrombectomy, venoplasty and iliac vein stenting. Follow-up surveillance duplex ultrasound showed patency of the iliac vein stent and arteriovenous graft at 1-year postoperatively.
The predictive value of platelet to lymphocyte ratio and D-dimer to fibrinogen ratio combined with WELLS score on lower extremity deep vein thrombosis in young patients with cerebral hemorrhage.
Wen Huijun,Chen Yingcong
Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology
OBJECTIVE:To study the predictive effect on YCH patients complicated with LEDVT by PLR and DFR combined with WELLS score. MATERIALS AND METHODS:A total of 109 patients with YCH were selected as the research subjects. Patients with combined LEDVT were in the thrombosis group (33 cases), and without LEDVT in the non-thrombosis group (76 cases). Wells score was used to evaluate the vascular of the lower extremities. The PLR and DFR were calculated. The diagnostic value of PLR and DFR combined with the Wells score was evaluated by the AUC, sensitivity, specificity, and other indicators in the ROC. RESULTS:The values of PLR, DFR, and Wells score in the thrombus group were 149.20 ± 52.17, 118.46 ± 8.37, and 2.67 ± 0.48, and that of the non-thrombotic group were 95.27 ± 29.48, 75.28 ± 10.16, and 0.72 ± 0.34, respectively. The differences were statistically significant. ROC results showed good diagnosis power of PLR (sensitivity 86.35%, specificity 75.18%, AUC 0.702.), DFR (sensitivity 88.57%, specificity 79.21%, AUC 0.786.), and the Wells score (sensitivity 90.17%, specificity 81.06%, AUC 0.889.). The combined application of the Wells score, PLR, and DFR for the occurrence of LEDVT had a sensitivity of 97.65%, a specificity of 92.43%, a missed diagnosis rate of 2.35%, and a misdiagnosis rate of 7.57%. The area under the ROC curve was 0.951, which was higher than using these variables independently. CONCLUSIONS:PLR and DFR combined with Wells score have high specificity for predicting LEDVT in YCH patients with low missed diagnosis and low misdiagnosis rates. They are worthy of popularization and application.
The risk of lower-limb superficial vein thrombosis relative to lower-limb venous thrombotic events is not increased in winter months.
Henni Samir,Ramondou Pierre,Duval Guillaume,Picquet Jean,Leftheriotis Georges,Abraham Pierre
OBJECTIVES:Ambient temperature (that impacts differently venous flow in superficial and deep veins) could have a different effect on the risk of superficial and deep venous thrombosis. We searched for a trimestral variation of the risk of superficial venous thrombosis among all lower-limb thrombotic events (lower-limb thrombotic events = superficial venous thrombosis + deep venous thrombosis). METHODS:We retrospectively analyzed the results of venous ultrasound investigations performed among 11,739 patients (aged 67 ± 19 years old, 56.1% males) referred for suspected lower-limb thrombotic events over a 12-year period. Chi-square test was used to compare the superficial venous thrombosis/lower-limb thrombotic events ratio observed by trimesters to a homogeneous distribution. RESULTS:The proportion of lower-limb thrombotic events were 30.7%, 28.8%, 31.1%, and 31.4% (Chi: 0.133; = 0.987) of total investigations, while that of superficial venous thrombosis among all lower-limb venous thrombotic events were 27.2%, 30.0%, 31.4%, and 31.0%, for the first, second, third, and fourth trimesters respectively (Chi: 0.357; : 0.949). CONCLUSION:No trimestral variation of the superficial venous thrombosis/lower-limb venous thrombotic events ratio was observed.
Laterality of lower extremity deep vein thrombosis after colectomy: A retrospective study using the national inpatient sample.
Saraiva Ivan E,Kato Hirotaka
BACKGROUND AND AIMS:Deep venous thrombosis (DVT) is known to occur preferentially on the left lower extremity. The renowned surgeon Denis Burkitt advanced the theory that a heavy sigmoid colon would compress the left pelvic veins and predispose to DVT. Our study aimed to evaluate this hypothesis by comparing the laterality distributions with and without a prior colectomy. METHODS:We conducted a retrospective analysis of the 2016 National Inpatient Sample database by stratifying the patients at any age with acute DVT of lower extremity by history of prior colectomy, thereby eliminating local gut mechanical factors in the development of DVT. We compared the laterality distribution (i.e., left, right, bilateral, and unspecified) between the patients with and without a prior colectomy. We also conducted a subgroup analysis by the sex category to examine the difference in laterality distribution for male and female patients. Chi-square test for independence was used. P value ≤0.05 was considered statistically significant. RESULTS:We found an estimated total of 342,525 cases. Among patients without a prior colectomy, 136,605 (41.6%) were left-sided DVT versus 119,555 (36.4%) right-sided, with 55,555 bilateral and 16,865 unspecified. Among patients with a prior colectomy, 5,750 (41.2%) were left-sided, 5,000 (35.9%) were right-sided, 2,345 were bilateral and 850 were unspecified. The laterality distribution between the two groups was not significantly different ( = .167). The left-side predominance disappeared only in males with a prior colectomy (37.1% for left vs. 38.9% for right, = .027). CONCLUSIONS:Our findings did not confirm the Burkitt's hypothesis. The left-side predominance of lower extremity DVT was attenuated only in male patients with a prior colectomy.