Predictive factors of clot propagation in patients with superficial venous thrombosis towards deep venous thrombosis and pulmonary embolism: a systematic review and meta-analysis

OBJECTIVE

A subset of patients with superficial venous thrombosis (SVT) experiences clot propagation towards deep venous thrombosis (DVT) and/or pulmonary embolism (PE). The aim of this systematic review is to identify all clinically relevant cross-sectional and prognostic factors for predicting thrombotic complications in patients with SVT.

DESIGN

Systematic review.

DATA SOURCES

PubMed/MEDLINE and Embase were systematically searched until 3 March 2023.

ELIGIBILITY CRITERIA

Original research studies with patients with SVT, DVT and/or PE as the outcome and presenting cross-sectional or prognostic predictive factors.

DATA EXTRACTION AND SYNTHESIS OF RESULTS

The CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling (CHARMS) checklist for prognostic factor studies was used for systematic extraction of study characteristics. Per identified predictive factor, relevant estimates of univariable and multivariable predictor-outcome associations were extracted, such as ORs and HRs. Estimates of association for the most frequently reported predictors were summarised in forest plots, and meta-analyses with heterogeneity were presented. The Quality in Prognosis Studies (QUIPS) tool was used for risk of bias assessment and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for assessing the certainty of evidence.

RESULTS

Twenty-two studies were included (n=10 111 patients). The most reported predictive factors were high age, male sex, history of venous thromboembolism (VTE), absence of varicose veins and cancer. Pooled effect estimates were heterogenous and ranged from OR 3.12 (95% CI 1.75 to 5.59) for the cross-sectional predictor cancer to OR 0.92 (95% CI 0.56 to 1.53) for the prognostic predictor high age. The level of evidence was rated very low to low. Most studies were scored high or moderate risk of bias.

CONCLUSIONS

Although the pooled estimates of the predictors high age, male sex, history of VTE, cancer and absence of varicose veins showed predictive potential in isolation, variability in study designs, lack of multivariable adjustment and high risk of bias prevent firm conclusions. High-quality, multivariable studies are necessary to be able to identify individual SVT risk profiles.

PROSPERO REGISTRATION NUMBER

CRD42021262819.

Oberflächliche Venenthrombose der Beinvenen – Eine systematische Übersicht – Teil 1: Definition, Ätiologie, Diagnostik

Einleitung Die oberflächliche Venenthrombose (OVT) der Beinvenen ist mit einer Inzidenz von 0,5–1/1000 Einwohner/Jahr ein häufiges und mit einer Frequenz assoziierter thromboembolischer Ereignisse in bis zu 25 % der Fälle ein ernst zu nehmendes Krankheitsbild. In der vorliegenden Übersichtsarbeit sollen alle relevanten Aspekte der OVT basierend auf der aktuellen wissenschaftlichen Literatur behandelt werden.

Methoden Die systematische Übersicht umfasst das Wissen über die OVT basierend auf dem gesamten, systemisch recherchierten Erkenntnismaterial in den Datenbanken PubMed und Google Scholar. Eine Literaturrecherche in PubMed von Publikationen (1968–2018) mit den Suchbegriffen „Superficial vein thrombosis; thrombophlebitis“ ergab 102 aussagekräftige Arbeiten, die nach Vorlage der Originalarbeit ausgewertet wurden. Teil 1 der Arbeit behandelt Aspekte zur Definition, Klassifikation, Ätiologie und Diagnostik.

Ergebnisse Die OVT manifestiert sich klinisch neben den typischen Entzündungszeichen als strangförmige Induration, die Ausdruck eines thrombotischen Verschlusses epifaszialer Venen ist. Ätiologisch bedeutsam ist das Vorhandensein von Varikose (68 % der Fälle), Adipositas (23 %), Gerinnungsstörungen (18 %) und Tumorleiden (8 %). Das Durchschnittsalter der Betroffenen beträgt 62 Jahre, in 60 % der Fälle sind Frauen betroffen. Zunehmendes Lebensalter ist ein relevanter Risikofaktor. Diagnostisch ist es wichtig, das genaue Ausmaß der OVT zu beschreiben, insbesondere die Thrombuslänge und die Entfernung zum tiefen Venensystem. Dies, einschließlich der Beurteilung des tiefen Beinvenensystems, sollte bei jedem Patienten mit möglicher OVT zeitnah mittels Ultraschalldiagnostik erfolgen. Eine hier vorgeschlagene Klassifikation von 4 Ausprägungsgraden der OVT kann die Zuordnung zur aktuell empfohlenen Therapie erleichtern.

Schlussfolgerung Aufgrund der Häufigkeit und des Risikos potenziell lebensbedrohender Komplikationen sollte der OVT der Beinvenen eine größere Beachtung zukommen, insbesondere mit Blick auf eine spezialisierte Diagnostik durch Phlebologen.

Analysis of vascular involvement in 460 patients with Behçet's syndrome: Clinical characteristics and associated factors

OBJECTIVES

To describe demographic and clinical characteristics of vascular involvement in patients with Behçet's syndrome (BS) and to evaluate associations with such involvement.

METHODS

We retrospectively evaluated records of 2118 BS patients. In total, 460 patients diagnosed with superficial thrombophlebitis (ST) and/or major vascular events (venous and/or arterial involvements) were included in current analysis. Isolated ST with no accompanying deep venous thrombosis might be accepted as part of skin involvement; therefore, we defined two different outcomes for vascular involvement ("any vascular event" and "major vascular events") and performed univariable and multivariable logistic regression to assess factors associated with these outcome variables.

RESULTS

Overall, 68 (14.8%) patients had isolated ST, and 392 (85.2%) had major vascular events. The mean age of vascular BS was 33.8 (SD: 10.5) years and median follow-up was 13.9 (Q1-Q3: 8.3-22.9) years. The primary sites of major vascular events were deep venous thrombosis (n=358, 77.8%), pulmonary arterial involvement (n=66, 14.3%), extrapulmonary arterial involvement (n=52, 11.3%), and intracardiac thrombosis (n=14, 3.0%), respectively. Male sex was significantly associated with a higher risk for both outcome variables. When it was added to analysis, ST itself was the strongest explanatory variable that was associated with major vascular events in all multivariable models (ORs=11.9, 12.0, 13.0, and 18.9). While HLA-B51 was significantly associated with any vascular event, there was no similar observation for major vascular events.

CONCLUSION

Male sex is a well-known risk factor for major vascular events in BS, but our study established that presence of ST was the strongest risk factor.

Prospective Analysis of the Mechanisms Underlying Ineffective Deep Vein Thrombosis Prophylaxis in Necrotizing Pancreatitis

BACKGROUND

Patients with necrotizing pancreatitis (NP) have the highest rate of venous thromboembolism (VTE) of any hospitalized patient (57%). We hypothesized that VTE prophylaxis might be inadequate in the setting of this profound inflammatory disease and that early detection of deep vein thrombosis would limit pulmonary embolism.

STUDY DESIGN

All patients with NP treated at a single center between August 2018 and December 2019 were enrolled in prospective, weekly VTE screening, including 4-extremity duplex ultrasound. Routine chemoprophylaxis included low-molecular-weight or unfractionated heparin. Peak serum anti-factor Xa concentration was measured during weekly screening (goal prophylaxis 0.2 to 0.4 IU/mL).

RESULTS

Eighty-five patients with NP underwent a total of 201 screening events (mean 2.4 per patient). VTE developed in 55 patients (65%), including splanchnic vein thrombosis in 41 patients (48%) and extremity deep vein thrombosis (eDVT) in 32 patients (38%). Extremity DVT was diagnosed a mean ± SD of 44 ± 30 days after NP onset. Symptomatic pulmonary embolism was prevented in all patients diagnosed with eDVT and no contraindication to anticoagulation (0 of 29). Prophylactic anti-factor Xa concentration was only achieved in 21% (12 of 57 screening events); no eDVTs developed in patients achieving prophylactic anti-factor Xa concentration.

CONCLUSIONS

In patients with NP, identification of eDVT by screening ultrasound permits early treatment and prevents symptomatic pulmonary embolism. Fixed dosing of chemical prophylaxis is inadequate in most patients with NP and likely contributes to the mechanism of increased VTE in NP.

A haemodynamic concept in the management of superficial non-saphenous vein thrombosis

Objective

Through the analysis of the haemodynamic model in the development of superficial non-saphenous vein thrombosis, the authors propose a therapeutic approach which is based on an ultrasound study of the superficial and perforating venous system of the lower limbs.

Methods

The authors propose the development of a haemodynamic model in the evolution of superficial non-saphenous vein thrombosis. They analyse three cases to highlight the importance of venous haemodynamics in the development of this condition and its possible complications, such as the progression of thrombosis in the deep vein system through the perforating veins.

Results

The evolution of a thrombosis in the venous network of the lower limbs from the peripheral collateral veins to the deep vein can be haemodynamically explained through this model involving the perforating vein system.

Conclusions

In the management and treatment of superficial non-saphenous vein thrombosis, it is essential to perform an accurate ultrasound evaluation of the superficial venous system, the deep venous system and the perforator system, according to venous haemodynamic principles. This study proposes a new model to be used in the ultrasonic management and treatment of superficial non-saphenous vein thrombosis.

Prevalence of deep vein thrombosis and pulmonary embolism in patients with superficial vein thrombosis: a systematic review and meta-analysis

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.

Does cryostripping add anything to the treatment of the ascending thrombophlebitis of the great saphenous vein?

OBJECTIVE

To analyse the differences of outcome between cryostripping and conservative therapy in the treatment of superficial vein thrombosis.

PATIENTS AND METHODS

A retrospective analysis was performed between the October of 2001 and the October of 2014. In all, 246 cases were eligible for the study. High ligation, cryostripping and local thrombectomy was carried out on 94 patients with thrombophlebitis of the proximal part of the great saphenous vein. Thromboembolic events, the presence of residual varices and time for recovery were compared to 152 cases treated conservatively because of superficial vein thrombosis.

RESULTS

Thromboembolic events were found without significant difference (mean ± SD for surgery: 1.11 ± 0.60 and conservative therapy: 1.11 ± 0.55; p = 0.988) in each group. The presence of residual varices (mean ± SD for surgery: 1.03 ± 0.52 and conservative therapy: 1.42 ± 0.99; p = 0.001) and the time for recovery (mean ± SD for surgery: 15 ± 10.50 and conservative therapy: 26 ± 12.32; p < 0.001) were more favourable in the cryostripping group.

CONCLUSION

Our analysis confirmed that cryostripping does not result in a lower risk for thromboembolic complications due to superficial vein thrombosis but can be an alternative method to treat the ascending thrombophlebitis of the great saphenous vein because it has some advantages over conservative treatment on the short term.

Risk of venous and arterial thrombotic events in patients diagnosed with superficial vein thrombosis: a nationwide cohort study

Recently, it has become apparent that superficial vein thrombosis (SVT) can have serious complications. However, the magnitude of the risk of subsequent deep venous and arterial thrombotic events remains unknown. We examined this in a nationwide population-based setting during a period when SVT was not treated routinely with anticoagulants. The Danish National Registry of Patients, covering all Danish hospitals, was used to identify 10 973 patients with a first-time diagnosis of SVT between 1980 and 2012. A comparison cohort of 515 067 subjects, matched by age, gender, and calendar year, was selected from the general Danish population. Outcomes were venous thromboembolism, acute myocardial infarction, ischemic stroke, and death. During median follow-up of 7 years, the incidence rate of venous thromboembolism was 18.0/1000 person-years (95% confidence interval [CI], 17.2-18.9). The highest risk occurred in the first 3 months (3.4%; 95% CI, 3.0-3.7). Compared with the general population, the hazard ratio was 71.4 (95% CI, 60.2-84.7) in this period, steadily decreasing to 5.1 (95% CI 4.6-5.5), 5 years after the SVT. The hazard ratios for acute myocardial infarction, stroke, and death were 1.2 (95% CI, 1.1-1.3), 1.3 (95% CI, 1.2-1.4), and 1.3 (95% CI, 1.2-1.3), respectively, with the highest risk also shortly after SVT. These data indicate the prognostic importance of SVT and may form the basis for clinical decision-making regarding anticoagulation.

The risk of venous thrombosis in individuals with a history of superficial vein thrombosis and acquired venous thrombotic risk factors

Superficial vein thrombosis (SVT) increases the risk of venous thrombosis fourfold to sixfold. As most individuals with SVT do not develop venous thrombosis, additional risk factors may explain the risk of developing a venous thrombosis. In the Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis study, we assessed the risk of venous thrombosis in individuals with previous SVT and a mild thrombotic risk factor (smoking or overweight/obesity), a strong risk factor (surgery, hospitalization, plaster cast immobilization, or malignancy), or a reproductive factor in women (oral contraception, postmenopausal hormone therapy, or pregnancy/puerperium). Individuals with previous SVT alone had a 5.5-fold (95% confidence interval [CI], 4.4-6.8) increased risk of venous thrombosis. This was 9.3 (95% CI, 7.2-12.1) combined with a mild thrombotic risk factor, 31.4 (95% CI, 14.6-67.5) with a strong risk factor, and 34.9 (95% CI, 19.1-63.8) in women with a reproductive risk factor. The highest separate risk estimates were found for SVT with surgery (42.5; 95% CI, 10.2-177.6), hospitalization (49.8; 95% CI, 11.9-209.2), or oral contraception (43.0; 95% CI, 15.5-119.3 in women). In conclusion, the risk of venous thrombosis is markedly increased in individuals with previous SVT who have an acquired thrombotic risk factor.

The skin and hypercoagulable states

Hypercoagulable states (HS) are inherited or acquired conditions that predispose an individual to venous and/or arterial thrombosis. The dermatologist can play a vital role in diagnosing a patient's HS by recognizing the associated cutaneous manifestations, such as purpura, purpura fulminans, livedo reticularis, livedo vasculopathy (atrophie blanche), anetoderma, chronic venous ulcers, and superficial venous thrombosis. The cutaneous manifestations of HS are generally nonspecific, but identification of an abnormal finding can warrant a further workup for an underlying thrombophilic disorder. This review will focus on the basic science of hemostasis, the evaluation of HS, the skin manifestations associated with hypercoagulability, and the use of antiplatelet and anticoagulant therapy in dermatology.

Superficial venous thrombosis and compression ultrasound imaging

BACKGROUND

A current debate concerning suspected superficial vein thrombosis (SVT) focuses on the need of performing a compression ultrasound (CUS) exploration for confirming the diagnosis of SVT. This study was conducted to determine the clinical relevance and optimal CUS exploration in patients with symptomatic SVT.

METHODS

We analyzed the characteristics of SVT and concomitant deep vein thrombosis (DVT) in patients included in the Prospective Observational Superficial Thrombophlebitis (POST) multicenter, observational prospective study. All patients underwent complete bilateral lower limb CUS, exploring both the superficial and deep venous systems.

RESULTS

A total of 844 patients with clinical symptoms of SVT were recruited, of which 99 isolated SVTs (21.4%) had saphenofemoral/popliteal junction involvement, and 198 (23.5%) had a concomitant DVT, with 41.8% of them proximal DVTs. In 83 patients (41.9%), DVT and SVT were not contiguous. Five of 639 patients (1%) had an isolated contralateral DVT (ie, not bilateral). Age ≥ 75 years (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.6-3.4), inpatient status (OR, 5.4; 95% CI, 3.4-8.7), a personal history of DVT or pulmonary embolism (OR, 1.8; 95% CI, 1.2-2.8), and SVT on nonvaricose veins (OR, 3.3; 95% CI, 2.1-5.0) were significantly and independently associated with an increased risk of concomitant DVT. Half of the patients exhibited none of these risk factors, and the prevalence of concomitant DVT dropped to 11%.

CONCLUSIONS

In patients with symptomatic SVT, a CUS exploration screening the whole venous system of the affected limb is useful because it provides information that has important consequences for the management of these patients.