Editor's Choice - European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

Trend, clinical characteristics, and pregnancy outcomes of pregnancy associated venous thromboembolism: a retrospective analysis of nearly 10 years

BACKGROUND

Pregnancy-associated venous thromboembolism (PA-VTE) seriously threatens maternal health. We aimed to investigate the clinical characteristics, risk factors, treatments, and pregnancy outcomes to better prevent and treat PA-VTE.

METHODS

PA-VTE patients were selected from 171,898 women who were registered in the Department of Obstetrics of Fujian Maternity and Child Health Hospital from January 2014 to August 2023 and delivered to calculate the incidence. Clinical data were collected to retrospectively analyze the clinical characteristics, risk factors, treatments, and pregnancy outcomes of PA-VTE. Descriptive statistical analysis was used.

RESULTS

There were 122 cases of PA-VTE with an incidence of 0.71 per 1000 pregnancies; the incidence showed an upward trend and peaked in 2022 (1.24‰). Pregnant women accounted for 28.69% (35/122), the onset were 5-39+6 weeks and incidence increased with the increase of trimester, reaching the highest level in puerperium with 87 cases (71.31%). VTE was mainly found in the lower extremities (112/122); a few were found in cranial venous sinus (4/122), pelvic vein (1/122), and pulmonary embolism (PE) in five cases. 78.68% (96/122) had clinical manifestations. By Royal College of Obstetricians and Gynaecologists (RCOG) risk assessment scale, 45.71% (16/35) of antepartum patients had risk score ≥3 with a maximum of 9, distributed in eight cases in the first trimester, four cases in the second trimester, and four cases in the third trimester. Patients with risk score <3 all occurred in the second and third trimester. Primary risk factors included advanced maternal age (AMA), thrombophilia. All patients received anticoagulant therapy, and seven patients were placed inferior vena cava (IVC) filter in antepartum period. Except one case of abortion in PPROM, the rest continued pregnancy to 29+1 to 40 weeks, only one case of postpartum hemorrhage and one case of severe neonatal asphyxia. The onset time in puerperium was three hours to 28 days after delivery; 62.07% (54/87) patients were scored ≥2. The main risk factors included elective cesarean section, AMA, and preterm birth. Anticoagulant therapy was given after diagnosis; two cases were placed with IVC filter, one case was placed with left iliac vein stent and thrombolysis.

CONCLUSIONS

The incidence of PA-VTE showed an increasing trend over the past decade, predominantly occurring postpartum. Main risk factors included AMA, thrombophilia, preterm birth, and elective cesarean section. Higher risk scores correlated with earlier onset. Early risk assessment, appropriate prophylaxis, and standardized anticoagulation therapy resulted in favorable maternal and fetal outcomes, with temporary IVC filter placement being beneficial in selected cases.

Revisiting the Open Vein Hypothesis to Reduce the Postthrombotic Syndrome: Implications for Multidisciplinary Care and Research: A Scientific Statement From the American Heart Association

The "open vein hypothesis" postulates that early thrombus clearance and restoration of venous blood flow may prevent postthrombotic syndrome after proximal deep vein thrombosis. Since its proposal several decades ago, new insights from basic and clinical studies have motivated a re-evaluation and refinement of this hypothesis. According to data from these studies, susceptibility to postthrombotic syndrome occurs as a result of differences in genetic composition, thrombophilic conditions, predilection to inflammation and fibrosis, endogenous fibrinolytic capability, timing of symptom presentation and treatment initiation, and efficacy of antithrombotic therapy. Although initial restoration of an open vein appears to be beneficial for selected patient groups, freedom from postthrombotic syndrome is more likely in the setting of long-term venous patency, reduced recurrent thrombotic episodes, and reduced perithrombotic (eg, vein wall and valve) inflammation. These underlying biological mechanisms need further elucidation, with a long-term goal of personalizing treatment by mapping the individuals' clinical presentation with their underlying risk factors and assessing time-dependent biological processes that occur as a clinical venous thrombosis resolves. This scientific statement (1) highlights historical fundamentals of the open vein hypothesis and then showcases new research insights into the pathophysiological factors driving postthrombotic syndrome; (2) discusses advantages and disadvantages of imaging modalities for deep vein thrombosis used in clinical practice, including the potential to depict thrombus chronicity and status of vein wall injury; (3) proposes measures to develop integrated multidisciplinary care for deep vein thrombosis focused on the reduction of postthrombotic syndrome; and (4) identifies priority areas and questions for further research.

Improvement of rheolytic thrombectomy for acute deep vein thrombosis of the whole lower limb by primary popliteal vein thrombosis clearance: protocol for (the Reformation study)

INTRODUCTION

Pharmacomechanical thrombectomy (PMT) can be a useful treatment for restoring vein patency quickly, especially for extensive acute deep vein thrombosis (DVT). However, previous evidence failed to validate the effectiveness of PMT in reducing the incidence of post-thrombotic syndrome (PTS). To address this controversy, the reformation study aims to improve rheolytic thrombectomy for acute DVT of the lower limb through primary popliteal vein thrombosis clearance.

METHOD AND ANALYSIS

Reformation is a prospective randomised multicentre trial. It has 160 patients in two groups: the modified access group (80 patients) and the traditional access group (80 patients). The purpose of this study is to assess whether the modified access approach for removing inflow thrombus in a one-stage procedure is more effective in enhancing the success rate of the procedure and reducing the incidence of PTS during a 24-month follow-up period, for patients with acute whole limb DVT.

ETHICS AND DISSEMINATION

The reformation study has been registered at www.

CLINICALTRIALS

gov. The study protocol has been approved by the Institutional Review Board and Human Research Ethics Committee of Renji Hospital, School of Medicine, Shanghai Jiao Tong University (approved number: KY2021-067-A). The results will be disseminated by publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05286710.

PROTOCOL VERSION AND DATE

V.1.2, 20 August 2022.

Fright of Long-Haul Flights: Focus on Travel-Associated Thrombosis

Travel-related thrombosis (TRT), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), poses a significant health risk associated with long-haul travel. Prolonged immobility, dehydration, and cabin pressure changes during flights contribute to venous stasis, hypoxia, and hypercoagulability, collectively increasing the risk of venous thromboembolism (VTE). While the absolute risk of TRT is relatively low in the population overall, it rises significantly among high-risk groups, including individuals with a history of VTE, thrombophilia, pregnancy, or recent surgery. This review explores the epidemiology, pathophysiology, clinical presentation, and diagnostic evaluation of TRT while highlighting the importance of early recognition and prevention. Risk assessment models can provide guidance for identifying at-risk travelers. Preventive strategies include pharmacological prophylaxis with low-molecular-weight heparin (LMWH) for high-risk individuals and nonpharmacological measures such as compression stockings, intermittent pneumatic compression, mobility exercises, and hydration. Guidelines from international societies recommend tailored interventions based on individual risk profiles, as randomized controlled trials are scarce. Given that long-haul travel dramatically expands, this review critically analyzes the available TRT management strategies in various clinical settings, aiming to increase awareness of this global health issue.

Management of Short Saphenous Vein Thrombosis Close to the Saphenopopliteal Junction: A Survey of the Membership of HaemSTAR, British Society for Haemostasis and Thrombosis and VTE Exemplar Centres in the United Kingdom

Introduction

The optimal management of superficial thrombophlebitis (STP) close to the saphenopopliteal junction (SPJ) is not known.

Methods

We conducted an online survey of members of the HaemSTAR network, British society of haemostasis and thrombosis and UK VTE exemplar network over a 6-week period.

Results

Fifty-three respondents participated in the survey (estimated 22% response rate). Note that 89% of respondents indicated they would manage all STP at the SPJ with anticoagulation, with 70% indicating they would offer 3 months of therapeutic anticoagulation. The most common threshold for instigating anticoagulation was being within 3 cm off the SPJ (68%). Factors most associated with the decision to anticoagulate included previous thrombosis, active malignancy, persistent immobilisation and severe symptoms (with hospitalisation, hyperestrogenaemic states, thrombophilia and recent surgery being additionally identified in the non-treatment group).

Conclusion

Despite lack of evidence, most UK practitioners surveyed offered intermediate to treatment doses of anticoagulation in the case of STP within 3 cm of the SPJ. Further research is needed to assess the validity of this approach.

Trial Registration

The authors have confirmed clinical trial registration is not needed for this submission.

Consensus on the Management of the Clinical Challenges of Venous Thromboembolism in Special Situations

Venous thromboembolism (VTE) can present different challenging situations for which high-quality evidence to guide optimal preventive and therapeutic management is lacking and for which clinical practice guidelines have not established solid recommendations. The aim of this article is to achieve consensus on a proposal of action for the clinical management of complex, clinically relevant situations with a low level of evidence which generate great uncertainty-the duration of VTE treatment and the role of thrombus recanalization, the prevention of VTE within the context of pregnancy, management of anticoagulant treatment in patients with VTE and special characteristics, such as renal insufficiency and obesity, the therapeutic management of pluripathological and polymedicated older patients with VTE, and finally, primary ambulatory thromboembolic prevention in cancer patients. This consensus article arose from a collaboration of experts in VTE from different medical specialties.

Catheter-Directed Thrombolysis vs. Anticoagulation in Deep Vein Thrombosis: A Comparative Study

Background: Deep vein thrombosis (DVT) is an important component of venous thromboembolism and can lead to pulmonary embolism with high morbidity and mortality. Anticoagulant therapy alone (AC) and catheter-directed thrombolysis (CDT) are commonly used strategies for the management of DVT. Although CDT has been reported to be effective in reducing the risk of post-thrombotic syndrome (PTS), it remains unclear in which patient groups it should be preferred due to the risk of bleeding. Methods: This retrospective study included 175 patients diagnosed with DVT between 2015 and 2024 (98 AC, 77 CDT). Patients with a diagnosis of proximal DVT, aged ≥18 years, and with at least 30 days of follow-up data were included. The primary endpoint was 30-day mortality and secondary endpoints were the length of hospitalization, pulmonary embolism, and bleeding complications. Results: The CDT group was superior to AC in thrombus clearance rates, especially in iliac vein thrombosis (97.7% vs. 78%, p = 0.003). Clinical symptoms improved faster in the CDT group, but total hospitalization was longer. There were no significant differences in bleeding complications and mortality rates between the two groups. Conclusions: The optimal approach to DVT treatment should be based on the patient's individual risk factors. Although CDT provides a higher thrombus clearance rate, especially in iliac vein thrombosis, it may not be suitable for all patients. Future large-scale studies will contribute to a better understanding of the long-term outcomes of interventional therapies.

Age-related risk factors and manifestations in deep venous thrombosis

ObjectiveThe incidence, risk factors, and clinical presentation of deep venous thrombosis (DVT) vary with age. This study aimed to evaluate the differences in clinical characteristics of DVT among patients of different ages.MethodsWe retrospectively analyzed 938 patients with symptomatic lower extremity DVT admitted to our hospital between January 2020 and January 2024. Patients were categorized into youth (<40 years), middle-aged (40-64 years), and elderly (>65 years) groups. Demographic data, comorbidities, risk factors, clinical presentations, and management approaches were collected and analyzed.ResultsMost participants were middle-aged or elderly, with young patients constituting only 11.19% of the study population. The youth group had a slight female predominance, while the middle-aged and elderly group had a balanced gender distribution. The elderly group were more likely to have comorbidities such as diabetes and malignancies, though they had a lower prevalence of autoimmune diseases compared to younger patients. Congenital risk factors were relatively rare in the overall population, yet were present in 22.86% of young patients, a significantly higher proportion than in the middle-aged and elderly groups. Most patients with DVT were provoked, especially in the elderly group. The prevalence of concurrent congenital and acquired factors was 13.33% in the youth group, compared to only 4.97% in the middle-aged group and 2.88% in the elderly group. Proximal DVT was most frequent in middle-aged patients, while young patients were more likely to seek treatment in the acute phase and undergo surgical intervention. Anticoagulation noncompliance was noted in nearly 40% of elderly patients but only 6.67% of young patients.ConclusionRisk factors and clinical characteristics of DVT vary significantly with age, particularly between young and elderly patients. Young patients were more inclined to seek prompt and effective treatment and demonstrated better adherence to anticoagulation therapy.

Mechanical thrombectomy and catheter directed thrombolysis utilization in patients with deep vein thrombosis: Analysis of a database of a tertiary hospital

OBJECTIVES

The aim of the study was to assess the mechanical thrombectomy (MT) and catheter-directed thrombolysis (CDT) use in patients with deep vein thrombosis (DVT) in tertiary care.

METHODS

We conducted a single-center retrospective cohort study. A tertiary hospital database from January 2022 to December 2023 was analyzed. All records of patients referred for DVT were extracted. The collected data included general patient information, medical history, results of physical examination, duplex ultrasound, and laboratory analyses. We assessed indications and contraindications for MT and CDT considering possible benefits and risks. We have identified patients who could be eligible for this technique.

RESULTS

A total of 2427 patients with DVT were referred to hospital from January 2022 to December 2023. Among them, 961 patients (39.6%) had no indications for hospital admission or refused it and were recommended to receive anticoagulation on an outpatient basis, and 1466 patients (60.4%) were admitted to the hospital. Among the hospitalized patients, 1277 had a proximal DVT and 189 had a distal DVT. The number of patients with iliofemoral DVT was 451 (18.6%). We found only 82 cases (3.4%) that could be potentially eligible for endovascular thrombectomy considering all possible indications and contraindications. Two attempts and 14 successful procedures were conducted during the period of the study.

CONCLUSIONS

The number of patients with DVT who could be eligible for MT and CDT in a tertiary hospital is low.

Plasma D-dimer changes and clinical value in acute lower extremity deep venous thrombosis treated with catheter-directed thrombolysis

OBJECTIVE

This study sought to investigate the changes in plasma D-dimer levels during catheter-directed thrombolysis (CDT) in patients with acute lower extremity deep venous thrombosis (DVT), analyze imaging results, and assess their clinical implications.

METHODS

We retrospectively analyzed 62 patients diagnosed with acute lower extremity DVT who underwent CDT between March 2019 and December 2022. Plasma D-dimer levels were measured before CDT, at regular intervals after CDT, and at the end of CDT. Lower limb venography was performed every 2 days during CDT to assess the thrombus clearance rate and level of thrombus dissolution. Statistical analyses were conducted to observe the D-dimer concentration changes and analyze the correlation between D-dimer concentration and thrombus clearance rate. Additionally, a receiver operating characteristic curve was constructed to determine the diagnostic performance of D-dimer in assessing the efficacy of thrombolysis, including the calculation of the area under the curve, sensitivity, specificity, and optimal cut-off value.

RESULTS

During CDT for acute lower extremity DVT, plasma D-dimer levels rapidly increased, peaking on CDT day 1, and then gradually decreased, followed by a rapid decline, but remained slightly elevated compared with normal levels. There was a positive correlation between D-dimer levels and thrombolysis efficacy (r = 0.809; P = .00). The linear regression equation for this correlation was Y = 0.161 + 0.028X. The area under the curve of D-dimer was 0.95, with a cut-off value of 9.935 mg/L (sensitivity, 93.2%; specificity, 95.4%).

CONCLUSIONS

Plasma D-dimer concentration can serve as an indicator for evaluating the efficacy of thrombolysis during CDT in acute lower extremity DVT.

Editor's Choice - Reporting and Methodological Quality of Systematic Reviews Underpinning Clinical Practice Guidelines for Vascular Surgery: A Systematic Review

OBJECTIVE

Clinical practice guideline recommendations are often informed by systematic reviews. This review aimed to appraise the reporting and methodological quality of systematic reviews informing clinical practice recommendations relevant to vascular surgery.

DATA SOURCES

MEDLINE and Embase.

METHODS

MEDLINE and Embase were searched from 1 January 2021 to 5 May 2023 for clinical practice guidelines relevant to vascular surgery. Guidelines were then screened for systematic reviews informing recommendations. The reporting and methodological quality of these systematic reviews were assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement and Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) 2017 tool. Pearson correlation and multiple regression analyses were performed to determine associations between these scores and extracted study characteristics.

RESULTS

Eleven clinical practice guidelines were obtained, containing 1 783 references informing guideline recommendations. From these, 215 systematic reviews were included for synthesis. PRISMA item completeness ranged 14 - 100%, with a mean of 63% across reviews. AMSTAR 2 item completeness ranged 2 - 95%, with a mean of 50%. Pearson correlation highlighted a statistically significant association between a review's PRISMA and AMSTAR 2 score (r = 0.85, p < .001). A more recent publication year was associated with a statistically significant increase in both scores (PRISMA coefficient 1.28, p < .001; and AMSTAR 2 coefficient 1.31, p < .001). Similarly, the presence of funding in a systematic review was shown to be statistically significantly associated with an increase in both PRISMA and AMSTAR 2 scores (coefficient 4.93, p = .024; and coefficient 6.07, p = .019, respectively).

CONCLUSION

Systematic reviews informing clinical practice guidelines relevant to vascular surgery were of moderate quality at best. Organisations producing clinical practice guidelines should consider funding systematic reviews to improve the quality of their recommendations.

An artificial intelligence interpretable tool to predict risk of deep vein thrombosis after endovenous thermal ablation

OBJECTIVE

Endovenous thermal ablation (EVTA) stands as one of the primary treatments for superficial venous insufficiency. Concern exists about the potential for thromboembolic complications following this procedure. Although rare, those complications can be severe, necessitating early identification of patients prone to increased thrombotic risks. This study aims to leverage artificial intelligence-based algorithms to forecast patients' likelihood of developing deep vein thrombosis (DVT) within 30 days following EVTA.

METHODS

From 2007 to 2017, all patients who underwent EVTA were identified using the American College of Surgeons National Surgical Quality Improvement Program database. We developed and validated four machine learning models using demographics, comorbidities, and laboratory values to predict the risk of postoperative DVT: Classification and Regression Trees (CART), Optimal Classification Trees (OCT), Random Forests, and Extreme Gradient Boosting (XGBoost). The models were trained using all the available variables. SHapley Additive exPlanations analysis was adopted to interpret model outcomes and offer medical insights into feature importance and interactions.

RESULTS

A total of 21,549 patients were included (mean age, 54 ± 14 years; 67% female). In this cohort, 1.59% developed DVT. The XGBoost model had good discriminative power for predicting DVT risk with area under the curve of 0.711 in the hold-out test set for the all-variable model. Stratification of the test set by age, body mass index, preoperative white blood cell count, and platelet count shows that the model performs equally well across these groups.

CONCLUSIONS

We developed and validated an interpretable model that enables physicians to predict which patients with superficial venous insufficiency has higher risk of developing DVT within 30 days following EVTA.

Exploring the efficacy of recombinant human pro-urokinase in catheter-directed thrombolysis for acute lower extremity deep venous thrombosis patients

BACKGROUND

Effective and innovative treatment for patients with acute lower-extremity deep venous thrombosis (DVT) is lacking. This study explored the use of recombinant human pro-urokinase (rhPro-UK) in catheter-directed thrombolysis for acute DVT patients.

METHODS

A retrospective analysis included 85 acute DVT patients undergoing CDT from January 2021 to December 2023. Patients were divided into an observation group (n = 43, rhPro-UK) and a control group (n = 42, UK). Outcomes assessed included total effective rate, venous patency score, limb circumference differences, coagulation parameters (PT, APTT, Fg), adverse events (BARC criteria), and post-thrombotic syndrome (PTS) incidence at 6 months (Villalta scale).

RESULTS

The observation group treated with rhPro-UK demonstrated superior clinical outcomes compared to the control group receiving urokinase. The total effective rate was significantly higher in the rhPro-UK group (P = 0.011), with improved venous patency reflected by a lower post-treatment patency score (P = 0.009) and higher patency rate (80.86% vs. 72.86%, P = 0.045). Limb swelling reduction was more pronounced in the rhPro-UK group, evidenced by smaller thigh (P = 0.002) and calf circumference differences (P = 0.001). Coagulation function improved significantly, with prolonged PT (P = 0.002) and APTT (P = 0.001), alongside reduced fibrinogen levels (P < 0.001). Safety outcomes favored rhPro-UK, with fewer total bleeding events (14.29% vs. 4.65%, P = 0.039) and no major bleeding (BARC Type 3) observed. At 6-month follow-up, the rhPro-UK group exhibited a markedly lower incidence of post-thrombotic syndrome (9.3% vs. 26.2%, P = 0.034) and sustained venous patency, confirming its long-term efficacy.

CONCLUSION

CDT with rhPro-UK significantly improves venous patency, reduces limb swelling, optimizes coagulation function, and minimizes complications compared to UK. Its fibrin-targeted mechanism enhances clinical efficacy and safety, supporting its adoption as a superior thrombolytic for acute DVT.

TRIAL REGISTRATION

Not applicable.

Association Between White Blood Cell Counts at Diagnosis and Clinical Outcomes in Venous Thromboembolism - From the COMMAND VTE Registry-2

BACKGROUND

White blood cell (WBC) counts were reported to be a risk factor for acute adverse events in patients with venous thromboembolism (VTE). However, there are limited data on VTE patients without active cancer.

METHODS AND RESULTS

The COMMAND VTE Registry-2 was a multicenter study enrolling 5,197 consecutive patients with acute symptomatic VTE. We divided 3,668 patients without active cancer into 4 groups based on WBC count quartiles (Q1-Q4) at diagnosis: Q1, ≤5,899 cells/μL; Q2, 5,900-7,599 cells/μL, Q3, 7,600-9,829 cells/μL; and Q4, ≥9,830 cells/μL. Patients in Q4 more often presented with pulmonary embolism (PE) than patients in Q1, Q2, and Q3 (68% vs. 37%, 53%, and 61%, respectively; P<0.001). The proportion of massive PEs among all PEs was higher in Q4 than in Q1, Q2, and Q3 (21% vs. 3.4%, 5.8%, and 11%, respectively; P<0.001). Compared with Q1, Q2, and Q3, patients in Q4 had a higher cumulative 5-year incidence of all-cause death (17.0%, 15.2%, 16.1%, and 22.8%, respectively; P<0.001) and major bleeding (10.9%, 11.0%, 10.3%, and 14.4%, respectively; P=0.002). The higher mortality risk of Q4 relative to Q2 was consistent regardless of the presentations of VTEs.

CONCLUSIONS

An elevated WBC count on VTE diagnosis was associated with a higher risk of mortality and major bleeding regardless of VTE presentation, suggesting the potential usefulness of WBC counts for further risk stratification.

How I approach the treatment of thrombotic complications in patients with myeloproliferative neoplasms

ABSTRACT

Arterial and venous thromboses are the most significant complications in patients with myeloproliferative neoplasms (MPNs), with the primary treatment goal being thrombotic risk reduction. In MPN with no history of thrombosis, primary prevention mainly involves the use of aspirin, and cytoreduction is added in high-risk patients. However, thrombotic complications can unveil an MPN in ∼20% of cases, necessitating the initiation of both antithrombotic therapy for the thrombosis and cytoreductive treatment for the MPN. The duration of anticoagulant therapy after an initial venous thromboembolic event is subject to discussion. Furthermore, the occurrence of a thrombotic complication in patients with a known diagnosis of MPN prompts a reconsideration of both antithrombotic and hematologic management. This review uses case-based discussions to explore the management of thrombotic complications in patients with MPN. It addresses the nature and duration of antithrombotic treatments, as well as the approach to cytoreduction. Special attention is given to the place of direct oral anticoagulants and to the management of patients with MPN with splanchnic vein thrombosis, which is disproportionately common in this group.

Low Post-Stent Placement Iliofemoral Vein Peak Velocity by Doppler Ultrasound: Prognostic Implication for Re-Intervention in Thrombotic Iliac Vein Lesions

PURPOSE

To investigate the association between post-stent placement peak velocity in the iliofemoral vein and re-intervention in patients with thrombotic iliac vein lesions.

METHODS

This was a single-center retrospective cohort study. Between January 2014 and February 2024, consecutive patients who received primary stent placement for thrombotic iliac vein lesions with eligible post-procedure duplex ultrasound were included. Twenty random limbs with normal duplex ultrasound findings were selected to investigate the venous peak velocities in normal limbs. Cox regression models were used to determine predictive factors for re-intervention with a hazard ratio (HR).

RESULTS

Fifty-one patients (54 limbs) were included. The mean age was 41.9 ± 18.2 years, and 78.4% were female. During a median follow-up of 32.7 months, 27.7% (15/54) of limbs encountered symptom recurrence with stent malfunction and received re-intervention. There was no significant difference in CIV peak velocity between patent stented limbs and normal limbs (30.3 vs 32.0 cm/s, p = .29). However, the limbs that required re-intervention had a significantly lower CIV peak velocity (25.3 vs 32.0 cm/s, p < .001). Post-stent placement peak velocities in the iliofemoral veins were significantly associated with re-intervention. ROC analysis suggested common iliac vein (CIV) peak velocity had the highest predictive performance (area under curve = 0.76). A CIV peak velocity < 26.6 cm/s (adjusted HR 6.66; p = .016) was significantly associated with an increased re-intervention risk.

CONCLUSION

Low post-stent placement peak velocities in the iliofemoral veins were significantly associated with future re-intervention in patients with thrombotic iliac vein lesions.

LEVEL OF EVIDENCE

Level 4, Case Series.

Iliofemoral Acute Deep Venous Thrombosis, Chronic Deep Venous Thrombosis, and May-Thurner Syndrome

Acute iliofemoral deep vein thrombosis (DVT) is associated with higher rates of severe chronic symptoms and complications, and in rare cases with acute limb ischemia. Early detection is a key to provide prompt treatment, including endovascular intervention, in selected patients. When iliofemoral DVT is related to external compression of the left iliac vein by the right common iliac artery is termed May-Thurner syndrome. Approximately, 20% to 50% of patients with chronic DVT will develop post-thrombotic syndrome, a collection of symptoms including lower extremity edema, skin changes, vein dilation, pain, fatigue, and ulcer formation.

Clinical Practice Guideline for detection and management of diabetic kidney disease: A consensus report by the Spanish Society of Nephrology

To address all the changes in the management of people with diabetes (DM) and chronic kidney disease (CKD), under the auspices of the Spanish Society of Nephrology (SEN), the Spanish Diabetic Nephropathy Study Group (GEENDIAB) decided to publish an updated Clinical Practice Guideline for detection and management of diabetic kidney disease (DKD). It is aimed at a wide audience of clinicians treating diabetes and CKD. The terminology of kidney disease in diabetic patients has evolved toward a more inclusive nomenclature that avoids underdiagnosis of this entity. Thus, the terms "diabetes and kidney disease" and "diabetic kidney disease" are those proposed in the latest KDIGO 2022 guidelines to designate the whole spectrum of patients who can benefit from a comprehensive therapeutic approach only differentiated according to eGFR range and albuminuria. Recommendations have been divided into five main areas of interest: Chapter 1: Screening and diagnosis of diabetic kidney disease, Chapter 2: Metabolic control in people with diabetes and CKD, Chapter 3: Blood pressure control in people with diabetic kidney disease, Chapter 4: Treatment targeting progression of CKD in people with diabetic kidney disease, and Chapter 5: Antiplatelet or anticoagulant therapy in people with diabetes and CKD. World Health Organization (WHO) recommendations for guideline development were followed to report this guideline. Systematic reviews were carried out, with outcome ratings and summaries of findings, and we reported the strength of recommendations following the "Grading of Recommendations Assessment, Development and Evaluation" GRADE evidence profiles.

Pre-Induction and Post-discharge Venous Thromboembolism Chemoprophylaxis Should be Considered in Patients After Major Vascular Open Abdominal Procedures

BACKGROUND

Venous thromboembolism (VTE) is a significant morbidity following major open abdominal surgery. While there are clear recommendations for perioperative and post-discharge VTE chemoprophylaxis in general surgery, guidance for vascular patients is unclear. We compared the incidence of VTE in vascular versus general surgery cases and then investigated the timing of VTE in vascular patients.

METHODS

Two cohorts of major open abdominal surgery, vascular (open abdominal aortic aneurysm and aortoiliac reconstruction) and general, were compared in ACS-NSQIP database. There were significant preoperative differences between cohorts that were corrected using 1:1 propensity matching and logistic regression. Thirty-day outcomes included incidence and timing of VTE (in-hospital and post-discharge), mortality, and major morbidities.

RESULTS

After propensity matching, there were 14,983 and 15,075 patients had vascular and general surgery, respectively. VTE rate was significantly lower in vascular. The distribution of in-hospital and post-discharge VTE was similar in both groups. Over the last 10 years, the overall incidence of VTE has decreased for both general and vascular surgery, with a corresponding decrease in in-hospital VTE but no change in post-discharge VTE. VTE occurrence showed a bimodal distribution with 76.92% of VTE occurring in early period (<14 days) and 23.08% occurring in late period (>14 days), which coincided with in-hospital (77.91%) and post-discharge (22.09%), respectively.

CONCLUSIONS

Although VTE incidence after vascular procedures has decreased, in-hospital VTE may be further reduced if pre-induction subcutaneous heparin is given. Furthermore, 22% VTE developed post-discharge in vascular patients, which suggests post-discharge VTE prophylaxis should be considered in selected high-risk patients.

Cohort study of prediction of venous thromboembolism in emergency department patients with extremity symptoms

Despite diagnostic algorithms, identification of venous thromboembolism (VTE) in emergency departments (ED) remains a challenge. We evaluated symptoms, background, and laboratory data in 27,647 ED patients presenting with pain, swelling, or other symptoms from the extremities, and identified predictors of VTE diagnosis within one year. Predictors of a clinical decision to perform phlebography, ultrasound, or computer tomography (CT) angiography of pelvic, lower, or upper extremity veins, CT of pulmonary arteries, or pulmonary scintigraphy at the ED or within 30 days, and the results of such investigations were also evaluated. A total of 3195 patients (11.6%) were diagnosed with VTE within one year. In adjusted analysis of patients in whom all laboratory data were available, a d-dimer value ≥ 0.5 mg/l (odds ratio [OR]: 2.602; 95% confidence interval [CI] 1.894-3.575; p < 0.001) at the ED and a previous diagnosis of VTE (OR: 6.037; CI 4.465-8.162; p < 0.001) independently predicted VTE within one year. Of diagnosed patients, 2355 (73.7%) had undergone imaging within 30 days after the ED visit and 1730 (54.1%) were diagnosed at this examination. Lower age (OR: 0.984; CI 0.972-0.997; p = 0.014), higher blood hemoglobin (OR: 1.023; CI 1.010-1.037; p < 0.001), C-reactive protein (OR: 2.229; CI 1.433-3.468; p < 0.001), d-dimer (OR: 8.729; CI 5.614-13.574; p < 0.001), and previous VTE (OR: 7.796; CI 5.193-11.705; p < 0.001) predicted VTE on imaging within 30 days, whereas female sex (OR 0.602 [95% CI 0.392-0.924]; p = 0.020) and a previous diagnosis of ischemic heart disease (OR 0.254 [95% CI 0.113-0.571]; p = 0.001) were negative predictors of VTE. In conclusion, analysis of 27,647 ED patients with extremity symptoms confirmed the importance of well-established risk factors for VTE. Many patients developing VTE within one year had initial negative imaging, highlighting the importance of continued symptom vigilance.

Syringe-assisted test-aspiration with mechanical aspiration thrombectomy results in good safety and short-term outcomes in the treatment of patients with deep venous thrombosis

ObjectiveTo evaluate the short-term outcomes and safety of syringe-assisted test-aspiration with mechanical aspiration thrombectomy in the treatment of deep venous thrombosis.MethodsThis was a single-center, retrospective study of hospitalized patients with iliofemoral and/or inferior vena caval deep venous thrombosis, excluding those with pulmonary embolism. We collected the following patient data from the electronic medical records: age, sex, provoked/unprovoked deep venous thrombosis, symptom duration, thrombosed segments, and the presence of a tumor, thrombophilia, diabetes, and/or iliac vein compression syndrome. Venography and computed tomographic venography were performed in all patients before the procedure. All patients underwent syringe-assisted test-aspiration with mechanical aspiration thrombectomy under local anesthesia and sedation, and all received low-molecular-weight heparin peri-operatively. All patients underwent implantation of an inferior vena caval filter. Rivaroxaban was administered post-procedure, instead of heparin, for 3-6 months, with lower extremity compression.ResultsOverall, 29 patients with deep venous thrombosis underwent syringe-assisted test-aspiration with mechanical aspiration thrombectomy from January 2022 to October 2022 in our institution. Technical success (>70% thrombus resolution) was achieved in all patients, and using a single procedure in 25/29 patients (86%). Concomitant stenting was performed in 18/29 (62%) of the patients, and 21/29 (69%) underwent angioplasty. The median (interquartile range) procedure time was 110 min (100-122), the median intra-operative bleeding volume was 150 mL (120-180), and the median decrease in the hemoglobin concentration from pre- to post-operative was 7 g/L (4-14). The median follow-up duration was 7 months (5-9). All patients obtained symptomatic relief, and 27/29 achieved near-remission or full remission (combined total). No patients experienced peri-operative bleeding complications, or symptom recurrence or post-thrombectomy syndrome during follow-up.ConclusionThe short-term outcomes following syringe-assisted test-aspiration with mechanical aspiration thrombectomy in the treatment of deep venous thrombosis were excellent, and the procedure was safe.

Endovascular Therapy versus Anticoagulation Alone for Subacute Iliofemoral Deep Vein Thrombosis

PURPOSE

To evaluate whether endovascular therapy (ET) improved early symptom relief and decreased the incidence of moderate-to-severe postthrombotic syndrome (PTS) compared with anticoagulation alone in patients with subacute (15-28 days) iliofemoral deep vein thrombosis (DVT).

MATERIALS AND METHODS

Consecutive patients with subacute iliofemoral DVT from January 2020 to June 2022 were identified. A total of 86 patients were assigned to receive treatment with ET alongside anticoagulation (endovascular group, n = 49) or anticoagulation alone (anticoagulation group, n = 37). Effectiveness outcomes including thrombus clearance rate, symptoms relief in 3 days (pain and swelling score), moderate-to-severe PTS rate, Villalta score, and Venous Clinical Severity Score (VCSS) at 12 months as well as safety outcomes including major bleeding, minor bleeding, and death within 12 months were compared between the 2 groups.

RESULTS

The endovascular group demonstrated greater symptoms relief in 3 days (1.1 ± 1.0 vs 3.6 ± 1.1; P < .001). The mean follow-up duration was 15.9 months for the endovascular group and 14.7 months for the anticoagulation group. Seventy-nine patients (91.8%) completed the 12-month follow-up. Villalta score (3.9 ± 2.6 vs 5.7 ± 4.3; P = .027), moderate-to-severe PTS (6.5% vs 27.3%; P = .011), and VCSS (2.3 ± 1.6 vs 3.6 ± 2.6; P = .004) at 12 months were significantly lower in the endovascular group. No significant differences were observed regarding minor bleeding events, recurrence of symptomatic DVT, and deaths between the 2 groups.

CONCLUSIONS

In patients with subacute iliofemoral DVT, the addition of ET to anticoagulation provided greater early symptoms relief and reduced the occurrence of moderate-to-severe PTS, with similar safety outcomes.

Action research on implementing the BOPPPS model in teaching mechanical prophylaxis techniques for deep vein thrombosis

OBJECTIVE

To explore the application effects of the BOPPPS model in teaching mechanical prophylaxis techniques for deep vein thrombosis (DVT).

METHODS

Following the "Plan-Act-Observe-Reflect" four-step process of action research, continuous improvements were made to the teaching process of DVT mechanical prophylaxis techniques based on the BOPPPS model. Data were collected by designated personnel and the teaching effectiveness was evaluated.

RESULTS

Through three rounds of action research, the overall practical training scores for DVT mechanical prophylaxis techniques among students from the 2019-2021 cohorts were 84.45 ± 4.75, 88.43 ± 3.92, and 91.15 ± 4.58, respectively. The self-evaluation scores for DVT prophylaxis awareness were 95.93 ± 2.78, 97.39 ± 2.54, and 98.47 ± 2.47, all of which were statistically significant (P < 0.01). Cohen's d effect sizes further confirmed substantial improvements.

CONCLUSION

Implementing the BOPPPS model in teaching DVT mechanical prophylaxis techniques helps improve students' knowledge, skills, and prevention awareness. The action research method contributes to the standardization and scientific design of the curriculum.

Calf Muscle-Venous Pump Dysfunction in Patients with Pelvic Venous Disorder

BACKGROUND

To study the evacuation function of calf muscle-venous pump (CMP) in patients with pelvic venous disorder (PeVD).

METHODS

This single-center cross-sectional study included 170 female patients (120 with PeVD ± chronic venous disease (CVD) and 50 with CVD without PeVD) and 20 healthy volunteers. All subjects underwent duplex ultrasound (DUS) of the pelvic and lower extremity veins, radionuclide venography (RV) of the lower extremities, and single-photon emission computed tomography (SPECT) of the pelvic veins (PVs) with in vivo labeled red blood cells (RBCs). The pelvic venous congestion (PVC) signs were deposition of labeled RBCs in the PVs and the PVC coefficient (CPVC) > 0.5. The CMP evacuation dysfunction was identified during RV as an increase in the average isotope transit time (Tave) in the tendon (Tt) and muscle (Tm) parts of CMP and in the popliteal vein (Tpv).

RESULTS

The CMP dysfunction was detected in 81.6% and 78.3% of patients with symptomatic and asymptomatic PeVD, accordingly, and in 92% of patients with CVD. This condition was characterized by a significant increase in the isotope transit time (Tt 18-30 s, Tm 27-45 s, and Tpv 20-40 s).

CONCLUSION

The CMP dysfunction is present in about 80% of patients with PeVD, regardless of the clinical course of PeVD and the presence of CVD of the lower extremities.

Retrospective analysis of the effectiveness and safety of sulodexide for venous thromboembolism prevention in neurosurgical patients

Neurosurgery patients are at high risk of developing venous thromboembolism (VTE) which increases the risk of morbidity and mortality. This study is designed to investigate the effectiveness and safety of sulodexide in combination with routine VTE prophylaxis compared with routine VTE prophylaxis alone for VTE prevention in neurosurgical patients. This retrospective, cohort study included neurosurgical patients received routine VTE prophylaxis (control group) or routine VTE prophylaxis plus sulodexide (experimental group) during hospitalization. Predictors of VTE during hospitalization were determined using multivariable logistic regression. A total of 694 eligible patients were included in this study. The incidence of VTE in the experimental group (4.52%, 10/221) was lower compared with that in the control group (6.98%, 33/473) (P = 0.212). The change from baseline in serum creatinine and blood urea nitrogen of the experimental group was significantly higher compared with that in the control group (both P < 0.05). In elderly patients (>65 years), VTE incidence in the experimental group was 3.51% which was significantly lower than that in the control group (10.8%; P = 0.03) and odd ratio [OR] was 0.3 (95% confidence interval [CI]: 0.07, 0.92). Multivariate logistic regression analysis revealed that use of sulodexide plus routine VTE prophylaxis (OR = 0.172, 95% CI: 0.055, 0.535; P = 0.006) and baseline Glasgow Coma Scale (GCS) score (OR = 0.587, 95% CI: 0.521, 0.792; P < 0.001) were protective factors for VTE risk, and the length of hospital stay (OR = 1.134, 95% CI: 1.021, 1.199; P=0.007) was a risk factor for VTE. Sulodexide in combination with routine VTE prophylaxis effectively reduces the risk of VTE in neurosurgical patients. A high baseline GCS score is a protective factor for VTE, whereas length of hospital stay is a risk factor for VTE.

Analysis of the efficacy of angiojet percutaneous mechanical thrombectomy combined with catheter-directed thrombolysis versus catheter-directed thrombolysis alone in the treatment of subacute iliofemoral deep venous thrombosis in elderly patients

PURPOSE

To analysis the clinical efficacy of Angiojet percutaneous mechanical thrombectomy (PMT) combined with Catheter-Directed Thrombolysis (CDT) compared to CDT in treatment of subacute iliofemoral deep venous thrombosis (IFDVT) in elderly patients.

METHODS

A retrospective analysis of the clinical data of 117 elderly patients hospitalized for subacute IFDVT was conducted. The patients'basic perioperative data and 2-years follow-up data were compared.

RESULTS

Group A (PMT + CDT) had a more patients reaching Grade III thrombus clearance, and a lower thrombolysis time, dosage of thrombolytic drugs, hospital stay, and bleeding incidence compared to Group B (CDT). There was a statistically significant difference in the occurrence rate of severe PTS within 2 years (p < 0.05).

CONCLUSION

In treating elderly patients with subacute IFDVT, PMT + CDT effectively reduces the thrombus burden and the dosage of thrombolytic drugs, shortens the hospital stay, and importantly, reduces the occurrence rate of severe PTS within 2 years.

Residual popliteal vein thrombosis after endovascular treatment of mixed-type lower extremity deep vein thrombosis is relevant to post-thrombotic syndrome

OBJECTIVE

Patients with mixed-type lower extremity deep vein thrombosis (DVT) have a higher incidence of post-thrombotic syndrome (PTS) after endovascular treatment (EVT). This study aimed to identify risk factors associated with PTS in these patients after EVT.

METHODS

This retrospective study included patients diagnosed with acute mixed-type lower extremity DVT who underwent EVT between January 2020 and December 2022. Patient assessments were conducted using ultrasound examination and the Villalta scale. Baseline characteristics, management details, and follow-up findings were compared between patients who developed PTS and those who did not at 6 months after EVT. Cox regression and nomogram analyses were performed to identify risk factors associated with the development of PTS.

RESULTS

The study enrolled 118 patients, of which 103 completed the follow-up. Among them, 24.3% developed post-thrombotic syndrome (PTS) within 6 months. Significant differences between the PTS and non-PTS groups were found concerning residual thrombosis in the popliteal, common femoral, and femoral veins. Multivariate Cox regression analysis indicated that residual popliteal vein thrombosis (RPVT) (hazard ratio [HR], 4.93; 95% confidence interval [CI], 1.61-15.11) and preoperative iliac vein stenosis (HR, 3.21; 95% CI, 1.11-9.33) were significant risk factors for PTS. Additionally, subgroup analysis for preoperative iliac vein stenosis and sensitivity analysis confirmed that RPVT remained a risk factor for PTS (HR, 4.48; 95% CI, 1.27-15.84).

CONCLUSIONS

Our study demonstrated a positive association between RPVT and PTS in patients with extensive mixed-type lower extremity DVT after EVT. These findings suggest that intensive monitoring and aggressive therapeutic interventions may be required for patients with RPVT to decrease the risk of PTS.

Therapeutic Enoxaparin Dosing in Obesity

OBJECTIVE

This review aims to systematically summarize the available data on efficacy and safety of therapeutic enoxaparin in obese patients and to identify gaps to guide future research.

DATA SOURCES

Medline and Embase were systematically searched for eligible studies (last searched December 20, 2023). Studies were included if they reported on therapeutic dosing regimens, adverse bleeding, thrombotic outcomes, or antifactor Xa (AFXa) monitoring in obese adult patients.

STUDY SELECTION AND DATA EXTRACTION

The systematic review management tool Covidence was used to manage the study selection and data extraction process. The reference list from eligible studies was screened to determine any additional eligible studies.

DATA SYNTHESIS

Sixteen studies were included in the analysis. Studies used a variety of doses, indications, and study designs making comparison difficult. Twelve studies reported the incidence of thrombotic events (median = 1.3% [interquartile range [IQR] = 0.3%-2.3%]) and all studies reported the incidence of bleeding events (median = 5.7% [IQR = 2.4%-14.5%]). Two of the 8 studies analyzing the influence of weight/body mass index (BMI) or dose per kg on AFXa levels reported statistically significant results. One study concluded that BMI did not affect achievement of target AFXa levels. However, the second study found that dosing using actual body weight was an independent predictor of supratherapeutic AFXa levels in the obese population.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

This is the first comprehensive review with a focus on therapeutic dosing of enoxaparin in obesity and has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. Seven of the included studies were published since 2018 indicating that new evidence on this topic is emerging.

CONCLUSION

There was inadequate evidence to support an optimal dosing strategy in obese patients due to the heterogeneity of the studies. The AFXa monitoring may be appropriate to guide dosing in this population. Further research is required to determine a suitable dosing regimen.

The age, sex, and provoked factors of acute symptomatic deep vein thrombosis on the left and right lower extremities

PURPOSE

Deep vein thrombosis (DVT) of the left and right lower extremities was treated in the same way, but the left and right extremities received different levels of attention. This study aimed to investigate the differences between the right and left lower extremity deep vein thrombosis (LEDVT).

METHODS

Clinical characteristics of LEDVT patients from July 2020 to June 2022 were retrospectively analyzed to compare the incidence of LEDVT on different limbs, demographics, predisposing factors, and anatomical characteristics. The exclusion criteria were bilateral LEDVT and recurrent thrombosis. Measured data was analyzed using independent samples t-test or Mann-Whitney test. Count data were analyzed by Chi-square test. A p < 0.05 was considered a statistically significant difference.

RESULTS

There were 478 patients included in this study and the ratio of left to right LEDVT on the left and right limbs was 3.16:1 (363:115). Left LEDVT predominantly affected female, with the major aged > 50 years (50 - 60 years: 16.80%; > 60 years: 57.30%). The primary predisposing factor was iliac vein compression syndrome, with iliofemoral thrombosis being the main type. Male patients with LEDVT on the right limb were predominant and the age of onset was usually ≤ 60 years (52.17%). The main predisposing factor was recent surgery or trauma (< 30 days) and femoropopliteal thrombosis was the main type. In more detail, the left iliac vein was compressed mainly in the proximal segment, and the right iliac vein was compressed mainly in the intermediate and distal segments. Recent surgery or trauma to the locomotor system and genitourinary system often induced LEDVT.

CONCLUSION

The incidence of LEDVT on the left is significantly higher than that on the right. LEDVT on different sides has different characteristics, which is crucial for prevention and diagnosis in the relevant population so there are also differences in treatment of the affected limbs.

Beyond Routine Monitoring: A Comprehensive Review of Direct Oral Anticoagulants and the Role of Coagulation Profiles in Their Management

Direct oral anticoagulants (DOACs) have revolutionized anticoagulation therapy, providing effective and safe management of thrombosis and related conditions. As their use continues to grow, accurately monitoring their effects is essential to achieve optimal patient outcomes. Traditional coagulation tests, such as prothrombin time (PT) and activated partial thromboplastin time, have long been used to evaluate clotting function and bleeding risk in patients on anticoagulants. However, these standard tests often fall short with DOACs due to complex interactions between the drugs and the assays. While PT offers some insight into coagulation, its reliability for drugs like apixaban, one of the most commonly prescribed DOACs, remains debated. This limitation underscores the need for alternative monitoring strategies, such as the modified diluted PT, which shows promise in providing more accurate assessments of DOAC levels. This review discusses the pharmacokinetics of DOACs, their impact on standard coagulation tests, and various factors - such as liver disease and drug interactions - that complicate these assessments. Additionally, it highlights the importance of incorporating specific assays, including anti-factor Xa activity and dilute thrombin time, for precise anticoagulation management. By synthesizing current evidence, this review aims to identify improved methods for monitoring DOAC therapy, guide clinicians in optimizing anticoagulation treatment, and ultimately enhance patient outcomes.

Intravascular Ultrasound Findings in Acute and Chronic Deep Vein Thrombosis of the Lower Extremities

Deep vein thrombosis (DVT) of the lower extremities, as part of venous thromboembolism disorder, is the third leading cause of acute cardiovascular syndrome after heart attack and stroke. It can result in disability due to pulmonary embolism (PE) and post-thrombotic syndrome (PTS), particularly in cases where the thrombosis extends to the iliofemoral veins. Anticoagulation therapy is effective in preventing thrombus propagation and embolism but may not be sufficient for thrombus degradation and venous patency restoration. Up to 50% of patients with iliofemoral DVT develop PTS, mainly due to venous outflow obstruction or valvular incompetence. To date, the advent of new devices that enables rapid thrombus elimination and the restoration of deep venous patency, known as the "OPEN VEIN hypothesis", may prevent valvular damage and reflux, cutting down the rate of PTS. Similarly, chronic venous disease could be related to a stenosis or occlusion of a major vein that can restrict blood flow. In this setting, intravascular ultrasound (IVUS) is an essential tool for correct diagnostic and therapeutic planning in acute and chronic vein disease. Only angiography in vein disease can limit the procedure's efficacy, with a high rate of stenosis misdiagnosed; IVUS provides further imaging that complements traditional angiographic study, and its role is now established by different international guidelines. If compared to angiography, IVUS allows for the evaluation of major axial veins in a 360-degree ultrasound image of the lumen and of the vessel wall structure. At the same time, the precise location and size of the major lower extremity veins allow for the placement of the stent to be more straightforward with a precise dimension of the vein in all of its diameters; moreover, other abnormalities should be visualized as acute or chronic thrombus, fibrosis, or trabeculations. This review aims to provide an in-depth analysis of IVUS findings in acute and chronic lower extremity DVT, emphasizing its diagnostic and therapeutic implications.

Minimally Invasive vs. Open Synovectomy in Rheumatoid Arthritis: Insights into Clinical Recovery, Systemic Inflammation, and Economic Impact

Background: Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by persistent synovial inflammation, leading to joint destruction and disability. Synovectomy, the surgical removal of inflamed synovial tissue, is performed when pharmacological treatments are insufficient. This study compares the clinical efficacy, systemic inflammatory response, and cost-effectiveness of minimally invasive arthroscopic synovectomy versus traditional open synovectomy in RA patients. Methods: A comparative observational study was conducted on 53 RA patients undergoing either arthroscopic (n = 30) or open synovectomy (n = 23) at "Pius Brînzeu" Timișoara County Emergency Clinical Hospital over nine years. Clinical outcomes, including pain relief (VAS), functional improvement (HAQ), complication rates, and recovery times, were assessed at baseline, 1, 3, 6, and 12 months postoperatively. Systemic inflammatory markers (CRP, IL-6, TNF-α, ESR, and fibrinogen) were measured preoperatively, at 48 h and 30 days postoperatively. A cost-effectiveness analysis evaluated direct and indirect healthcare costs. Results: Arthroscopic synovectomy demonstrated significantly faster pain reduction and functional recovery within the first three months (p < 0.001), shorter hospital stays (3.1 vs. 6.4 days, p < 0.001), and quicker returns to daily activities (14.5 vs. 22.3 days, p < 0.001) compared to open synovectomy. Inflammatory markers were significantly lower postoperatively in the arthroscopic group (p < 0.01), indicating reduced systemic inflammation. Complication rates were markedly lower in the arthroscopic group (26.66% vs. 82.60%, p < 0.001). Despite higher procedural costs, arthroscopic synovectomy proved more cost-effective due to reduced hospitalization and faster recovery. Conclusions: Arthroscopic synovectomy offers superior early postoperative outcomes, reduced systemic inflammation, and greater cost-effectiveness compared to open synovectomy, with comparable long-term joint stability. These findings support its preference as the surgical technique of choice for RA patients requiring synovectomy.

Angioplasty or stenting for deep venous thrombosis

BACKGROUND

The best medical treatment (BMT) for treating deep venous thrombosis (DVT) includes anticoagulation and compression stockings. Angioplasty and stenting restore vessel patency and facilitate blood flow. In some people with DVT, angioplasty or stenting is used to minimise complications such as post-thrombotic syndrome (PTS), but their effects are under discussion.

OBJECTIVES

To assess the effects of adjunctive angioplasty or stenting on a background treatment of anticoagulation and thrombolysis, compared with BMT, sham procedure, thrombolysis, or any combination of these treatments, in people with DVT.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, IBECS, CINAHL, and AMED databases, as well as the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers, to 20 April 2023. We checked the bibliographies of included trials for further references to relevant trials and contacted specialists in the field, manufacturers, and authors of the included trials for any unpublished data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing angioplasty or stenting on a background treatment of anticoagulation and thrombolysis, compared with BMT, sham procedure, thrombolysis, or any combination of these treatments, in the management of people with acute obstruction due to DVT. We excluded participants who had a baseline PTS diagnosis or who had received any form of mechanical thrombectomy, as this was investigated in a separate Cochrane review.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. The primary outcomes were PTS and venous thromboembolism (VTE); secondary outcomes were mortality, major bleeding, secondary patency, duration of hospitalisation, quality of life (QoL), and adverse events. We used the Cochrane RoB 1 tool to assess the risk of bias for RCTs and GRADE to assess the certainty of evidence. We performed meta-analysis where appropriate.

MAIN RESULTS

We included two RCTs (134 participants) that were conducted in China and presented comparisons for acute obstruction after DVT based on length of follow-up (12 months (early), 24 months (intermediate), and 36 months (long term)). Angioplasty or stenting plus BMT and thrombolysis versus BMT and thrombolysis for acute obstruction due to DVT (intermediate time point) In the intermediate time point, angioplasty or stenting may have little to no effect on PTS (Venous Clinical Severity Score (VCSS): mean difference (MD) -3.21, 95% confidence interval (CI) -7.74 to 1.33; 2 studies, 133 participants; very low-certainty evidence) and adverse events (limb pain) (risk ratio (RR) 0.68, 95% CI 0.04 to 10.33; 1 study, 67 participants; very low-certainty evidence), but the evidence is very uncertain. Angioplasty or stenting may increase secondary patency (RR 0.26, 95% CI 0.11 to 0.59; 2 studies, 133 participants; very low-certainty evidence), but the evidence is very uncertain. The evidence is very uncertain about the effect of angioplasty or stenting on quality of life (MD 10.54, 95% CI -1.34 to 22.41; 2 studies, 133 participants; very low-certainty evidence), and is not estimable for VTE, mortality, or major bleeding. We downgraded the certainty of evidence for all reported outcomes in this comparison by two levels due to serious study limitations (risk of performance and other bias), and another level for imprecision (small numbers of events and participants). The imbalance between study group size and different vein access may also have contributed to the high heterogeneity seen in the analyses of these outcomes. We downgraded the certainty of evidence for PTS and quality of life by one level for inconsistency (no similarity of point estimates in any of the included studies, no overlap of CIs, and considerable heterogeneity in results). There is an additional difficulty with blinding personnel in this type of intervention, but the trialists should have reported blinding of outcome assessment.

AUTHORS' CONCLUSIONS

Although angioplasty or stenting may increase secondary patency in people with acute obstruction due to DVT, the evidence is very uncertain; the evidence is also very uncertain about the effect of angioplasty or stenting on PTS, quality of life, and adverse events in people with acute obstruction due to DVT. The effects on VTE, mortality, and major bleeding were not estimable or not assessed by the included studies. Future trials must be large enough to detect significant clinical outcomes, and provide data on original stenosis before angioplasty or stenting and differing times from the initial event, among other essential characteristics.

A Modified Viscoelastic Point-of-Care Method for Rapid Quantitative Detection of Enoxaparin: A Single-Centre Observational Study

Background: Laboratory monitoring of the effect of low-molecular-weight heparins (LMWHs) is generally not necessary. However, prompt evaluation of heparin inhibitory effects (i.e., anti-Xa activity) is important in cases of life-threatening bleeding, need for urgent surgery or acute thromboembolism under LMWH treatment. We aimed to establish a simple and reliable point-of-care method for the detection of enoxaparin. Methods: Eighty patients under enoxaparin therapy and ten healthy volunteers without any anticoagulant treatment were enrolled. Simultaneous measurements of anti-Xa activity using the chromogenic method and clotting times in the absence and presence of polybrene using viscoelastometric assays containing Russell's viper venom (RVV-test) were performed on the ClotPro device. Results: Among the measured and derived RVV-test parameters, the ratio of the RVV clotting times (RVV CT) detected in the absence and presence of polybrene showed the best statistically significant correlation with anti-Xa activity (r = 0.774, p < 0.001). Based on ROC analysis, we designated RVV CT ratios of 1.02, 1.23 and 1.6 as the best cut-off values for separating anti-Xa ranges below and above 0.3 and 0.6 IU/mL, respectively. If the RVV CT ratio is below or above 1.23, the anti-Xa activity is suggested to be below 0.6 IU/mL or above 0.3 IU/mL with high certainty, respectively. Further differentiation is possible if the RVV CT ratio is measured below 1.02 or above 1.6. In these cases, the measured anti-Xa values are below 0.3 IU/mL or above 0.6 IU/mL, respectively, with high probability and good predictive values. Conclusions: Our method can provide semiquantitative information on the effect of enoxaparin and the expected anti-Xa activity within 10 min in real clinical situations.

Relationship between calf muscle pump function and severity of chronic venous disease

BACKGROUND

The calf muscle pump is an understudied contributor to venous return from the lower extremity. This study aimed to determine if calf pump function (CPF) is independently associated with the severity of chronic venous disease classified by CEAP (Clinical-Etiology-Anatomy-Pathophysiology).

METHODS

The Mayo Clinic Vascular Laboratory database was analyzed from January 2015 through September 2023. Ambulatory adults who underwent venous air plethysmography were included. Venous plethysmography assessed the severity of venous incompetence, and CPF was measured as ejection fraction (EF) per leg. The clinical component (C0 through C6) of the CEAP score was evaluated for each extremity at the time of the study.

RESULTS

A total of 7760 limbs from 3733 patients were analyzed. The mean age was 62 years, with 62% women. Venous obstruction was detected in 3.2% of limbs. Venous incompetence severity was categorized as normal (44%), mild (26%), moderate (19%), and severe (10%). A significant trend of reduced CPF was observed with higher CEAP scores (p < 0.001). Multivariable logistic regression, adjusted for age, sex, degree of venous incompetence, and obstruction showed reduced CPF was a significant predictor (odds ratio 1.84, CI: 1.5-2.2) of active/prior ulcer (C5 or C6). In contrast to more severely reduced CPF, mildly reduced CPF (EF 40-49%) was not associated with active/prior ulcers.

CONCLUSION

This large contemporary study demonstrates that decreased CPF is associated with worse chronic venous disease. Importantly, we demonstrate for the first time that CPF is independently associated with active/prior venous ulcers after accounting for other venous physiologic parameters and demographics.

Causal relationship between educational attainment and the occurrence of venous thromboembolism

BACKGROUND

The association between educational attainment (EA) and arterial thrombotic disease has been reported, but the causal relationship between EA and venous thromboembolism (VTE) is not clear. We aimed to assess the causal effect of EA on VTE using the two-sample mendelian randomization (MR) method.

METHODS

Data mining was conducted on the genome wide association studies (GWAS), with exposure factor EA and outcome factor VTE. Two-sample Mendelian Randomization (TSMR) analysis was conducted, with the results obtained from the random effects inverse variance weighted method (IVW). Use the MR-Egger method for pleiotropy analysis and leave one method for sensitivity analysis to verify the reliability of the data.

RESULTS

Genetically predicted decreased EA was associated with a decreased risk of VTE in both the FinnGen consortium and UK Biobank (FinnGen-VTE: OR = 0.848; 95% CI 0.776-0.927; P = 2.84 × 10-4; UKB-VTE OR = 0.996; 95% CI 0.994-0.999; P = 0.008) under a multiplicative random-effects IVW model. Results were consistent in all sensitivity analyses and no horizontal pleiotropy was detected.

CONCLUSIONS

The MR technique instructed a potential inverse causative relationship between EA and occurrence of VTE. Therefore, patients with low EA should be more vigilant about the occurrence of VTE.

The Incidence and Significance of Iliac Vein Stenosis in Patients with Deep Vein Thrombosis

BACKGROUND

The role of iliac vein stenosis (IVS) in the development of deep vein thrombosis (DVT) is poorly understood. This study determines the incidence of IVS in patients diagnosed with DVT and assesses its impact on presentation and outcomes. Our hypothesis is that the presence of IVS increases the risk of long-term ipsilateral DVT recurrence.

METHODS

A retrospective study of the electronic medical records of consecutive adult patients treated for lower extremity DVT was performed. Only patients with cross-sectional imaging (computed tomography or magnetic resonance with intravenous contrast) were included. Patient and DVT characteristics were recorded. Cross-sectional imaging was reviewed for the presence or absence of ipsilateral IVS (≥50%). Patients were divided into 2 groups based on the presence or absence of IVS to compare characteristics and outcomes. Subgroup analyses on patients with provoked DVT, cancer-related DVT, and unprovoked DVT were performed.

RESULTS

There were 548 patients with DVT and 32% had evidence of ipsilateral IVS on cross-sectional imaging. There were no significant differences in baseline characteristics or treatment methods between the 2 groups. There was a trend toward patients with IVS having less incidence of pulmonary embolism on presentation (22.9% vs. 29.7%, P = 0.1) but that difference did not reach statistical significance in the overall comparison. Subgroup analysis in patients with cancer-related DVT (n = 227) showed that patients with IVS were significantly more likely to develop ipsilateral recurrent DVT compared to patients with no IVS (12.9% vs. 4.5%, P = 0.045). Patients with unprovoked DVT with IVS had significantly lower pulmonary embolism on presentation than patients with unprovoked DVT without IVS (24.2% vs. 39.8%, P < 0.03).

CONCLUSIONS

Ipsilateral ≥50% IVS is present in approximately a third of patients presenting with DVT. The presence of IVS seems to play a differential role in ipsilateral DVT recurrence and prevention of pulmonary embolization in different groups of patients presenting with DVT.

Initiation of Anticoagulants During the COVID-19 Pandemic in Sweden: An Interrupted Time Series Analysis

The COVID-19 pandemic may have increased anticoagulant initiation due to the thrombogenic nature of the disease or decreased due to the societal impact of the pandemic. We aimed to study the effect of the COVID-19 pandemic on initiation of anticoagulants in Sweden. We conducted a single interrupted time series analysis on the monthly cumulative incidence of nonvitamin K antagonist oral anticoagulants (NOAC), warfarin, or heparins, before and after March 2020, using SCIFI-PEARL dataset. For anticoagulants in total, there were no statistically significant changes or differences in the trends of initiation after the start of the pandemic. There was a slight numerical decrease in initiation after the onset of the pandemic, particularly for NOACs. For individuals aged ≥ 65 years, however, the immediate decrease in initiation was considerable for NOACs. The prepandemic declining trend of warfarin initiation seemed to attenuate, that is, became less negative, after March 2020. We did not find any profound effect of the COVID-19 pandemic on the initiation of anticoagulants in total. However, among individuals aged ≥ 65 years, a notable immediate decrease in initiation of NOACs was observed. Furthermore, the onset of the pandemic may have attenuated the downward temporal trend in initiation of warfarin use.

Clinical outcomes of cancer-associated isolated distal deep vein thrombosis: a comparison between asymptomatic and symptomatic thrombosis-findings from the ONCO DVT Study

Background

The risk of recurrent venous thromboembolism (VTE) in patients with isolated distal deep vein thrombosis (IDDVT) is generally low, particularly when IDDVT is asymptomatic. However, cancer patients with IDDVT, even asymptomatic IDDVT, may be at a higher risk of recurrent VTE.

Objectives

To compare the clinical outcomes of cancer patients with asymptomatic and symptomatic IDDVT.

Methods

The ONCO DVT trial is a randomized clinical trial that compared 12-month versus 3-month edoxaban treatment regimens in cancer patients with IDDVT. In this post hoc analysis, 601 patients were categorized into the asymptomatic (n = 479) and symptomatic (n = 122) groups based on IDDVT-related symptoms at diagnosis. The primary outcome was the composite of symptomatic recurrent VTE or VTE-related death at 12 months, while the major secondary outcome was major bleeding at 12 months.

Results

The cumulative 12-month incidence of the primary outcome was lower in the asymptomatic group than that in the symptomatic group (2.9% vs 13.4%; P < .001; hazard ratio, 0.21; 95% CI, 0.10-0.47). Among the 12 patients with symptomatic recurrent VTE in the asymptomatic group, 8 (67%) had recurrent IDDVT, and 11 (92%) experienced recurrence after discontinuing anticoagulation therapy. The cumulative 12-month incidence of major bleeding was lower in the asymptomatic group than that in the symptomatic group (7.8% and 13.2%; P = .048).

Conclusion

The risk of recurrent symptomatic VTE was lower in cancer patients with asymptomatic IDDVT than in those with symptomatic IDDVT. Most recurrent VTE events were recurrent IDDVT, with the majority occurring after discontinuing anticoagulation therapy.

Real-world outcomes of Zilver Vena® Venous Self Expanding Stent placement for thrombotic and non-thrombotic indications in Spain

PURPOSE

To evaluate longer term outcomes of the Zilver Vena Venous Stent in patients undergoing venous stenting.

MATERIALS AND METHODS

Patients with iliofemoral obstructive venous disease and treated with venous stents were retrospectively enrolled in a physician-led real-world data collection effort. Results were analyzed by etiologies: post-thrombotic syndrome (PTS), non-thrombotic iliac vein lesion (NIVL), and iliocaval acute deep vein thrombosis (aDVT). Patency outcomes (primary, assisted-primary, secondary), reinterventions (in-stent and all), adverse events, and venous clinical outcome measures (VCSS, CEAP, Villalta Score) were reported using Kaplan-Meier estimates and summary statistics.

RESULTS

A total of 219 patients (89.5% women, mean age 45.3 ± 11.9 years) were identified: 56 PTS, 153 NIVL, and 10 aDVT patients. Devices were placed across the inguinal ligament in 80.4%, 0%, and 70.0% of patients in the PTS, NIVL, and aDVT groups, respectively. Through 1-year, Kaplan-Meier estimated primary patency rate was 96.4% for PTS, 99.3% for NIVL, and 100% for aDVT patients, respectively, and followed the same trend through 3 years. Freedom from (FF) all and within stent reinterventions estimated by Kaplan-Meier was 87.9% and 90.1% for PTS, 98.2% and 98.2% for NIVL through 3 years. No reinterventions were reported for the aDVT group. Improved venous clinical outcome measures were seen in all groups at the last follow-up visit. Stent fractures occurred in 2 PTS patients without related reintervention or clinical sequelae. No stent migrations were reported.

CONCLUSION

Real-world use showed high patency rates and improved venous clinical outcome measures (VCSS, Villalta, and CEAP) after venous stent placement.

Cardiovascular diseases, prevention, and management of complications in older adults and frail patients treated for elective or post-traumatic hip orthopaedic interventions: a clinical consensus statement of the ESC Council for Cardiology Practice (CCP), the European Association of Preventive Cardiology (EAPC), the Association for Acute CardioVascular Care (ACVC), the Association of Cardiovascular Nursing & Allied Professions of the ESC (ACNAP), the ESC Working Group on Aorta and Peripheral Vascular Diseases (WG APVD), and the ESC Working Group on Thrombosis (WG T)

Due to the aging population, focusing on healthy aging has become a global priority. Cardiovascular diseases (CVDs) and frailty, characterized by increased vulnerability to adverse stress and health events, interact synergistically in advanced age. In older adults, hip fractures are a frequent dramatic "life-transition" event. Conditions such as arrhythmias, orthostatic hypotension, heart failure, peripheral artery disease and adverse drug reactions may facilitate falls and thus bone fractures in older adults. Cardiovascular complications or the worsening of previous CVDs may increase the degree of frailty and disability following this surgery. The close relationship between older age, CVDs, frailty and orthopaedic surgery leads to the need to focus on the various phases of interventions in a multidisciplinary approach. This document aims to provide practical support to prevent cardiovascular complications in older and frail patients undergoing hip procedures by suggesting specific assessments and interventions. In particular, in pre-operative care the focus should be on the assessment and management of concomitant CVD and frailty, while immediate peri- and post-operative care should highlight specific concerns for anesthesia, prevention and management of thrombotic complications, specific nursing needs, including the prevention of infections and delirium, and the establishment of an integrated rehabilitation program focusing on CVDs and the risk of new falls, with a positive role for care-givers. Furthermore, by optimizing the "hip surgery pathway" the objective is to help avoid the deterioration of health and loss of independence that often result from this surgery through the correct management of cardiovascular patients in this peculiar context.

From thrombosis to tamponade: unveiling severe pericardial effusion in a misdiagnosis case

BACKGROUND

Anticoagulants increase the risk of cardiac tamponade in patients with pericardial effusion (PE). Therefore, inappropriate administration of them in the presence of PE can lead to a catastrophic outcome. This study presents a patient with a provisional misdiagnosis of venous thromboembolism (VTE).

CASE PRESENTATION

An 83-year-old Iranian female was transferred to the emergency department of a tertiary cardiology hospital complaining of neck swelling concomitant with chest pain and dyspnea. The patient had been diagnosed with jugular vein thrombosis in another local center, and since the chief complaint was neck swelling, she underwent Doppler sonography, and the diagnosis was confirmed. Subsequently, the treatment with unfractionated heparin was started. After 5 h, considering the worsening of symptoms with the suspicious diagnosis of COVID-19 based on her symptoms and laboratory data, a chest computed tomography scan was requested, which showed a massive PE. Subsequently, transthoracic echocardiography confirmed the diagnosis. The patient was immediately transferred to the operating room and underwent pericardiotomy. The post-surgery period was uneventful, and she was discharged 5 days later.

CONCLUSION

Patients with viral infections, specifically COVID-19, are at risk of undiagnosed severe pericardial effusions. Venous stasis in the jugular veins due to PE can mimic jugular vein thromboembolism, causing a wrong diagnosis. Since treating thrombosis can exacerbate tamponade to hemodynamic instability and collapse, sufficient investigation before starting anticoagulants is necessary.

CLINICAL KEY MESSAGE

Distinguishing VTE from PE is not always straightforward. Therefore, it is important to ensure physicians have reached an appropriate level of certainty about their diagnosis by performing precise diagnostics before using anticoagulants. Mismanagement with anti-thrombotics can result in catastrophic consequences. Therefore, taking an accurate history, performing a precise physical examination, and using rapid and available diagnostic modalities can avoid delays in definitive management.

Expert-Based Narrative Review on Compression UltraSonography (CUS) for Diagnosis and Follow-Up of Deep Venous Thrombosis (DVT)

Deep venous thrombosis (DVT) is a pathological condition that develops when a thrombus forms within the deep venous system. Typically, it involves the lower limbs and, less frequently, the upper extremities or other unusual districts such as cerebral or splanchnic veins. While leg DVT itself is rarely fatal and occasionally can lead to limb-threatening implications, its most fearsome complication, namely pulmonary embolism, is potentially fatal and significantly contributes to increased healthcare costs and impaired quality of life in affected patients and caregivers. Thanks to its high accuracy, ease of use, and safety profile, duplex ultrasound (DUS), particularly compression ultrasound (CUS), has emerged as the first-line imaging modality for DVT diagnosis. The evaluation of suspected DVT needs a multifaceted approach, and in this context, CUS rapidly became a key diagnostic tool owing to its many unique advantages. Its central role in the diagnostic algorithm of suspected DVT is clearly established in the latest clinical practice guidelines from the European Society for Vascular Surgery and the American Society of Haematology. Indeed, DUS effectively visualizes blood flow and identifies abnormalities like clot formation with high sensitivity (typically exceeding 90% for proximal DVT) and specificity (often approaching 100% for proximal DVT). Additionally, CUS is non-invasive, readily available at the bedside, and avoids radiation exposure, resulting in an ideal method for various clinical settings. CUS has been shown to have a substantial role not only in the diagnosis of an acute DVT but also in the follow-up of its management. Moreover, this method can provide a prognostic assessment, mostly in terms of risk stratification for recurrent thrombosis and/or for potential complications, such as post-thrombotic syndrome. In summary, given its established benefits, CUS is a technique that many physicians should be familiar with, especially those working in emergency departments, intensive care units, or general wards. When needed, healthcare operators with more advanced US skills (such as radiologists, angiologists, or vascular surgeons) may be called upon to provide a second look in case of uncertainty and/or need for additional information.

From Cell Interactions to Bedside Practice: Complete Blood Count-Derived Biomarkers with Diagnostic and Prognostic Potential in Venous Thromboembolism

Venous thromboembolism (VTE), encompassing deep vein thrombosis and pulmonary embolism, is a significant burden on health and economic systems worldwide. Improved VTE management calls for the integration of biomarkers into diagnostic algorithms and scoring systems for risk assessment, possible complications, and mortality. This literature review discusses novel biomarkers with potential diagnostic and prognostic value in personalized VTE management. The pathophysiology of thrombosis starts with cell interactions in the vascular environment and continues with more complex, recently discussed processes such as immunothrombosis and thromboinflammation. Their clinical applicability is in the use of complete blood count (CBC)-derived immuno-inflammatory indices as attractive, readily available biomarkers that reflect pro-thrombotic states. Indices such as the neutrophil-to-lymphocyte ratio (NLR = neutrophil count divided by lymphocyte count), platelet-to-lymphocyte ratio (PLR = platelet count divided by lymphocyte count), and systemic immune-inflammation index (SII = NLR multiplied by platelet count) have demonstrated predictive value for thromboembolic events. Nevertheless, confounding data regarding cutoffs that may be implemented in clinical practice limit their applicability. This literature review aims to investigate neutrophil and platelet interactions as key drivers of immunothrombosis and thromboinflammation while summarizing the relevant research on the corresponding CBC-derived biomarkers, as well as their potential utility in day-to-day clinical practice.

Antiproliferative agent attenuates postthrombotic vein wall remodeling in murine and human subjects

BACKGROUND

Despite appropriate treatment, up to 50% of patients with proximal deep vein thrombosis will develop postthrombotic syndrome (PTS). Once PTS occurs, there is no specific treatment, and some patients constantly experience intolerable symptoms. Hence, prevention of PTS is important.

OBJECTIVES

To characterize vein wall remodeling after thrombus and investigate the effects of antiproliferative agent on postthrombotic vein wall remodeling in murine and human subjects.

METHODS

Features of postthrombotic vein wall remodeling in murine and human subjects were characterized using imaging and histologic examinations. Paclitaxel-loaded hydrogels were used to assess the effects of antiproliferative agent on the remodeling in murine model. Based on the abovementioned results, a pilot study was conducted to assess the effects of paclitaxel-coated balloon dilation in patients with severe PTS experiencing intolerable symptoms. The control cohort was obtained by 1:1 propensity score matching from a prospective database.

RESULTS

Structural and functional alterations in postthrombotic vein wall were verified by imaging and histologic examinations, and predominant active α-smooth muscle actin-positive cells and fibroblast-specific protein 1-positive cells proliferation was observed. In the murine model, the application of paclitaxel-loaded hydrogels inhibited the remodeling. In the pilot clinical study, patients receiving drug-coated balloon demonstrated benefits in Villalta scores and venous clinical severity scores compared with those not receiving drug-coated balloon, and no severe adverse events were reported except for thrombosis recurrence.

CONCLUSION

Cell proliferation plays an important role in postthrombotic vein wall remodeling. Inhibition of cell proliferation inhibits the remodeling in murine model and may reduce signs and symptoms in patients with severe PTS.

Multimorbidity and Venous Thromboembolism: Epidemiological Evidence, Pathophysiology, Prophylactic and Therapeutic Anticoagulation Efficacy, Safety, and Difficulties. A Review

Multimorbidity defined as the co-occurrence of two or more chronic comorbidities, is becoming increasingly burdensome and is a big challenge for healthcare systems all over the world. Venous thromboembolism (VTE) is a potentially lethal disease and is the third most common cardiovascular disease. Multimorbidity is closely associated with VTE, and the VTE risk is approximately fourfold higher in individuals with multimorbidity compared to those without. Notable and consistent evidences show a significant association between multimorbidity and VTE. Plausible mechanisms for the observed associations between multimorbidity and VTE have been outlined, including higher prevalence of identified VTE risk factors, organ function and coagulation function disorders, reduced physical activity, older age, low cognitive level of VTE, and complications following the multimorbidity. Worse therapeutic and prophylactic anticoagulation efficacy, and safety are suggested by the studies, and the VTE recurrence and bleeding risk are higher in patients with multimorbidity compared to those without. Management of the therapeutic and prophylactic anticoagulation for VTE in patients with multimorbidity is difficult, and a balanced and detailed evaluation of the risks of VTE and bleeding is needed, and antiplatelet medications, increased doses or alternative direct oral anticoagulants (DOACs), thromboelastography (TEG), and physical activity may be helpful.