Benefit of anticoagulation for the treatment of lower extremity superficial venous thrombosis

Guidelines for superficial venous thrombosis

Superficial venous thrombosis (SVT) or superficial thrombophlebitis is characterized by thrombi within superficial veins, with partial involvement or occlusion of the lumen and inflammatory reaction along the course of the vein. Clinical diagnosis tends to be straightforward, but supplementary tests and examinations are needed to confirm thrombosis extension and possible thromboembolic complications. SVT can be associated with deep venous thrombosis in 6 to 40% of cases, with asymptomatic pulmonary embolism (PE) in 20 to 33%, and with symptomatic PE in 2 to 13%. Despite the morbidity and complications, there are currently no Brazilian guidelines for SVT. These guidelines cover the most important issues related to SVT definition, terminology, and etiology, and set out recommendations for diagnosis and treatment.

Tinzaparin in intermediate dose for the treatment of superficial vein thrombosis: Results from an observational multicenter study—SeVEN study

Objectives

Low-molecular-weight heparins are recommended in the treatment of superficial vein thrombosis but with low grade of evidence. This study was conducted to assess the treatment outcomes of acute superficial vein thrombosis with intermediate dose of Tinzaparin.

Methods

Retrospective analysis of records from outpatients over a period of 16 months treated in seven centers with Tinzaparin 0.5 ml (10,000 anti-Xa IU) once daily for a period that was at the treating physician’s discretion. All the patients were followed up for at least 12 weeks.

Results

A total of 296 patients (189 females, mean age 57.4 years) were included. Two thirds of the patients (191/296, 64.5%) received treatment for approximately five weeks (mean 36.9 days) and the remaining (105/296, 35.5%) for a shorter period (mean 16.2 days). There was no difference in patients’ characteristics between the two treatment duration groups. The presence of thrombus above the knee and restricted daily activity were associated with longer period of treatment. Only one case with minor bleeding was observed. Recurrence of thrombosis over a 12-week follow-up period occurred in 6% (superficial vein thrombosis in 14 (4.7%), deep vein thrombosis in 3 (1%) and thrombus extension in the superficial veins in 1 (0.3%)). Recurrence was not related to the duration of treatment.

Conclusions

Intermediate dose of Tinzaparin was an effective and safe treatment for superficial vein thrombosis in the setting of real world practice. Location of thrombus and status of patients’ mobilization were associated with longer duration of treatment. Future prospective randomized studies are needed to corroborate these findings.

The hemodynamic effects of pregnancy on the lower extremity venous system

OBJECTIVE

Pregnancy has significant effects on the lower extremity venous system. Increasing venous pressure and blood volume, in combination with reduced flow rates within the deep veins, predisposes pregnant women to both primary and secondary chronic venous insufficiency (CVI). This review article highlights the specific physiologic and hemodynamic changes that occur during pregnancy and examines the nonpharmacologic, pharmacologic, and invasive interventions that are appropriate for both prophylaxis and treatment of CVI and venous thromboembolism (VTE).

METHODS

This study is a review article of the key literature related to VTE and CVI in pregnancy.

RESULTS

Significant hemodynamic changes occur in the lower extremities during pregnancy. Although well documented and essential to fetal development, these changes can have a negative impact on the maternal lower extremity venous circulation. Consequences of pregnancy can result in venous disease only during pregnancy or, particularly in the multiparous patient, can progress to CVI. An abundance of literature and guidelines exist for the management of VTE during pregnancy; however, the quality and extent of literature based around the management of primary CVI during pregnancy are modest at best.

CONCLUSIONS

The physiologic changes throughout the arterial and venous systems during pregnancy are well documented. However, there is a paucity of data available to construct guidelines for care, particularly in the pregnant patient with symptomatic superficial venous insufficiency. Further investigation in the form of prospective randomized trials is required to establish appropriate guidelines for treatment.

Risk of Pulmonary Embolism in Patients With Isolated Great Saphenous Vein Thrombus

Risks associated with isolated great saphenous vein (GSV) thrombosis remain controversial. The purpose of this study is to identify the risk of pulmonary embolism (PE) in patients with isolated GSV thrombosis, particularly those with thrombus within 3 cm of the sapheno-femoral junction. A retrospective chart review of color flow Doppler lower extremity venous ultrasound examinations from an academic hospital from 2011 to 2016 was conducted. Seventy-eight patients were identified as having acute thrombus in their GSV and were then further stratified based on the presence or absence of concomitant deep venous thrombosis (DVT). A control group of 49 patients who presented with leg swelling and were found to have a normal color flow Doppler examination was also identified. Patients without thrombus (n = 49), patients with isolated GSV thrombus (n = 29), and patients with GSV thrombus with concomitant DVT (n = 49) underwent full chart review to determine whether any patients developed PE. This was diagnosed specifically by computed tomography angiogram or ventilation/perfusion scan, within 60 days of initial diagnosis of lower extremity thrombus. In our analysis, there was no significant difference in the risk of PE in patients with isolated GSV thrombus compared with a control group of normal patients (3.5% vs 2.0%, P = 0.38). However, patients with GSV thrombus and concomitant DVT had a significantly increased risk of PE compared with patients with isolated GSV thrombus (26.5% vs 3.5%, P = 0.01). We found that the risk of PE in patients with isolated GSV thrombus is not significantly increased compared with a normal cohort.