Diverse management of isolated calf deep venous thrombosis in a university hospital

Risk factors and prediction model of nomogram for preoperative calf muscle vein thrombosis in geriatric hip fracture patients

Introduction

Calf muscular vein thrombosis (CMVT) is a common complication in geriatric hip fracture patients. Despite its high incidence, prior research on the topic is limited. The occurrence of CMVT in patients will prolong the preoperative waiting time and even lead to serious thromboembolic events, which can be detrimental to the patient's prognosis. Therefore, this study aimed to identify the risk factors for preoperative CMVT in geriatric hip fracture patients and construct a nomogram model to predict the risk of preoperative CMVT in patients.

Materials and methods

Geriatric hip fracture patients who underwent surgery between January 2019 and January 2022 were included. The patients were categorized into two groups depending on whether they had preoperative CMVT, confirmed through Color Doppler ultrasound or venography examination. Univariate and multivariate logistic regression analyses were used to analyze demographic characteristics, medical history, comorbidities, and laboratory tests. A nomogram was constructed to predict preoperative CMVT in geriatric hip fracture patients based on the results of the multivariate logistic regression.

Results

Three hundred and eighty-eight geriatric hip fracture patients, including one hundred and thirty-four patients with CMVT and two hundred and fifty-four patients without CMVT, were ultimately included in our study. After multivariable logistic regression analysis, the time from injury to admission, smoking history, serum albumin levels, and D-dimer levels was identified as independent risk factors and was entered into a nomogram model. The nomogram showed robust discrimination, with an area under the receiver operating characteristic curve of 0.805. The calibration curve showed strong agreement between the CMVT probabilities predicted by the nomogram and the actual probabilities. The decision curve analysis illustrates the excellent clinical utility of the model.

Conclusion

We have constructed a new nomogram prediction model that can effectively predict the risk of preoperative CMVT in geriatric hip fracture patients based on their medical history and blood test results. This model can help clinicians make individualized predictions of CMVT that are tailored to each patient's unique circumstances.

Incidence and risk factors of isolated calf muscular venous thrombosis after tibial plateau fractures surgery

BACKGROUND

The risks associated with deep vein thrombosis (DVT) have gained significant recognition over time. A prevalent form of distal DVT is isolated calf muscular venous thrombosis (ICMVT). Despite its common clinical occurrence, data on ICMVT subsequent to tibial plateau fracture (TPF) surgery are scarce. This study aimed to examine the epidemiological characteristics and associated risk factors (RFs) of ICMVT following TPF surgery.

METHODS

For this retrospective analysis, we included patients from our hospital, who underwent TPF surgery between March 2017 and March 2021. Patients' electronic medical records were reviewed, including admission details, fracture classification, surgical procedures, and laboratory biomarkers. The HSS (The American Hospital for Special Surgery) and Rasmussen scores were employed to evaluate the clinical effect. A Color Duplex Flow Imager (CDFI) was regularly used to detect pre- and postoperative venous thrombosis in the lower limbs. Finally, uni- and multivariate logistic regression analyses were used to identify independent RFs associated with ICMVT.

RESULTS

Overall, 481 participants were recruited for analysis. Postoperative ICMVT occurred in 47 patients. All ICMVTs occurred on the affected side. Four of the 47 ICMVT patients exhibited sudden postoperative swelling in the affected limb. The HSS and Rasmussen scores in the non-ICMVT cohort (87.6 ± 8.2, 16.0 ± 1.7) were markedly different from the ICMVT cohort (84.8 ± 8.2, 15.5 ± 1.6) (p = 0.014, p = 0.031). This study finally identified five postoperative ICMVT-related RFs, which were age (> 55 years old) (OR 3.06; 95% CI 1.47-6.37; p = 0.003), gender (female) (OR 2.67; 95% CI 1.37-5.22; p = 0.004), surgical duration (> 114 min) (OR 3.14; 95% CI 1.44-6.85; p = 0.004), elevated white blood cell content (OR 2.85; 95% CI 1.47-5.51; p = 0.002), and hyponatremia (OR 2.31; 95% CI 1.04-5.12; p = 0.040).

CONCLUSION

The epidemiological findings of this study may help predict ICMVT risk after surgery thus facilitating the development of individualized clinical assessments and targeted prevention programs.

Development of Risk Prediction Model for Muscular Calf Vein Thrombosis with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Purpose

This study aims to establish a risk prediction model for muscular calf vein thrombosis (MCVT) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Methods

The research sample consisted of 248 patients with AECOPD and all of them underwent vascular ultrasounds of both lower limbs in this retrospective study. Univariate analysis and multivariate logistic regression analysis were conducted on factors with significant group differences to screen for the independent risk factors of MCVT. A nomogram to predict the risk of MCVT was constructed and validated with bootstrap resampling.

Results

According to the exclusion criteria, 240 patients were included for analysis, divided into the MCVT group (n = 81) and the non-MCVT group (n = 159). Multivariate logistic regression analyses showed that hypertension, elevated MPV, reduced albumin (ALB), elevated D-dimer and bed rest ≥3 days were independent risk factors for MCVT in AECOPD. A nomogram model for predicting AECOPD with MCVT was established based on them. The area under the curve (AUC) of receiver operating characteristic (ROC) curve for the prediction model and the simplified Wells score was 0.784 (95% CI: 0.722–0.847) and 0.659 (95% CI: 0.583–0.735), respectively. The cut-off value and Youden index of prediction model were 0.248 and 0.454, respectively. At the same time, the sensitivity, specificity, positive predictive value, and negative predictive value of the prediction model were 85.9%, 59.5%, 84.6%, and 77.4%, respectively. The sensitivity and specificity of the simplified Wells score were 67.9% and 56.3%, respectively. Validation by the use of bootstrap resampling revealed optimal discrimination and calibration, and the decision analysis curve (DAC) suggested that this prediction model involved high clinical practicability.

Conclusion

We developed a nomogram that can predict the risk of MCVT for AECOPD patients. This model has the potential to assist clinicians in making treatment recommendations and formulating corresponding prevention measures.

Incidence and risk factors of preoperative isolated calf deep venous thrombosis following hip fractures

There is still a lack of data on isolated calf deep vein thrombosis (ICDVT) following hip fractures surgery. The study aimed to determine the incidence of preoperative ICDVT and the associated risk factors in patients with hip fractures requiring surgery.The 289 patients who required hip surgery were included, duplex ultrasonography was routinely used to make a definite diagnosis of preoperative ICDVT located in unilateral or bilateral calf. Data on demographics and laboratory-associated blood biomarkers results were included. Univariate analyses were used to analyse the data of demographics, comorbidities, personal history operation related indexes and laboratory biomarkers, then the multivariate logistic regression analysis was employed to identify the independent risk factors associated with ICDVT.Sixty-eight (23.5%) patients were diagnosed with preoperative ICDVTs. The univariate analyses showed significant differences regarding ICDVT were age, current smoking, alcohol consumption, time from injury to operation, albumin, white blood cells, lymphocyte, red blood cells, hemoglobin, hematocrit, and activated partial thromboplastin time level among the 44 factors. The multivariable model confirmed 3 risk factors were significantly independent in association with preoperative ICDVTs, including current smoking, time delay from injury to operation and activated partial thromboplastin time ( < 28seconds).The incidence of preoperative ICDVT in hip fracture was 23.5%, and patients with associated risk factors are prone to form ICDVTs, identification of these factors may help to reduce the incidence of ICDVT with hip fractures by taking early prevention measures.

Clinical presentation of isolated calf deep vein thrombosis in inpatients and prevalence of associated pulmonary embolism

OBJECTIVE

There is a controversy over the clinical significance and optimal treatment for isolated calf DVT. This study aimed to investigate the clinical presentation of isolated calf deep vein thrombosis (DVT) and the association of isolated calf DVT with pulmonary embolism (PE) in inpatients.

METHODS

A total of 1435 hospitalized patients underwent whole-leg duplex ultrasound between January 2018 and June 2020. Among them, 135 were diagnosed with isolated calf vein DVT.

RESULTS

The soleal vein was the most frequently involved (52.6%). Thrombus was detected only in axial veins in 57 patients (42.2%), muscular veins in 46 patients (34.4%), and in both axial and muscular veins in 32 patients (23.7%). Of the 135 patients, 44 patients (32.6%) had underwent recent orthopedic surgery, 31 patients (23.0%) had active cancer, and 22 patients (16.3%) had a history of recent stroke. The reasons for duplex ultrasound were leg edema and/or pain in 57 patients (42.2%), diagnosis of PE in 33 (24.4%), and elevated D-dimer level in 27 patients (20.0%). Sixteen patients (11.9%) were diagnosed as incidental findings on imaging studies for other purposes. Ninety-six patients (71.1%) received anticoagulation therapy. Concurrent PE was diagnosed in 45 patients (33.3%) and 14 patients had lesions in the main pulmonary artery. Among 45 patients with concurrent PE, 35 patients were diagnosed without leg edema and/or pain. Recurrent VTE was observed in four patients (3.0%) with a mean follow-up of 15.5±12.7 months.

CONCLUSIONS

Isolated calf DVT was associated with a high prevalence of PE in hospitalized patients. Patients with isolated calf DVT even without leg edema and/or pain may have concurrent PE. Anticoagulation therapy should be considered for isolated calf DVT in inpatients. The muscular veins were frequently involved, thus should be thoroughly evaluated and imaged.

Isolated calf deep venous thrombosis: frequency on venous ultrasound and clinical characteristics

Background

It remains controversial whether to include calf veins in the initial ultrasound evaluation of suspected deep venous thrombosis (DVT). We sought to investigate the frequency and clinical characteristics of isolated calf DVT.

Materials and methods

In this retrospective analysis, we investigated a cohort of 596 patients (median age 69 years, 52.3% women) who had been imaged with complete lower extremity venous duplex ultrasound for suspected acute DVT. Radiology reports were analyzed for the presence and localization of DVT. Clinical information was collected from patients’ electronic charts.

Results

DVT was found in 157 patients (26.3%), of which 74 patients (47.1%) had isolated calf DVT. Isolated calf DVTs were located in the posterior tibial veins (22 patients, 29.7%), peroneal veins (41 patients, 55.4%) and muscle veins (19 patients, 25.7%). There were no differences in age or sex between patients with isolated calf DVT and patients with proximal DVT. Isolated calf DVT was more commonly associated with leg pain (52.7% vs. 33.7%, p = 0.0234) and less commonly associated with subjective leg swelling (35.1% vs. 55.4%, p = 0.0158) and objectively measured difference in leg circumference (23% vs. 39.8%, p = 0.0268). D-Dimers were significantly lower in patients with isolated lower leg DVT (median 2.3 vs. 6.8 mg/L, p < 0.0001) compared to patients with proximal DVT.

Conclusions

Isolated calf DVT represents approximately half of DVT cases and has different clinical characteristics than proximal DVT.

Literature review of distal deep vein thrombosis

OBJECTIVE

Although distal deep vein thrombosis (DDVT) has been more frequently diagnosed with the availability of better ultrasound imaging quality, the data on the best method to manage DDVT have been conflicting. The aim of the present review was to summarize the current and evidence-based recommendations for the diagnosis and management of DDVT and to provide a summary of the most recent societal guideline recommendations.

METHODS

A literature review of DDVT was performed. The PubMed databases were queried for articles on the epidemiology, risk factors, diagnosis, and management of DDVT.

RESULTS

The prevalence of isolated DDVT has been reported in a broad range. The reported risk factors include older age, active malignancy, a low degree of mobility, acute infection, and atrial fibrillation. With more evidence, anticoagulation therapy was found to be associated with a reduced risk of recurrent venous thromboembolism (VTE) and/or thrombus propagation compared with conservative management. However, anticoagulation was associated with an increased risk of bleeding in a number of studies. The rate of VTE recurrence ranged from 7% to 23% during a follow-up period ranging from 3 months to 8 years. The significant risk factors for VTE recurrence included cancer, older age, an unprovoked event, and inpatient status.

CONCLUSIONS

Few studies have addressed the diagnosis and management of DDVT. Further research is needed to standardize the best approach to diagnose and treat DDVT.

Management of isolated distal deep-vein thrombosis with direct oral anticoagulants in the RIETE registry

Isolated distal deep-vein thrombosis (DVT, infra-popliteal DVT without pulmonary embolism) is a common presentation of venous thromboembolism (VTE), but was an exclusion criterion from the pivotal trials that validated the use of direct oral anticoagulants (DOACs) for VTE management. Using data from the international RIETE registry, we analyzed and compared trends in DOACs prescription between January 2011 and June 2019 in patients with distal vs. proximal DVT. We also assessed DOACs' prescriptions and compared the outcomes (VTE recurrence, bleeding and death) of distal DVT patients treated with DOACs vs. those on vitamin K antagonists (VKAs). 2308 patients with distal DVT and 11,364 patients with proximal DVT were included in the current analysis. DOACs were more frequently prescribed in patients with distal than proximal DVT (25% vs. 16%, p < 0.001). DOACs use increased sharply during the observation period (P < 0.001 for trend). In 2018, 56% of patients with distal DVT received DOACs. Distal DVT patients treated with rivaroxaban or edoxaban received the dose recommended for VTE management in most (> 85%) cases. Patients treated with apixaban were older, more likely to have underlying conditions than patients treated with rivaroxaban and, in most cases (> 75%), did not receive the recommended 1-week loading dose for acute VTE management. Outcomes between distal DVT patients treated with VKAs or DOACs appeared to be similar. In patients with distal DVT, DOACs have become the most common anticoagulant regimen. Specific trials are needed to determine the optimal DOACs dose regimen for treatment of distal DVT.

Long-term risk of postthrombotic syndrome after symptomatic distal deep vein thrombosis: The CACTUS-PTS study

BACKGROUND

After a proximal lower limb deep vein thrombosis (DVT; involving popliteal veins or above), up to 40% of patients develop postthrombotic syndrome (PTS) as assessed by the Villalta scale (VS). Poor initial anticoagulant treatment is a known risk factor for PTS. The risk of developing PTS after isolated distal DVT (infra-popliteal DVT without pulmonary embolism), and the impact of anticoagulant treatment on this risk, are uncertain.

METHODS

Long-term follow-up of CACTUS double-blind trial comparing 6 weeks of s.c. nadroparin (171 IU/kg/d) versus s.c. placebo for a first symptomatic isolated distal DVT. At least 1 year after randomization, patients had a PTS assessment in clinic or by phone using the VS.

RESULTS

After a median follow-up of 6 years, PTS was present in 30% (n = 54) of the 178 patients who had a PTS assessment. PTS was moderate or severe in 24% (n = 13) of cases. There was no statistically significant difference in prevalence of PTS in the nadroparin versus placebo groups (29% versus 32%, P = .6), except in patients without evidence of primary chronic venous insufficiency (9% versus 24%, P = .04). Rates of venous thromboembolism recurrence during follow-up in the nadroparin and placebo groups were, respectively, 8% (n = 7) and 14% (n = 13; P = .2).

CONCLUSION

After a first isolated distal DVT, the risk of PTS is substantial but much lower than that reported after proximal DVT. Anticoagulation with nadroparin doesn't provide any clear benefit to prevent PTS, except in patients without preexisting chronic venous insufficiency. Anticoagulation might be associated with a lower risk of venous thromboembolism recurrence.